Recall after procedural sedation in the emergency department

Abstract

Background: Procedural sedation (PS) is common in the emergency department (ED) and ideally patients should have no recall of the procedure. Aim: To determine the incidence of recall. Methods: A prospective observational study in an university ED of all patients undergoing PS. Data were collected on a pre-formatted data sheet. Levels of satisfaction with the sedation by the treating physician and nurse were recorded on a 10 cm visual analogue scale. On recovery, the patient was asked a validated questionnaire to determine the rate of immediate recall and at telephone follow-up for delayed recall. Results: 125 patients (88 male, 70%) were enrolled and 110 had completed follow-up. Mean (range) age was 51.6 (13-91) years. Procedures included 84 (67%) orthopaedic reductions and 41 (33%) cardioversions. A wide range of drug combinations were used, including fentanyl/propofol 32 (25.6%), fentanyl/midazolam 30 (24%), fentanyl/midazolam/propofol 16 (12.8%), propofol 13 (10.4%). 87.2% of procedures were successful. A grimace/groan was observed in 61 of 125 (49%). Immediate recall occurred in 9 of 121 (7.4%; 95% CI 3.7 to 14.0) and delayed recall in 5 of 110 (4.5%; 95% CI 1.7 to 10.8). No drug combination was correlated with recall (Spearman's rho = 0.149), nor the presence of a grimace/groan (r = 20.039). Median sedation satisfaction scores were physician 9.0, nurse 10, patient 10. Correlation of delayed recall with patient satisfaction was -0.471 (p,0.001). Conclusions: Recall following PS in ED is uncommon. There is no association of recall with drugs used or the presence of a grimace/groan. There is high patient satisfaction with PS in the ED.

Procedural sedation and recall in the emergency department: the relationship between depth of sedation and patient recall and satisfaction (a pilot study)

“…Recall and satisfaction has been reported to be a complex and multidimensional relationship 1. The preliminary results reported here suggest a simpler relationship between patient satisfaction and recall (figure 1B).…”

“…Procedural sedation is commonly used in emergency medicine 1. Few studies have explicitly measured recall after sedation in the emergency department (ED), but it is reported to be higher than after general anaesthesia 1.…”

“…Few studies have explicitly measured recall after sedation in the emergency department (ED), but it is reported to be higher than after general anaesthesia 1. To our knowledge, no study has specifically examined the relationship between depth of sedation, subsequent recall, pain perception and the potential influence of these on patient satisfaction.…”

Procedural sedation: what would the patient like?

“…Analysis of the emergency medicine literature reveals widely varying recall rates: 7%,1 12%–13%,2 12%–16%,3 65%4 and 90% 5. More importantly, patients reporting painful recall of the procedure on return to baseline mental status has been recorded as 2%–6%,2 10%–14%3 and 30% 4.…”

“…More importantly, patients reporting painful recall of the procedure on return to baseline mental status has been recorded as 2%–6%,2 10%–14%3 and 30% 4. In a randomised controlled trial comparing sedation with ketamine versus propofol by Miner et al , patients recall of any pain during the procedure was 2% of those randomised to ketamine and 6% of those given propofol; all reported 100% satisfaction with the treatment they received during the procedure 1. In an earlier randomised controlled trial targeting deep sedation, Miner et al recorded painful recall more often: in 9.9% of those patients given 1 mg/kg propofol and 10 μg/kg alfentanil, and in 13.5% in those given propofol alone 3.…”