Procedural sedation in emergency departments: Efficacy and adverse outcomes from a systematic review and meta-analysis

BACKGROUND: Procedural sedation reduces pain, anxiety, and discomfort during emergency department (ED) procedures. Analgesics, sedatives and anxiolytics ensure patient comfort but can cause respiratory, cardiovascular, neurological, and gastrointestinal (GI) side effects. OBJECTIVES: To synthesize data on adverse events and procedural efficacy from randomized controlled trials (RCTs) involving the use of different drugs/drug combinations used for procedural sedation. MATERIAL AND METHODS: A systematic literature review was conducted using MEDLINE and CENTRAL databases for RCTs that involved adult patients who were administered drugs for procedural sedation in the ED. Outcomes such as hypoxia, hypotension, apnea, agitation, GI disturbances (nausea, vomiting), and bradycardia/dysrhythmia were extracted from the trials. A meta-analysis was performed using OpenMeta (Analyst) software to determine the pooled incidence of each adverse outcome and procedural success for the different drugs and drug combinations. RESULTS: A total of 50 RCTs were included in the meta-analysis with information from 5,398 patients. Meta-analysis of the data showed a pooled incidence of 136 events/1,000 sedations (95% confidence interval (95% CI): 112-160) for hypoxia, 23 events/1,000 sedations (95% CI: 15-31) for hypotension, 143 events/1,000 sedations (95% CI: 110-177) for agitation, 51 events/1,000 sedations (95% CI: 38-64) for apnea, 45 events/1,000 sedations (95% CI: 30-60) for GI disturbances, and 30 events/1,000 sedations (95% CI: 19-41) for bradycardia/dysrhythmia. The procedural success rate was 921 events/1,000 sedations (95% CI: 896-946). CONCLUSION: The results of this meta-analysis shed light on the adverse effects of various procedural sedation agents used for different procedures in the ED. Ketamine-propofol combinations were associated with less hemodynamic instability, whereas propofol caused hypotension and respiratory events and GI disturbances were associated with the administration of fentanyl and ketamine. Thus, individual patient factors such as age and comorbidities and the risk profile of different agents should be considered during procedural sedation protocols. This meta-analysis summarizes the side effects of several drugs to help physicians administer them safely.