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Objective: The aim of the present study was to describe procedural sedation practices undertaken in a spectrum of Australian EDs. Methods: Eleven Australian EDs enrolled consecutive adult and paediatric patients between January 2006 and December 2008. Patients were included if a sedative drug was administered for an ED procedure. Data collection was prospective and used a specifically designed data collection document. Results: 2623 patients were enrolled. 1581 were male (60.3%, 95% CI 58.4-62.2) and the mean patient age was 39.2 (SD 25.2) years. Reductions of fracture/dislocated shoulders (694 cases, 26.7%), wrist/forearm fractures (403, 15.5%) and tibia/fibula fractures (341, 13.1%) were the most common procedures. Procedures were supervised by consultants and registrars in 1424 (54.3%) and 1025 (39.1%) cases, respectively. Of 2413 patients with complete fasting status data, 1252 (51.9%, 95% CI 49.9-53.9) patients had consumed food or fluid in the previous 6 h. 1399 (53.3%, 95% CI 51.4-55.3) patients received pre-procedural medication. Pre-procedural morphine (894, 34.1%) exceeded fentanyl use (323, 12.3%), both as a sole agent and in combination with another agent. The principal sedatives used alone were propofol (857, 38.5%), midazolam (224, 10%) and ketamine (165, 7.4%). Ketamine and nitrous oxide were most commonly used in children with propofol, midazolam and opiates largely restricted to adults ( P < 0.001). The intra-procedural use of adjunct fentanyl exceeded that of morphine (ratio 4:1). Conclusions: Procedural sedation practice across Australian EDs is varies considerably. Procedural sedation 'best practice' guidelines, based upon the findings of the present study and the available evidence, are recommended. [ABSTRACT FROM AUTHOR] more...

Objective: To determine the nature, incidence and risk factors for sedation-related events during ED procedural sedation, with particular focus on the drugs administered. Methods: Eleven Australian EDs enrolled consecutive adult and paediatric patients between January 2006 and December 2008. Patients were included if a sedative drug was administered for an ED procedure. Data collection was prospective and employed a specifically designed form. Multivariate logistic regression was employed to determine risk factors for sedation-related events. Results: Two thousand, six hundred and twenty-three patients were enrolled (60.3% male, mean age 39.2 years). Reductions of fracture/dislocations of shoulders, wrists and ankles were most common. Four hundred and sixty-one (17.6%) cases experienced at least one airway event that required intervention. Airway obstruction, hypoventilation and desaturation occurred in 12.7%, 6.4% and 3.7% of all patients, respectively. Two thousand, one hundred and forty-six cases had complete datasets for further analyses. Increasing age and level of sedation, pre-medication with fentanyl, and sedation with propofol, midazolam or fentanyl were risk factors for an airway event ( P < 0.05). Ketamine was a protective factor. Hypotension (systolic pressure <80 mmHg) occurred in 34 (1.6%) cases with midazolam being a significant risk factor ( P < 0.001). Vomiting also occurred in 34 (1.6%) cases, 12 of whom required an intervention. One patient aspirated. Vomiting occurred after administration of all drugs but was not associated with fasting status. Other events were rare. Conclusions: Sedation-related events, especially airway events, are common but very rarely have an adverse outcome. Elderly patients, deeply sedated with short-acting agents, are at particular risk. The results will help tailor sedation to individual patients. [ABSTRACT FROM AUTHOR] more...

Objective: To determine factors associated with failure to successfully complete a procedure during sedation in the ED. Methods: Eleven Australian EDs enrolled consecutive adult and paediatric patients between January 2006 and December 2008. Patients were included if a sedative drug was administered for an ED procedure and the success or failure of the procedure was recorded. Results: Data were available for 2567 patients. Of these, 1548 (60.3%, 95% CI 58.4-62.2) were male and 456 (17.8%, 95% CI 16.3-19.3) were age <16 years. The most common procedures performed were reduction of major joints and laceration repair. A total of 149 procedures (5.8%, 95% CI 5.0-6.8) failed. There were significant differences in failure rates between the types of procedure undertaken, with reduction of hips, digits and mandibles associated with the highest failure rates ( P < 0.001). In adults, body weight >100 kg was also associated with increased risk of procedural failure (odds ratio 2.3, 95% CI 1.3-4.1). Ketamine used as a single agent had the lowest procedural failure rate (2.5%, 95% CI 1.1-5.4) whereas propofol had the highest (5.9%, 95% CI 4.6-7.6). However, these two drugs were generally used in different age groups and for different procedures. Conclusions: Procedures performed under sedation in the ED have a low failure rate. However, increased body weight and specific procedures, such as hip reduction, are associated with significantly higher failure rates. Special consideration should be given to these patient groups before undertaking sedation in the ED. [ABSTRACT FROM AUTHOR] more...