The Utility of Supplemental Oxygen During Emergency Department Procedural Sedation and Analgesia With Midazolam and Fentanyl: A Randomized, Controlled Trial

Study objective To determine whether supplemental oxygen reduces the incidence of hypoxia by 20% in study patients receiving midazolam and fentanyl for emergency department procedural sedation and analgesia. Methods Patients were randomized to receive either supplemental oxygen or compressed air by nasal cannula at 2 L per minute. Physicians were blinded to the gas used and end-tidal carbon dioxide (etco2) data. Respiratory depression was defined a priori as oxygen saturation less than 90%, etco2 level greater than 50 mm Hg, an absolute change from baseline of 10 mm Hg, or loss of the etco2 waveform. Results Of the 80 patients analyzed, 44 received supplemental oxygen and 36 received compressed air. Twenty supplemental oxygen patients and 19 compressed air patients met at least 1 criterion for respiratory depression. Six supplemental oxygen patients and 5 compressed air patients experienced hypoxia (P=.97; effect size 0%; 95% confidence interval –15% to +15%). Fourteen patients in each group met etco2 criteria for respiratory depression but were not hypoxic. Physicians identified respiratory depression in 8 of 11 patients who became hypoxic and 0 of 28 patients who met etco2 criteria for respiratory depression but who did not become hypoxic. There were no adverse events. Conclusion Supplemental oxygen did not reduce (or trend toward reducing) the incidence of hypoxia in patients moderately sedated with midazolam and fentanyl. However, our lower-than-expected rate of hypoxia limits the power of this comparison. Blinded capnography frequently identified respiratory depression undetected by the treating physicians.