Procedural Sedation Publications (1440)


Procedural Sedation Publications

Clin Neuroradiol
Clin Neuroradiol 2017 Jan 12. Epub 2017 Jan 12.
Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany.

The aim of our study was the technical evaluation of a first pass approach of primary thrombus aspiration (AST) in patients with emergency large intracerebral vessel occlusions (ELVO) under routine clinical conditions.
We collected procedural and clinical data of 104 patients who underwent mechanical thrombectomy due to ELVO between June 2014 and January 2016 with intentional first-line thrombus aspiration. Procedures were conducted due to occlusions of the distal internal carotid artery, middle cerebral artery, anterior cerebral artery, basilar artery and posterior cerebral artery and were performed with the patient under either conscious sedation or general anesthesia. Read More

If the AST technique failed completely or to some extent, stent retriever-based thrombectomy (SRT) was performed.
As a stand-alone method AST was successful in achieving TICI (Thrombolysis in Cerebral Infarction) score 2b or 3 results in 29 cases (27.8%). After additional use of SRT successful recanalization was achieved in a total of 95 cases (91.3%, p = 0.048). If AST was performed exclusively, median procedure time until TICI 2b/3 was 15 min, in cases of combined procedures 35 min (p = 0.001). Subarachnoid hemorrhage (SAH) after thrombectomy appeared only if additional SRT was performed (12.0%) and not in cases of AST maneuvers alone (p = 0.09).
When used as a first pass attempt AST is a fast and safe approach for patients suffering from stroke due to ELVO. Nonetheless, early conversion to SRT is needed in most cases and leads to overall excellent procedural results with low complication rates.

Am J Emerg Med
Am J Emerg Med 2017 Jan 3. Epub 2017 Jan 3.
Department of Emergency Medicine, Medical Centre Leeuwarden, Leeuwarden, The Netherlands. Electronic address:

Procedural sedation for painful procedures in the emergency department (ED) can be accomplished with various pharmacological agents. The choice of the sedative used is highly dependent on procedure- and patient characteristics and on personal- or local preferences.
We conducted a multicenter retrospective cohort study of procedural sedations performed in the EDs of 5 hospitals in the Netherlands over a 4year period to evaluate the efficacy- (success rate of the intended procedure) and safety (incidence of sedation (adverse) events) of propofol sedations compared to midazolam sedations. Read More

A total of 592 ED sedations were included in our study. Patients sedated with propofol (n=284, median dose 75mg) achieved a deeper level of sedation (45% vs. 25% deep sedation, p<0.001), had a higher procedure success rate (92% vs. 81%, p<0.001) and shorter median sedation duration (10 vs. 17min, p<0.001) compared to patients receiving midazolam (n=308, median dose 4mg). A total of 112 sedation events were registered for 99 patients. Transient apnea was the most prevalent event (n=73), followed by oxygen desaturation (n=18) airway obstruction responsive to simple maneuvers (n=13) and hypotension (n=6). Propofol sedations were more often associated with the occurrence of apnea's (20% vs. 10%, p=0.004), whereas clinically relevant oxygen desaturations (<90%) were found more often in patients sedated with midazolam (8% vs. 1%, p=0.001). No sedation adverse events were registered CONCLUSION: Propofol is more effective and at least as safe as midazolam for procedural sedation in the ED.

World J Gastrointest Endosc
World J Gastrointest Endosc 2016 Dec;8(20):770-776
Alexandra Shingina, Department of Gastroenterology, Faculty of Medicine, University of Toronto, Toronto General Hospital, Ontario M5G 2C4, Canada.

To develop a prediction model aimed at identifying patients that may require higher than usual sedation doses during colonoscopy.
A retrospective chart review on 5000 patients who underwent an outpatient colonoscopy at St. Paul's Hospital from 2009 to 2010 was conducted in order to develop a model for identifying patients who will require increased doses of sedatives. Read More

Potential predictor variables including age, gender, endoscopy indication, high sedation requirements during previous endoscopies, difficulty of the procedure, bowel preparation quality, interventions, findings as well as current use of benzodiazepines, opioids and alcohol were analyzed. The outcome of study was the use of high dose of sedation agents for the procedure. In particular, the high dose of sedation was defined as fentanyl greater than 50 mcg and midazolam greater than 3 mg.
Analysis of 5282 patients (mean age 57 ± 12, 49% female) was performed. Most common indication for the procedure was screening colonoscopy (57%). Almost half of our patients received doses exceeding Fentanyl 50 mcg and Midazolam 3 mg. Logistic regression models identified the following variables associated with high sedation: Younger age (OR = 0.95 95%CI: 0.94-0.95; P < 0.0001); abdominal pain (OR = 1.45, 95%CI: 1.08-1.96); P = 0.01) and Inflammatory Bowel Disease (OR = 1.45, 95%CI: 1.04-2.03; P = 0.02) as indications for the procedure; difficult procedure as defined by gastroenterologist (OR = 1.73, 95%CI: 1.48-2.03; P < 0.0001); past history of abdominal surgery (OR = 1.33, 95%CI: 1.17-1.52; P <0.0001) and previous colonoscopy (OR = 1.39, 95%CI: 1.21-1.60; P = 0.0001) and alcohol use (OR = 1.26, 95%CI: 1.03-1.54; P = 0.02). Age and gender adjusted analysis yielded inflammatory bowel disease as an indication (OR = 3.17, 95%CI: 1.58-6.37; P = 0.002); difficult procedure as defined by an endoscopist (OR = 5.13 95%CI: 2.97-8.85; P = 0.0001) and current use of opioids, benzodiazepines or antidepressants (OR = 2.88, 95%CI: 1.74-4.77; P = 0.001) having the highest predictive value of high sedation requirements. Our prediction model using the following pre-procedural variables including age, gender, indication for the procedure, medication/substance use, previous surgeries, previous high sedation requirements for colonoscopy yielded an area under the curve of 0.76 for Fentanyl ≥ 100 mcg and Midazolam ≥ 3 mg.
Pre-procedural planning is the key in conducting successful, efficient colonoscopy. Logistic regression analysis of 5000 patients who underwent out-patient colonoscopy revealed the following factors associated with increased sedation requirement: Younger age, female gender, difficult endoscopy, specific indications as well as cardiopulmonary complications and current use of opioids/benzodiazepines. Age and gender adjusted analysis yielded similar results. These patients are more likely to need a longer recovery periods post-endoscopy, which could result in additional time and personnel requirements. The final predictive model has good predictive ability for Fentanyl ≥ 100 mcg and Midazolam ≥ 3 mg and fair predictive ability for Fentanyl ≥ 50 mcg and Midazolam ≥ 2 mg. The external validity of this model is planned to be tested in another center.

Int J Clin Pharm
Int J Clin Pharm 2016 Dec 31. Epub 2016 Dec 31.
Anesthesia and Operation Center, Chinese General Hospital of PLA, No. 28, Fuxing Road, Haidian District, Beijing, 100853, China.

Background Dexmedetomidine, an α2-receptor agonist, provides potent sedation, analgesia, and anxiolysis without respiratory depression and is used in a variety of surgical and procedural situations. Aim of the review The aim of this study was to estimate the incidence of bradycardia in pediatric patients who received dexmedetomidine as a sole agent for any procedural, intensive care or surgical sedation. Method Literature was searched in electronic databases and studies were selected by following pre-determined eligibility criteria. Read More

Meta-analyses were carried out by pooling the percent incidence of bradycardia to attain a weighted overall effect size. Age-wise subgroup analyses and meta-regression analyses for the identification of factors affecting the incidence were also performed. Results Data of 2835 patients from 21 studies were included. The mean age was 62.21 ± 35.68 months. Initial, maintenance and total doses of dexmedetomidine (mean ± standard deviation) were 1.63 ± 0.33 μg/kg body weight, 0.86 ± 0.68 μg/kg/h, and 26.7 ± 20.8 μg/kg. The overall incidence of bradycardia (95% confidence interval) was 3.067 (2.863, 3.270)%; P < 0.0001. However, range was wider (0-22%) with 9 studies observed 0% incidence. The mean change in the heart rate was -17.26 (-21.60, -12.92); P < 0.00001. In the meta-regression analyses, age, body weight and dexmedetomidine dose were not significantly associated with the incidence of bradycardia. The minimum heart rate observed during the dexmedetomidine treatment period was positively associated with baseline heart rate. Conclusion Incidence of bradycardia in dexmedetomidine treated pediatric patients is 3%.

Intern Emerg Med
Intern Emerg Med 2016 Dec 28. Epub 2016 Dec 28.
Department of Health Management and Policy, University of Iowa College of Public Health, 145 N. Riverside Drive, Iowa City, IA, 52246, USA.

End-tidal CO2 has been advocated to improve safety of emergency department (ED) procedural sedation by decreasing hypoxia and catastrophic outcomes. This study aimed to estimate the cost-effectiveness of routine use of continuous waveform quantitative end-tidal CO2 monitoring for ED procedural sedation in prevention of catastrophic events. Markov modeling was used to perform cost-effectiveness analysis to estimate societal costs per prevented catastrophic event (death or hypoxic brain injury) during routine ED procedural sedation. Read More

Estimates for efficacy of capnography and safety of sedation were derived from the literature. This model was then applied to all procedural sedations performed in US EDs with assumptions selected to maximize efficacy and minimize cost of implementation. Assuming that capnography decreases the catastrophic adverse event rate by 40.7% (proportional to efficacy in preventing hypoxia), routine use of capnography would decrease the 5-year estimated catastrophic event rate in all US EDs from 15.5 events to 9.2 events (difference 6.3 prevented events per 5 years). Over a 5-year period, implementing routine end-tidal CO2 monitoring would cost an estimated $2,830,326 per prevented catastrophic event, which translates into $114,007 per quality-adjusted life-year. Sensitivity analyses suggest that reasonable assumptions continue to estimate high costs of prevented catastrophic events. Continuous waveform quantitative end-tidal CO2 monitoring is a very costly strategy to prevent catastrophic complications of procedural sedation when applied routinely in ED procedural sedations.

J. Gastrointest. Surg.
J Gastrointest Surg 2016 Dec 19. Epub 2016 Dec 19.
Digestive Disease and Surgery Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA.

Transcatheter aortic valve implantation (TAVI) can now be considered a standard of care for inoperable and high-risk surgical patients with severe aortic stenosis, and its uptake worldwide is rapidly increasing. Indeed, many centers performing the procedure have now moved towards treating intermediate-risk patients with TAVI rather than referring them for surgical aortic valve replacement. Although the incidence of peri-procedural acute and subacute stroke following TAVI has fallen to 2-5%, its occurrence can be life-threatening and life-changing, and every effort must be made to improve patient outcome should stroke occur. Read More

Many cardiologists would not instinctively consider the use of thrombolytic therapy for post-transfemoral TAVI ischemic stroke because of concern about the risk of major bleeding from the access site, despite it being a standard of care for ischemic stroke in other circumstances. The present case highlights the benefit of using intravenous thrombolytic therapy for an acute basilar artery thrombotic stroke after transfemoral TAVI (TF-TAVI) that would otherwise have almost certainly resulted in the patient's death. The case may also prompt interventional cardiologists to consider performing TF-TAVI under conscious sedation rather than general anesthesia, as this can result in an earlier detection of acute stroke and allow an earlier intervention with thrombolytic agents, with an improved outcome.

Am J Emerg Med
Am J Emerg Med 2016 Oct 11. Epub 2016 Oct 11.
Department of Pediatrics, University of Louisville, Louisville, KY.

Ketamine is commonly used in the emergency department for short, painful procedures. We describe changes in blood pressure (BP) and heart rate (HR) during procedural sedation with ketamine, as these changes have not been well described in children.
We performed a secondary analysis of a prospective, observational study involving children aged 8 to 18 years who received procedural sedation with ketamine in a pediatric emergency department. Read More

Serial vital signs and sedation scores were recorded from baseline until recovery from ketamine procedural sedation. Time of orthopedic manipulation was also recorded. Linear mixed-effect models were used to evaluate changes in systolic BP (SBP), diastolic BP (DBP), and HR using 3 sedation strata: presedation (baseline), sedated (ketamine administered and patient deeply sedated), and recovery (ketamine administered with patient minimally sedated), controlling for age and weight.
Sixty children were enrolled; 10 were excluded due to missing manipulation time. A total of 394 observations were recorded. Mean sedated SBP, DBP, and HR were 8 mm Hg, 4 mm Hg, and 13 beats/min higher than presedation SBP (P<.001), DBP (P<.01), and HR (P<.001), respectively. Mean sedated SBP and DBP were 3 and 4 mm Hg higher than SBP (P=.006) and DBP (P<.01) during recovery. Manipulation increased mean SBP by 5 mm Hg (P<.001), mean DBP by 7 mm Hg (P<.001), and mean HR by 1 beat/min (P=.35).
Ketamine administered during procedural sedation for painful procedures causes a statistically significant but modest increase in SBP, DBP, and HR. Orthopedic manipulation further increases BP.


Emesis is one of the most common adverse events associated with ketamine sedation. However, the predictors of emesis have not been clearly studied among Asian children. This study aimed to determine the incidence and predictors of emesis in local children undergoing intramuscular (IM) ketamine sedation in the emergency department (ED), and identify high-risk groups(s), so that antiemetics may be administered prophylactically. Read More

In a prospective observational study, all children requiring procedural sedation under IM ketamine in the paediatric ED between 1 April 2013 and 31 January 2015 were included. All patients with emesis post ketamine sedation were documented in the procedural sedation charting form prospectively. Univariate and multivariate logistic regression analyses were performed to identify the predictors of emesis.
2,502 sedations were performed using IM ketamine in the ED during the study period. Overall incidence of emesis associated with IM ketamine sedation was 8.4%. Children aged 8 years and above were significantly associated with increased risk of emesis (OR 4.636, 95% CI 3.271-6.570; p < 0.001), with an emesis rate of 19.5% in this subgroup. Other variables, such as initial dose (3 mg/kg vs. 4 mg/kg), total dosage (including top-ups), types and site of procedure, gender and ethnicity were not significant predictors. The number needed to treat with antiemetics in children aged 8 years and above was ≥ 5.
Age is a significant predictor of emesis. We recommend a randomised controlled trial that compares the effects of prophylactic IM ondansetron with patients stratified as those aged up to and over 8 years.

Transplant. Proc.
Transplant Proc 2016 Nov;48(9):3067-3069
Department of Anesthesia and Intensive Care, Città della Salute e della Scienza Hospital, Turin, Italy; Department of Surgical Sciences, University of Turin, Turin, Italy. Electronic address:

We aim to describe management of a patient receiving renal transplantation for chronic renal failure due to Alport syndrome with low dose of intrathecal bupivacaine and continuous epidural infusion of local anesthetic.
A 38-years-old man with chronic renal failure secondary to Alport syndrome underwent kidney transplantation. Because of a high risk of respiratory and cardiovascular complications related to the patient's baseline lung disease and abnormalities in heart conduction, we selected combined spinal-epidural anesthesia. Read More

The block was ultrasound-guided and performed at the T12-L1 interspace with 4.5 mg of 0.5% intrathecal hyperbaric bupivacaine followed by a continuous epidural infusion of 0.5% levobupivacaine mixed with 25 μg of Fentanyl at the initial rate of 8 mL/h. Sensory block to T5-T6 was obtained within 10 minutes. The patient then received mild sedation with Propofol and Remifentanil. Methylprednisolone and diuretics were administered before vascular unclamping according to our internal protocol. Surgery lasted 3 hours with no clinical or procedural complication.
Although renal transplantation is usually performed under general anesthesia, in a particularly complex patient with chronic renal failure, chronic obstructive pulmonary disease and a worsened respiratory mechanics, we applied a combined approach with a low dose of intrathecal bupivacaine and continuous epidural infusion of local anesthetic. The technique did not affect hemodynamics while having a positive impact on recovery of function of the transplanted organ with rapid improvement of urine output, serum creatinine, and blood urea nitrogen levels.