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Objectives:To examine the safety of emergency department (ED) procedural sedation and analgesia (PSA) and the patterns of use of pharmacologic agents at a Canadian adult teaching hospital. Methods: Retrospective analysis of the PSA records of 979 patients, treated between Aug. 1, 2004, and July 31, 2005, with descriptive statistical analysis. This represents an inclusive consecutive case series of all PSAs performed during the study period. Results: Hypotension (systolic blood pressure ≤ 85 mm Hg) was documented during PSA in 13 of 979 patients (1.3%; 95% confidence interval [CI] 0.3%-2.3%), and desaturation (SaO 2 ≤ 90) in 14 of 979 (1.4%; CI 0.1%-2.7%). No cases of aspiration, endotracheal intubation or death were recorded. The most common medication used was fentanyl (94.0% of cases), followed by propofol (61.2%), midazolam (42.5%) and then ketamine (2.7%). The most frequently used 2-medication combinations were propofol and fentanyl (P/F) followed by midazolam and fentanyl (M/F), used with similar frequencies 58.1% (569/979) and 41.0% (401/979) respectively. There was no significant difference in the incidence of hypotension or desaturation between the P/F and M/F treated groups. In these patients, 9.1% (90/979) of patients received more than 2 different drugs. Conclusions: Adverse events during ED PSA are rare and of doubtful clinical significance. Propofol/fentanyl and midazolam/fentanyl are used safely, and at similar frequencies for ED PSA in this tertiary hospital case series. The use of ketamine for adult PSA is unusual in our facility.

P Pu ur rp po os se e: : The responsibility of acute airway management often falls into the hands of non-anesthesiologists. Emergency physicians now routinely use neuromuscular blockade to facilitate intubation. The literature in support of this practice has almost exclusively been published in emergency medicine (EM) journals. This body of literature is presented and issues of educational support are discussed.S So ou ur rc ce e: : A narrative review of the literature on the practice of airway management by non-anesthesiologists.P Pr ri in nc ci ip pa al l f fi in nd di in ng gs s: : A significant proportion of acute airway management occurring outside the operating room is being performed by non-anesthesiologists. Rapid sequence intubation (RSI) is recognized as a core procedure within the domain of EM. RSI is being performed routinely by emergency physicians practicing in larger centres. Anesthesiologist support for the practice of RSI by nonanesthesiologists has been weak. Formal educational support outside of postgraduate training in the form of dedicated programs for advanced airway management are now being offered. The majority of the literature on the use of RSI by non-anesthesiologists represents retrospective case series, observational studies and registry data published in EM journals. The reported success rates for RSI performed by non-anesthesiologists is high. Complication rates are significant, however reporting consistency has been poor. C Co on nc cl lu us si io on ns s: : The role of non-anesthesiologists in acute airway management is significant. Despite shortcomings in methodology, current evidence and practice supports the use of RSI by trained emergency physicians. Constructive collaborative efforts between anesthesiology and EM need to occur to ensure that educational needs are met and that competent airway management is provided. Objectif : La responsabilité de l'assistance respiratoire d'urgence revient souvent à des médecins non-anesthésiologistes. Les urgentistes utilisent maintenant de routine le bloc neuromusculaire pour faciliter l'intubation. La documentation à l'appui de cette pratique a été publiée presque exclusivement dans les journaux de médecine d'urgence (MU). Nous présentons l'ensemble de ces documents et exposons les questions de formation. Source : Une revue traditionnelle de la documentation sur la pratique de l'assistance respiratoire par des non-anesthésiologistes. Constatations principales : Une proportion significative de l'assistance respiratoire d'urgence, réalisée à l'extérieur de la salle d'opéra-tion, relève de non-anesthésiologistes. L'intubation en séquence rapide (ISR) est reconnue comme une intervention centrale dans le domaine de la MU. L'ISR est généralement réalisée par des urgentistes dans les grands centres. Le soutien anesthésiologique pour la pratique de l'ISR

This report describes local administration of submicron particle paclitaxel (SPP) (NanoPac®: ~ 800-nm-sized particles with high relative surface area with each particle containing ~ 2 billion molecules of paclitaxel) in preclinical models and clinical trials evaluating treatment of carcinomas. Paclitaxel is active in the treatment of epithelial solid tumors including ovarian, peritoneal, pancreatic, breast, esophageal, prostate, and non-small cell lung cancer. SPP has been delivered directly to solid tumors, where the particles are retained and continuously release the drug, exposing primary tumors to high, therapeutic levels of paclitaxel for several weeks. As a result, tumor cell death shifts from primarily apoptosis to both apoptosis and necroptosis. Direct local tumoricidal effects of paclitaxel, as well as stimulation of innate and adaptive immune responses, contribute to antineoplastic effects. Local administration of SPP may facilitate tumor response to systemically administered chemotherapy, targeted therapy, or immunotherapy without contributing to systemic toxicity. Results of preclinical and clinical investigations described here suggest that local administration of SPP achieves clinical benefit with negligible toxicity and may complement standard treatments for metastatic disease. Graphical abstract

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