Impact of timing of pre-procedural opioids on adverse events in procedural sedation.

BACKGROUND Risk of respiratory depression is increased when opioids are added to sedative agents. In our recent multi-center emergency department (ED) procedural sedation cohort we reported a strong association between pre-procedural opioids and sedation-related adverse events. We sought to examine the association between timing of opioids and the incidence of adverse sedation outcomes. METHODS We conducted a secondary analysis of a prospective cohort of children aged 0-18 years who received sedation for a painful procedure in six Canadian pediatric EDs from July/2010-Feb/2015. Primary Risk Factor: timing of opioid administration; adjusted for age, opioid type, pre-procedural and sedation medications, and procedure type. OUTCOMES a) oxygen desaturation, b) vomiting and c) positive pressure ventilation (PPV). RESULTS Of the 6,295 children in the original cohort, 1,806 (29%) received a pre-procedural opioid. Patients receiving pre-procedural opioids had a higher incidence of oxygen desaturation (risk difference 4.3%, 95%CI 2.9 to 5.8%), vomiting (risk difference 2.0%, 95%CI 0.7 to 3.3%) and PPV (risk difference 1.5%, 95%CI 0.7 to 2.3%). Multivariable regression with timing of opioids modeled as a restricted cubic spline revealed the risk for each outcome was highest when opioids were administered in the 30 minutes prior to sedation. Timing of opioid administration was statistically significantly associated with oxygen desaturation and vomiting (p<0.0001) but not with PPV (p=0.113). CONCLUSION Timing of opioids was significantly associated with the risk of oxygen desaturation and vomiting. Being aware of this increased risk will help clinicians prepare for sedation and the potential need for patient rescue.

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