What are common sedation regimens?

Updated: Nov 06, 2018
  • Author: Arul M Lingappan, MD; Chief Editor: Erik D Schraga, MD  more...
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Benzodiazepines and barbiturates (in combination with an analgesic) are proven to be effective sedative agents. This section focuses on the effectiveness of some of the newer agents when compared with other sedatives and analgesics.

The use of propofol in procedural sedation has been gaining increasing popularity since the 1990s. Many studies have proven its utility as an effective agent. Havel et al showed that the sedation scores and rates of oxygen desaturation between propofol and midazolam were similar within the pediatric population, with equal complication rates. [50] A recent systematic review among adult patients showed no difference in procedural sedation success when comparing propofol and midazolam, and neither agent showed a significant risk of major adverse events. [51]

Another study performed by Miner et al randomized patients into a methohexital/morphine or a propofol/morphine group for ED fracture reduction. The 2 groups were equally efficacious at providing adequate sedation (as measured by the BIS) and had statistically similar rates of respiratory depression. [52] Similar study results were seen in another randomized trial that compared propofol with etomidate and midazolam during cardioversion. [53]

Taylor et al had equally good results when comparing propofol to midazolam/fentanyl in patients who required shoulder reduction, with shorter recovery times in the former group. [8] Some potential limitations to propofol usage do exist. Taylor et al expressed concern over respiratory depression. Clinicians must exercise caution when administering propofol to patients with cardiovascular or pulmonary disease. Under those circumstances, etomidate may be a better alternative.

Etomidate is a safe and efficacious in the ED for procedural sedation. Like propofol, it has a quick onset and short duration of action. In a prospective, double-blinded trial, Burton et al compared midazolam with etomidate for shoulder reduction and found an equal success rate between the 2 groups, with no cardiopulmonary complications. [54] Hunt et al [55] found fast sedation and recovery times with etomidate compared with other medications. Data on etomidate use in children have been limited, but it shows promise when compared to more popular sedatives like midazolam. [56]

The combination of ketamine and propofol, known as ketafol, has become increasingly popular in procedural sedation, partly because of their very divergent adverse event profiles. The combination also satisfies the sedation-amnestic-analgesia balance that is ideal in procedural sedation. It has been defined as a 1:1 mixture of ketamine 10 mg/mL and propofol 10 mg/mL. A prospective evaluation of ketafol showed 96% effectiveness at providing adequate sedation and analgesia. [57] The median recovery time of 15 minutes is comparable to other regimens with short recovery times. Adverse events were minor, and no episodes of hypotension were reported. [57] Ketafol will require larger, more rigorous comparative studies with other regimens to determine its role in procedural sedation.

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