Case Present EBM 2009312

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Case Present - EBM2009/3/12

• Present R1???
• Supervisor VS???

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Basic Information

• Name??O?
• Chart No. 27143997
• Age 72
• Gender female
• Ethnic origin ??
• Date of admission 98/02/28

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Chief Complaint

• Progressive short of breathe in recent 3 days

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Present Illness

• Chronic dizziness, cough for a period of time
• Dyspnea on exertion and intermittent palpitation
• No fever, no chills, no chest pain
• Right hip pain for long time

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Past History

• Hypertension for 10 years with regular
  medication control
• Right OA hip
• Surgical history
• Left septic hip s/p 10 years ago

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Personal History

• Smoking (-)
• Alcohol consumption (-)
• Herbal (-)
• No food or drug allergy history

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Physical Examination

• Vital sign T/P/R37/86/18, BP 126/75mm-Hg
• Consciousness Clear
• HEENT No abnormality
• Chest Bilateral coarse breathing sounds
• Heart Regular heart beat, no murmur
• Abdomen Soft, not distended, no tenderness, no
  rebounding tenderness, normoactive bowel sound
• Right leg pitting edema

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Examinations at ER

• CBC/DC, BCS, PT/aPTT, Cardiac enzyme, B/C x2,
  ABG, EKG, CXR

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Chest X-ray
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EKG

• Non-specific ST-T changes
• Poor R-wave progress
• Right axis deviation
• S1Q3
• Incomplete RBBB pattern

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Lab data on 2/27
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Lab data on 2/27
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Impression

• 1. Suspect COPD with AE
• 2. HTN

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After admission 2nd day

• Consciousness change(acute delirium) was noted in
  the evening on 2/28
• No tachypnea, no wheezing
• No chest pain
• No cold sweating

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2/27 Chest X-ray 2/28
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Lab data on 2/28
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• On endo
• Transfer to ICU
• Patient became clear with adequate response late
  at night in ICU

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Problem and PICO

• Problem
• Which one is better for procedure sedation?
  Midazolam or Propofol
• PICO
• P Procedure sedation
• I Midazolam
• C Propofol
• O Safety and Effectiveness

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Database and search key words
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Search result
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Paper appraised
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Objective

• To synthesize the evidence comparing the adverse
  event profile and clinical effectiveness of
  midazolam and propofol for procedural sedation in
  adults in the emergency care setting.

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Methods

• Systematic review of RCTs and observational
  studies reporting the use of either midazolam and
  / or propofol for adult PS in the emergency
  department

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Result

• Of 229 articles identified, 28 met the inclusion
  criteria for the analysis of AEs
• Four studies were RCTs that met the inclusion
  criteria for the analysis of clinical
  effectiveness
• Two trials met criteria for good quality

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Result

• Two of the four pooled RCTs were rated with Jadad
  scores of 2, and two were rated with scores of 3
• All trials were randomized, but only three trials
  reported adequate methods for randomization
• None of the trials were double-blinded

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Result- Data analysis

• Primary outcome analysis AE
• Secondary outcome analysis Successful PS
• Sensitivity analysis

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Successful PS
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Sensitivity analysis
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Level 1a?
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Conclusion

• The authors found no significant difference in
  the safety profile and the proportion of
  successful PS between midazolam and propofol for
  adults in the ED

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Thanks for listening!