Elsevier

Journal of Emergency Nursing

Volume 39, Issue 5, September 2013, Pages 502-507
Journal of Emergency Nursing

PHARM/TOX CORNER
Propofol for Procedural Sedation and Analgesia Reduced Dedicated Emergency Nursing Time While Maintaining Safety in a Community Emergency Department

https://doi.org/10.1016/j.jen.2013.03.001Get rights and content

Introduction

Procedural sedation and analgesia is a core competency in emergency medicine. Propofol is replacing midazolam in many emergency departments. Barriers to performing procedural sedation include resource utilization. We hypothesized that emergency nursing time is shorter with propofol than midazolam, without increasing complications.

Methods

Retrospective analysis of a procedural sedation registry for two community emergency departments with combined census of 100,000 patients/year. Demographics, procedure, and ASA physical classification status of adult patients receiving procedural sedation between 2007–2010 with midazolam or propofol were analyzed. Primary outcome was dedicated emergency nursing time. Secondary outcomes were procedural success, ED length of stay, and complication rate. Comparative statistics were performed with Mann–Whitney, Kruskal-Wallis, chi-square, or Fisher's exact test. Linear regression was performed with log-transformed procedural sedation time to define predictors.

Results

Of 328 procedural sedation and analgesia, 316 met inclusion criteria, of which 60 received midazolam and 256 propofol. Sex distribution varied between groups (midazolam 3% male; propofol 55% male; P = 0.04). Age, procedure, and ASA status were not significantly different. Propofol had shorter procedural sedation time (propofol 32.5 ± 24.2 minutes; midazolam 78.7 ± 51.5 minutes; P < 0.001) and higher rates of procedural success (propofol 98%; midazolam 92%; P = 0.02). There were no significant differences between complication rates (propofol 14%; midazolam 13%; P = 0.88) or emergency department length of stay (propofol 262.5 ± 132.8 minutes; midazolam 288.6 ± 130.6 minutes; P = 0.09).

Discussion

Use of propofol resulted in shorter emergency nursing time and higher procedural success rate than midazolam with a comparable safety profile.

Section snippets

Methods

This was a retrospective review of a computerized PSA registry established within a 2-hospital community health system with a combined annual ED census of 100,000 patients. The University of Maryland Institutional Review Board granted exemption.

We created a computerized data registry to track PSA cases and a relational database with MySQL 5.1 (Oracle, Redwood Shores, CA) to collect individual case data. We then created a custom Web interface for user management, data entry, and auditing. We

Results

A total of 328 PSAs were performed between January 2007 and November 2010. Of the 316 patients who met the inclusion criteria, 60 (19%) received midazolam and 256 (81%) received propofol. Age (P = .76), American Society of Anesthesiologists physical classification status (P = .82), and procedure performed (P = .74) were similar between groups. Only the distribution of sex varied between groups (P = .04; Table 2).

The mean PSA time was 78.7 ± 51.5 minutes for patients receiving midazolam and 32.5

Discussion

Patients who received propofol for PSA in the 2 community hospital emergency departments analyzed enjoyed a shorter PSA time and higher procedural success rate than those receiving midazolam while trending toward a shorter ED LOS without additional complications.

This study examined the association of PSA agent selection with ED efficiency, specifically PSA time. The duration of PSA directly affects available ED resources, primarily nursing time. Before and after a provider has completed the

Limitations

There are several limitations to this study. It is retrospective and, as such, is subject to the limitations of the data recorded at the time of the PSA. Practitioners were not randomized to a particular agent. There is a large disparity in the group sizes, which may indicate a bias toward the use of propofol. The differences in sex distribution between agents used, as well as missing data elements from the PSA registry, highlight the retrospective and nonrandomized nature of this analysis.

Implications for Emergency Nurses

The use of propofol for PSA in our 2 community emergency departments resulted in shorter durations of dedicated nursing time at the patient bedside. Both emergency departments and emergency nurses may benefit from the routine use of propofol for PSA, because a decrease in dedicated one-on-one nursing time could free up nursing resources to improve patient flow throughout the entire department.

Conclusion

In our PSA registry, adult patients in 2 US community hospital emergency departments who received propofol instead of midazolam for PSA had shorter PSA times and higher procedural success rates without additional complications. Future directions for this line of inquiry include a prospective randomized efficiency comparison of propofol and midazolam in adult patients to determine the reproducibility of this association between agent used and PSA time.

Joshua C. Reynolds is Clinical Instructor, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA.

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    • Propofol versus midazolam for procedural sedation in the emergency department: A study on efficacy and safety

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      This is accordance with previous publications, in which procedural sedation with propofol was associated with clinically relevant shorter sedation times compared to procedural sedation with midazolam [7,9-11]. Although we did not measure time to discharge in our current study (since this was not recorded on the sedation registry forms), previous studies have demonstrated that patients sedated with propofol for procedures in the ED could be discharged from the ED up to 40 min earlier compared to patients receiving midazolam for PSA [8-10]. This is something to consider in the current era of ED-crowding.

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    Joshua C. Reynolds is Clinical Instructor, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA.

    Michael K. Abraham is Clinical Assistant Professor, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD.

    Fermin F. Barrueto Jr is Clinical Associate Professor, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD.

    Daniel L. Lemkin is Assistant Professor, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD.

    Jon M. Hirshon is Associate Professor, Department of Emergency Medicine and Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD.

    Earn Up to 8.5 CE Hours. See page 520.

    Section Editor: Allison A. Muller, PharmD, D.ABAT

    Dr Hirshon was supported by US National Institutes of Health–National Heart, Lung and Blood Institute Career Grant 5K08HL073849.

    Submissions to this column are encouraged and may be sent to Allison A. Muller, PharmD, D.ABAT [email protected]

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