Randomized Clinical Trial of Propofol With and Without Alfentanil for Deep Procedural Sedation in the Emergency Department

Objectives: The objectives were to compare the efficacy, occurrence of adverse events, and recovery duration of propofol with and without alfentanil for use in procedural sedation in the emergency department (ED). Methods: This was a randomized nonblinded prospective trial of adult patients undergoing procedural sedation for painful procedures in the ED. Patients with pain before the procedure were given intravenous (IV) morphine sulfate until their pain was adequately treated at least 20 minutes before starting the procedure. Patients received 1 mg ⁄kg propofol either with or without a supplemental dose of 10 lg ⁄kg alfentanil for deep procedural sedation. Doses, vital signs, nasal end-tidal CO2 (ETCO2), pulse oximetry, and bispectral electroencephalographic (EEG) analysis scores were recorded. Subclinical respiratory depression was defined as a change in ETCO2 of >10 mmHg, an oxygen saturation of <92% at any time, or an absent ETCO2 waveform at any time. Clinical events related to respiratory depression were noted during the procedure, including the addition of or increase in the flow rate of supplemental oxygen, the use of a bag-valve mask apparatus, airway repositioning, or stimulation to induce breathing. After the procedure, patients were asked if they experienced pain during the procedure or had recall of the procedure. Results: A total of 150 patients were enrolled; 146 underwent sedation and were included in the analysis. Seventy-four patients received propofol, and 71 received propofol with alfentanil. No clinically significant complications were noted. Subclinical respiratory depression was seen in 24 ⁄74 patients in the propofol group and 30 ⁄71 patients in the propofol ⁄alfentanil group (effect size = 9.8%, 95% CI = ‐5.8% to 25.5%). Clinical signs of respiratory depression included an increase in supplemental oxygen use in 25 of the 74 propofol patients and 31 of the 71 propofol ⁄alfentanil patients (effect size 9.9%, 95% CI = ‐5.9% to 25.7%), the use of bag-valve mask apparatus in seven patients in the propofol group and 12 in the propofol ⁄alfentanil group (effect size = 5.6%, 95% CI = ‐3.5% to 18.4%), airway repositioning in 13 propofol patients and 20 propofol ⁄alfentanil patients (effect size = 10.6%, 95% CI = ‐3.0% to 24.2%), and stimulation to induce breathing in 11 propofol patients and 20 propofol ⁄alfentanil patients (effect size = 13.3%, 95% CI = 0.1% to 26.5%). The total time of the procedure was longer for the alfentanil ⁄propofol group (median = 11 minutes, range = 5‐22 minutes) than for the propofol group (median = 9 minutes, range = 1 to 43 minutes; effect size = 1.93 minutes, 95% CI = 0.73 to 2.58, p = 0.02). Pain during the procedure was reported by 10 of the 74 patients in the propofol group and 7 of the 71 patients in the propofol ⁄alfentanil group (effect size = 4.5%, 95% CI = ‐6.8% to 14.1%). Recall of some part of the procedure was reported by 12 patients in the propofol group and 9 in the propofol ⁄alfentanil group (effect size = 3.5%, 95% CI = ‐7.9% to 15.0%). All procedures were successfully completed. Conclusions: The use of supplemental alfentanil with propofol for procedural sedation did not result in a difference in reported pain or recall immediately after the procedure. There was an increase in the proportion of patients who required stimulation to induce respiration during the procedure in patients who received propofol with supplemental alfentanil. The addition of supplemental opioid to procedural sedation with propofol does not appear beneficial. ACADEMIC EMERGENCY MEDICINE 2009; 16:825‐834 a 2009 by the Society for Academic Emergency