Objective We sought to determine the performance characteristics of remifentanil as an agent of procedural sedation and analgesia (PSA) for adult and paediatric patients undergoing procedures similar to those executed in the ED.

Methods We systematically reviewed electronically published literature, grey literature, conference proceedings and trial registries from 1946 to 2015. Outcome measures included PSA effectiveness, recovery time, patient safety and resource management. We performed narrative summary analyses. Heterogeneity among selected studies precluded meta-analysis.

Results We found 1525 citations, reviewed 34 full manuscripts (kappa=0.64) and included 10 studies (kappa=0.71). Seven were randomised controlled trials and three studies took place in the ED. Included procedures were lumbar puncture (80), cardioversion (66), orthopaedic manipulation (63), incision and drainage (15), thoracostomy (8) and nasal packing (2). There was extensive variation in remifentanil dosing (0.15– 1.5 μg/kg), administration protocols and use of additional PSA drugs. All studies noted superior or equivalent sedation effectiveness compared withcontrols. Several studies, including all those performed in the ED, noted faster procedure completion or patient recovery with remifentanil compared with control groups. The most commonly reported adverse event was respiratory depression, especially in paediatric patients. All studies were found to carry significant risk of bias.

Conclusions There is currently a lack of high-quality data on the use of remifentanil in the ED. Physicians should exert caution when using remifentanil in the absence of published standardised dosing protocols in light of frequently reported paediatric respiratory depression. However, PSA efficacy combined with faster recovery times merit ongoing investigations into its use.