CAEP/ACMU 2000 Scientific Abstracts: 58-60

CAEP Abstracts

CJEM 2001;2(3):169-187

058 Ketamine vs. Fentanyl/Midazolam for Procedural Sedation in Intravenous Drug Users.
Innes G, Grafstein E, Christenson JM, Roland K. St. Paul's Hospital, University of British Columbia, Vancouver, BC.

OBJECTIVES: To compare the safety and adverse effects of fentanyl/midazolam (F/M) vs. ketamine (ket) procedural sedation (PS) in injection drug users (IDUs).

METHODS: All patients undergoing PS in our inner city ED have medications, vital signs and adverse events recorded in real time on an explicit procedural sedation record. We reviewed PS records from all IDUs who underwent PS from Jan. 1997 to Oct. 1999. RESULTS: Of 163 patients, 50 received IV ket and 113 received F/M. Females comprised 58% of the ket group and 42% of the F/M group. Other baseline parameters including age (mean = 33.3), pulse, RR, BP and O2 saturation were similar between groups. The most common procedures were abscess drainage (76 vs. 73%) and shoulder relocation (10 vs. 14%) in the ket and F/M groups respectively. Median ketamine dose was 75 mg (IQR, 50­100). Most (49/50) ket patients received midazolam pre-treatment (median 4 mg; IQR = 2­4.75), and 26 received supplementary fentanyl (median 100 ug; IQR = 0­250). Nadir systolic BP fell below 90 mm Hg in 3 ket patients (6%) and 15 F/M patients (13%). Nadir O2 saturation fell below 90% in 3 ket patients (6%) and 6 F/M patients (5%). Six ketamine patients (12%) suffered emergence reactions, 3 requiring benzodiazepine treatment. Reactions included agitation (3) and transient delirium (3). One other patient described "weird" but pleasant dreams. In the F/M group, median fentanyl and midazolam doses were 300 ug (IQR, 200­500) and 4 mg (IQR 3­6). Six F/M patients (5%) suffered AEs, including agitation (3), hypoventilation requiring bagging (2) and prolonged hypotension (1). No patients required intubation and none suffered significant or ongoing morbidity. ED length of stay was 140 minutes (IQR, 92­191) in the ketamine group and 98 minutes (IQR, 59­162) in the F/M group. CONCLUSIONS: IV ketamine has fewer adverse hemodynamic and ventilatory effects but is associated with longer ED lengths of stay. It causes emergence agitation that is transient and easily treated.
Key words: procedural sedation, intravenous drug user, ketamine, fentanyl, midazolam

059 Factors Predicting ED Patients' Perception of Inadequate Analgesic Treatment: A Logistic Regression.
Lee J, Stiell I, Hobden E, Nuth J, Wells G. Clinical Epidemiology Unit, University of Ottawa, Ottawa.

OBJECTIVES: Little data exist regarding factors associated with ED patients' perceptions of the effectiveness of their analgesic treatment. The objective of this study was to explore factors associated with patients' perceptions of inadequate treatment of acute pain.
METHODS: Logistic regression data were collected as part of a prospective observational study. Adult patients presenting to a teaching hospital ED with acute pain (renal colic, migraines, extremity injuries, and abdominal and back pain of less than 72 hours duration) were eligible. Patients who provided informed consent were asked to rate their pain severity on a 100-mm horizontal Visual Analog Scale (VAS). At discharge, the VAS was repeated and patients were asked whether they had received adequate pain treatment. Logistic regression was used to explore factors associated with the patients' perceptions of inadequate analgesic therapy, using automated stepwise procedures to select the final model. A significance level of 0.05 was required for model entry.
RESULTS: 124 patients were enrolled: the mean age was 36 years and 66 were female (53%). Presenting complaints included abdominal pain (36%), extremity pain (38%), back pain (12%) and other (14%). Inadequate analgesia was reported by 26/124 patients (21%). Variables predictive of perceived inadequate treatment, their odds ratios, and 95% CIs were: 1) "reduction in VAS per 10 mm" (OR 0.7, 95% CI 0.9­0.6) and 2) "female gender" (OR 3.8, 95% CI 1.4­10.6). Age, presenting complaint, waiting time, and if analgesics were ordered did not enter the model. The Hosmer­Lemeshow statistic was 2.5, (p = 0.96 to reject hypothesis of good fit). CONCLUSION: A significant number of ED patients have inadequate pain control. Change in pain severity on VAS and gender may be associated with perceived adequacy of pain control, however further study is warranted.
Key words: analgesia, visual acuity scale

060 Code School: Applied Use of a Computer-Operated Patient Simulation Manequin to Teach Post Graduate Year One (PGY-1) Residents.
Rabin EA, Rosenblum RM, Lund AJ, Brindley P, Paul T. University of Alberta, Edmonton, Alta.

OBJECTIVES: PGY-1 residents act as code team leaders during Coronary Care Unit (CCU) rotations. Residents prepare for this role by completing the Advanced Cardiac Life Support (ACLS) course prior to residency. In ACLS, algorithms are memorized and practiced in controlled and unrealistic situations using rhythm generators. There is a gap between ACLS and acting as code team leader in the hospital setting. The objective of this project was to develop and evaluate an innovative method of delivering this educational requirement using a computerized patient simulator. Educational Intervention: The PGY-1 Code School was designed to provide a practical review of ACLS and related skills. The course outlines roles and responsibilities of the multidisciplinary code team and teaches leadership skills. There is time reserved for hands-on experience leading mock codes on a computer-operated patient simulator that provides a unique, realistic and real time environment for the learner. Evaluation: The two day PGY-1 Code School allows for the training of 48 students each week. The pilot course will run in the summer of 2000. PGY-1 residents will be surveyed with questions related to perceived knowledge, experience and confidence in running cardiac codes. The answers of those who have participated in a CCU rotation without the Code School preparation will be compared to those who have completed the Code School. CONCLUSION: PGY-1 Code School is designed to bridge the gap between training and clinical reality, and to facilitate the acquisition of leadership skills. The program evaluation will probe for evidence of the effectiveness of such a course in enhancing the skills, knowledge, multidisciplinary teamwork and confidence of residents.
Key words: medical education, resuscitation, ACLS