Sedation and pain management/original researchThe Utility of Supplemental Oxygen During Emergency Department Procedural Sedation and Analgesia With Midazolam and Fentanyl: A Randomized, Controlled Trial
Introduction
Procedural sedation and analgesia is the use of analgesic, dissociative, and sedative agents to prevent the pain, anxiety, and unpleasant memories associated with painful diagnostic and therapeutic procedures. All the agents used for procedural sedation and analgesia have the potential for serious adverse effects, including respiratory depression.1
The benefits of supplemental oxygen during procedural sedation and analgesia are unknown. In theory, supplemental oxygen may prevent hypoxemia in some patients, which has prompted the American Society of Anesthesiology to recommend supplemental oxygen for patients undergoing deep sedation (and to suggest that it be considered during moderate sedation).2 However, patients receiving supplemental oxygen may have normal oxygen saturation despite significant ventilatory depression.3 This could hinder the physician’s ability to recognize respiratory depression, leading to serious adverse events. The utility of supplemental oxygen during emergency department (ED) procedural sedation and analgesia has not been adequately studied. As a result, the use of supplemental oxygen is generally in accordance with institutional protocols or at the discretion of the treating physician.
Procedural sedation and analgesia has become an integral part of emergency medicine practice. Agents such as propofol and etomidate, once reserved for the operating suite, are now routinely used in the ED setting.1 These agents, as well as others used for ED procedural sedation and analgesia (eg, barbiturates, benzodiazepines, opiates), may cause significant respiratory depression.1 If supplemental oxygen can limit the incidence or severity of hypoxia without masking the presence of underlying respiratory depression, it should be incorporated into standard ED procedural sedation and analgesia protocols. If supplemental oxygen prevents hypoxia but masks respiratory depression, then additional precautions such as monitoring end-tidal carbon dioxide (etco2) may be indicated.4 If supplemental oxygen does not prevent hypoxia, its use should be abandoned.
The goal of this study was to determine whether supplemental oxygen delivered at 2 L per minute by nasal cannula would reduce the incidence of hypoxia by 20% in study patients receiving midazolam and fentanyl for ED procedural sedation and analgesia.
Section snippets
Study Design
This was a prospective, randomized, double-blind, placebo-controlled study conducted between October 1, 2004, and March 1, 2005. The institutional review board at the Albert Einstein Medical Center approved the study.
Setting and Selection of Participants
The study was performed in the ED at the Albert Einstein Medical Center, a Level I trauma center located in Philadelphia, PA. The ED features a well-established emergency medicine residency program and has an annual census of approximately 70,000 patient visits.
All patients older
Results
Of 140 patients screened, 83 patients were enrolled in the study. Three patients were subsequently excluded, leaving 80 patients for analysis (Figure). The 2 groups were similar with respect to age, sex, and weight (Table 2). Abscess incision and drainage and fracture and joint reduction accounted for the majority of procedures (Table 2). There were no differences between the groups in the type or duration of procedures performed, the median doses of midazolam and fentanyl administered, the
Limitations
We administered oxygen at 2 L per minute to the subjects in the treatment group. Although the addition of higher flow rates may have reduced the incidence of hypoxia in patients receiving supplemental oxygen, we believe this flow rate is consistent with common practice.
The results of our study indicated that the use of supplemental oxygen did not reduce the incidence of hypoxia in patients undergoing ED procedural sedation and analgesia with fentanyl and midazolam. The study was powered to
Discussion
Supplemental oxygen (2 L/minute by nasal cannula) did not reduce (or trend toward reducing) the incidence of hypoxia in patients moderately sedated with midazolam and fentanyl. However, our lower-than-expected rate of hypoxia limits the power of this comparison. This is the first study specifically designed to evaluate the potential benefits or hazards of supplemental oxygen. Previous studies have provided some insight about the use of supplemental oxygen. However, none have been specifically
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2019, African Journal of Emergency MedicineCitation Excerpt :Since the harms and toxic effects of high concentrations of oxygen are well known [34], the routine administration of supplemental oxygen during procedural sedation (70.6% of ECs in this study) may be controversial. In two separate randomised controlled studies that included patients who underwent procedural sedation with the administration of either propofol [32] or midazolam and fentanyl [35], the routine use of supplemental oxygen was not associated with significant reductions in the number of hypoxic episodes. Surprisingly, the combination of ketamine and propofol (Ketofol), was reported as the agent of choice at 23.5% of hospitals.
Acute Pain
2019, A Practice of Anesthesia for Infants and ChildrenAcute Pain
2018, A Practice of Anesthesia for Infants and Children
Supervising editor: Steven M. Green, MD
Author contributions: KD and CRC conceived the study and designed the trial. KD, CRC, and PD supervised the conduct of the trial and data collection. KD, CRC, and PD managed the data, including quality control. PD provided statistical advice on study design and analyzed the data. KD drafted the manuscript, and all authors contributed substantially to its revision. KD takes responsibility for the paper as a whole.
Funding and support: The authors report this study did not receive any outside funding or support.
Reprints not available from the authors.