Abstract:

Background and Objectives: Is there greater risk for adverse events (AEs) with emergency department (ED) procedural sedation (PS) in overweight/obese vs. non-obese patients?

Methods: 3,274 consecutive prospective ED PS (2000-2015) at an urban ED. AEs were complications: RR <8 or >20, sys BP 180, HR 100, SpO2 90%; plus side effects (SE): nausea, emergence reaction, paradoxical reaction, itching/rash, cough, myoclonus, hiccups. Statistics of outcomes included age, sex, ASA class, diagnosis, procedure performed, weight. BMI for groups included: underweight < 18.5, normal weight 18.5-24.9, overweight 25.0-29.9, obese >30.0. BMIs were adjusted for age and gender.

Results: Median age 45 years, 56% male. 28.9% ASA 1, 26.2% ASA 2, 38.1% ASA 3, 6.1% ASA 4, 0.8% ASA 5. Procedures: orthopedic 56.0%, fracture reduction 24.1%, dislocation reduction 31.9%, 25.3% cardioversion, 6.9% suturing, 2.4% I&D, 2.0% EGD, 1.7% LP, 5.7% other. Diagnoses: 31.9% dislocation, 25.0% arrhythmia, 24.1% fracture, 6.9% laceration, 2.5% foreign body, 2.3% abscess, 7.3% other. Sedatives: propofol 36.3%, ketamine 16.5%, ketofol 3.5%, etomidate 17.6%, barbiturates 4.3%, benzodiazepines 6.5%, combinations 15.3%. Analgesics: IV opioids 56.9%, po 35.8%, IV & po 8.4%. Interventions (4.5%) were airway maneuvers: suctioning, repositioning: jaw thrust/chin lift, non-rebreather mask, bag-valve mask, nasopharyngeal, intubation; medications and/or IV fluid bolus. Medications given: diphenhydramine, solumedrol, narcan, atropine. One overweight patient was intubated (0.03%). She was extubated in < 5 minutes, at baseline, and discharged home 88 minutes after the intubation. AEs were easily treated and no patient needed vasopressors, CPR or admission. The SEs, complications, AEs, and interventions for groups:
Underweight (n = 497): 4.2%, 2.8%, 6.8%, 1.6%
Normal weight (n = 738): 4.6%, 13.4%, 17.5%, 4.2%
Overweight (n = 772): 5.3%, 20.1%, 23.2%, 5.2%
Obese (n = 752): 4.4%, 20.6%, 24.3%, 7.3%
All patients (n = 2,759): 4.7%, 15.3%, 19.1%, 4.9%
AEs, complications, and interventions were significantly different between the BMI groups (p < 0.0001). SEs were not significantly different (p = 0.784). As BMI increased, so did the percentages of AEs, complications, and interventions.

Conclusion: Overweight/obese patients have a significantly greater risk of AEs and a greater need for interventions, yet can safely and effectively undergo ED PS.