This POTD was requested by one of our sim fellows and new attendings, Vishnu Muppala, who wanted to know what the literature was on different medications for procedural sedation, particularly for orthopedic reductions (fractures/dislocations). So let's dive in.
To start off, let's talk about procedural sedation. There's a few agents that we commonly use in the ED.
The doses and pros/cons of each are nicely summed up in this table from our very own Reuben Strayer:
(https://emupdates.com/emergency-department-procedural-sedation-checklist-v2/)
The above link also has a bunch of info on how to set up for a procedural sedation and what to do if things go wrong.
But today, we're diving into the literature on which one is best for orthopedic procedures. In my experience, our ortho colleagues often times want us to use midazolam, but we often want to use propofol or "ketofol", which is a mix of ketamine and propofol. So is one better than the other?
In a 2015 RCT from Hatamabadi et al., they examined the safety profile and the time it takes from induction to fully awake (aka probably good for dispo) between propofol vs midazolam. In this study, it was found that the safety profile was similar between the two, but propofol had a significantly shorter time from induction to awakening.
In another RCT (Taylor et al., 2005), propofol was compared with midazolam/fentanyl in shoulder dislocation reductions. Again in this study, propofol was found to have shorter time to awakening. Also, this study found that propofol led to easier shoulder reductions and fewer reduction attempts. There was no statistically significant difference between their safety profiles. Another point for propofol!
One last RCT I found compared a combination of ketamine and propofol to a combination of midazolam and fentanyl (Nejati et al., 2011). In this study, the ketofol group had lower perceived pain compared to the midazolam/fentanyl group. In this study, both groups had similar sedation time and safety profiles.
However, in the only systematic review I could find comparing the two, there was no difference in safety nor in the effectiveness between the two (Holh, et al., 2008). Of note though, they could only find 4 RCTs looking at effectiveness, and only 2 of them were graded as "good" by the authors. Also, this wasn't specifically for ortho procedures but for all procedural sedations. So maybe not the best sample for our clinical question.
My conclusions that I gathered from this quick lit review is that is seems like propofol is more effective, takes less time for the patient to wake up, and (ketofol) leads to less pain than midazolam. Both medications, in the purposes of these RCTs, seem to have similar safety profiles. However, as with many things, more data is required to make a stronger conclusion.
Resources:
Hatamabadi HR, Arhami Dolatabadi A, Derakhshanfar H, Younesian S, Ghaffari Shad E. Propofol Versus Midazolam for Procedural Sedation of Anterior Shoulder Dislocation in Emergency Department: A Randomized Clinical Trial. Trauma Mon. 2015;20(2):e13530. doi:10.5812/traumamon.13530
Taylor DM, O'Brien D, Ritchie P, Pasco J, Cameron PA. Propofol versus midazolam/fentanyl for reduction of anterior shoulder dislocation. Acad Emerg Med. 2005;12(1):13-19. doi:10.1197/j.aem.2004.08.039
Nejati A, Moharari RS, Ashraf H, Labaf A, Golshani K. Ketamine/propofol versus midazolam/fentanyl for procedural sedation and analgesia in the emergency department: a randomized, prospective, double-blind trial. Acad Emerg Med. 2011;18(8):800-806. doi:10.1111/j.1553-2712.2011.01133.x
Hohl CM, Sadatsafavi M, Nosyk B, Anis AH. Safety and clinical effectiveness of midazolam versus propofol for procedural sedation in the emergency department: a systematic review. Acad Emerg Med. 2008;15(1):1-8. doi:10.1111/j.1553-2712.2007.00022.x