Short-acting agents for procedural sedation and analgesia (PSAs) propofol, ketamine HCl, etomidate, and ketamine combined with low-dose propofol (ketofol).
Adults who present to emergency departments (EDs) for painful procedures (i.e., treatment for bone fractures, major joint dislocations, cardioversion, and other procedures).
Short-acting agents have been perceived as superior to traditional agents, but uncertainty still remains regarding the optimal use of these agents, partly due to the lack of a comprehensive technology assessment in a Canadian context.
Methods and Results
A systematic review and survey of Canadian practice patterns was conducted. A systematic review of studies that compared short-acting procedural sedation drugs with one another or with conventional opioid and benzodiazepine agents for adult ED PSA was also conducted. Forty-four studies (nine randomized clinical trials, one prospective cohort, and 34 case series studies) were included:
32 evaluated propofol, 13 etomidate, 12 midazolam, nine ketamine, and two ketofol. A cost-minimization analysis was conducted. Propofol, etomidate, ketamine, and ketofol yield cost savings per procedure of $335.70, $301.76, $244.41, and $243.47 respectively, compared with standard therapy.
Implications for Decision Making
- Clear differences exist between short-acting and traditional agents. Short-acting agents are at least as effective as other regimens in terms of procedural success and clearly more effective in terms of reduced procedure time. With the exception of etomidate, short-acting agents were associated with no additional risk of minor adverse events (AEs) (and some may argue fewer risks of AEs).
- Short-acting agents are associated with reduced costs. Propofol, etomidate, ketamine, and ketofol yield cost savings per procedure of $335.70, $301.76, $244.41, and $243.47 respectively, compared with standard therapy. Etomidate generates the greatest savings from a time and labour costing perspective, but savings associated with propofol are greater because the differences in hospitalization and AE rates costs more than offset the differences in labour costs.
- Opportunities for optimal usage exist. A survey of Canadian EDs revealed traditional agents are still in common usage. Opportunities may exist for the use of these agents by clinicians with less experience (e.g., rural physicians and nonphysician extenders, such as nurse practitioners and paramedics), given enough guidance or training.
This summary is based on a comprehensive health technology assessment available from CADTH’s web site (www.cadth.ca): Bond K, Fassbender K, Karkhaneh M, Spooner C, Horton J, Sivilotti MLA, Campbell SG, Vandermeer B, Tjosvold L, Seal R, Rowe BH. Short-Acting Agents for Procedural Sedation and Analgesia in Canadian Emergency Departments: A Review of Clinical Outcomes