title: Recovery from sedation with remifentanil and propofol, compared with morphine and midazolam, for reduction in anterior shoulder dislocation.
abstract: OBJECTIVE
  To compare recovery from sedation using remifentanil and propofol with our standard regimen of morphine and midazolam for closed reduction in shoulder dislocation in an ED.
  
  
  METHODS
  We randomised 40 patients for closed shoulder reduction to receive either remifentanil and propofol (R&P) (20 patients) or morphine and midazolam (M&M) (20 patients). A suitably trained ED doctor gave the sedation. R&P patients received oxygen from a tight-fitting facemask and Mapleson C circuit to prevent hypocapnia and thus reduce the risk of apnoea. Shoulder reduction was performed by another doctor with an ED nurse also present. We noted recovery times, pain and sedation scores, operative conditions, additional medication and adverse events.
  
  
  RESULTS
  All patients given remifentanil and propofol had recovered within 30 min in contrast to the morphine and midazolam group where 17 of 20 patients had recovered after 60 min, the remainder requiring a total of 90 min. Median recovery times were 15 min (95% CI 15 to 20) for the remifentanil and propofol group, and 45 min (95% CI 29 to 48) for the morphine and midazolam group. Reduction conditions and scores for pain/distress did not differ between the groups. Seven patients required additional sedation (four R&P, three M&M) to enable shoulder reduction. Five patients (three R&P, two M&M) had received analgesia prior to the procedure from the ambulance service (one R&P, one M&M) and ED (two R&P). Two patients given morphine and midazolam required flumazenil to counter oversedation.
  
  
  CONCLUSIONS
  Remifentanil and propofol reduces patient recovery time and provides equivalent operating conditions compared with morphine and midazolam for the reduction of anterior glenohumeral dislocation.
authors.affiliation: Emergency Department, The Royal Infirmary of Edinburgh, Edinburgh, UK.
authors.forename: Mark J G
authors.initials: MJ
authors.lastname: Dunn
authors.forename: Robin
authors.initials: R
authors.lastname: Mitchell
authors.forename: Cyrus I B
authors.initials: CI
authors.lastname: DeSouza
authors.forename: Gordon B
authors.initials: GB
authors.lastname: Drummond
authors.forename: Alasdair
authors.initials: A
authors.lastname: Waite
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000762:Anesthesia Recovery Period; D018686:Anesthetics, Intravenous / Q000627:therapeutic use; D016292:Procedural Sedation / Q000379:methods; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D008297:Male; D008874:Midazolam / Q000627:therapeutic use*; D008875:Middle Aged; D009020:Morphine / Q000627:therapeutic use*; D010147:Pain Measurement; D010880:Piperidines / Q000627:therapeutic use*; D015742:Propofol / Q000627:therapeutic use*; D000077208:Remifentanil; D012783:Shoulder Dislocation / Q000628:therapy*; D018709:Statistics, Nonparametric; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D018686:Anesthetics, Intravenous; D010880:Piperidines; D009020:Morphine; D000077208:Remifentanil; D008874:Midazolam; D015742:Propofol