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Sedation Using a One-Physician/One-Nurse Model Is Safe for Orthopedic Procedures

Summary and Comment |
March 8, 2013

Sedation Using a One-Physician/One-Nurse Model Is Safe for Orthopedic Procedures

  1. Diane Birnbaumer, MD, FACEP

This supports the recent change in recommendations reducing the number of physicians required for procedural sedation from two to one

  1. Diane Birnbaumer, MD, FACEP

To evaluate the safety of a one-physician/one-nurse model for procedural sedation for orthopedic reductions, researchers reviewed records for 435 patients who underwent reduction of fractured forearms or dislocated shoulders, hips, or elbows at three community emergency departments during an 18-month period. Procedures were performed by attending physicians while nurses administered medications; all nurses were trained and certified in procedural sedation.

Sedative agents used included propofol, etomidate, ketamine, methohexital, and midazolam in 303, 67, 57, 17, and 13 cases, respectively (some patients required a second reduction). Adverse events (predefined as events requiring airway interventions, reversal agents, anti-dysrhythmic agents, or chest compressions) occurred in 12 patients (2.8%). Respiratory complications included apnea (1 patient) and ventilator insufficiency (8); all patients responded to airway maneuvers or brief bag-valve-mask ventilation. Two patients developed hypotension: one responded to intravenous (IV) fluids and the other to flumazenil IV. No patient required endotracheal intubation and no complication resulted in prolonged observation or hospital admission.

Comment

The Centers for Medicare and Medicaid Services (CMS) and the American Society of Anesthesiology initially recommended that two physicians be involved in these cases: one to perform the procedure and the second to monitor the sedation. Since then, based on studies such as this one, the CMS and the American College of Emergency Physicians have supported the change to the one-physician/one-nurse model. Now, if only the ASA would follow suit.

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