Shiraz E-Med J. 2020 September; 21(9):e96024. Published online 2020 September 6. doi: 10.5812/semj.96024. Systematic Review Midazolam, Etomidate, Propofol, Fentanyl, Ketamine, and Propofol/Ketamine for Procedural Sedation and Analgesia Among Adults in the Emergency Departments: A Systematic Review Maryam Massaeli 1 , Soheil Nasouhi 1 , Afshin Motallebzadeh 2 and Masoud Shahabian 1, * 1 Department of Emergency Medicine, AJA University of Medical Sciences, Tehran, Iran 2 Department of Cardiac Surgery, Razavi Hospital, Mashhad, Iran * Corresponding author: Resident, Department of Emergency Medicine, AJA University of Medical Sciences, Tehran, Iran. Email: elmpajooh.ac.ir@gmail.com Received 2019 July 10; Revised 2020 February 24; Accepted 2020 February 28. Abstract The current systematic review aimed at investigating different medications commonly used for procedural sedation and analgesia (PSA) in emergency departments (EDs) for adults. The articles related to the subject of interest were searched in five electronic databases, including Google Scholar, PubMed, Medline, Web of Science, Scopus, and Embase, up to 2019. The blinded, randomized, controlled, clinical trials comparing common PSA medications, including midazolam, etomidate, propofol, fentanyl, ketamine, and ketofol, among the adults undergoing PSA in EDs were included in the study. The search process resulted in the inclusion of 35 papers in the study. The main information, including clinical features, sedation duration, recovery time, and incidence of adverse events, was extracted from the selected studies. Based on the reviewed studies, various combinations of medications are used for PSA depending on the hospital protocols and policies; however, there is still controversy over the best choice. As the results of the retrieved articles indicated, propofol is the most common medication used for PSA in EDs due to the shorter time of induction, rapid recovery of consciousness, and fewer side effects. Etomidate and ketamine were also identified as other common sedatives applied for PSA. Keywords: Procedural Sedation, Emergency Department, Midazolam, Etomidate, Propofol, Ketofol 1. Context Procedural sedation and analgesia (PSA) is commonly used in emergency departments (EDs) to facilitate the im- plementation of potentially painful procedures (1). Pa- tients undergoing painful procedures need moderate or deep procedural sedation to achieve appropriate thera- peutic outcomes; accordingly, the provision of all levels of sedation in ED is necessary (2). The PSA can be induced by a wide range of medications, such as midazolam, etomidate, propofol, fentanyl, ketamine, and propofol/ketamine-i e, ketofol. Some short-acting sedative agents, such as propo- fol (3), etomidate, (4), and ketamine, are extensively ap- plied for PSA in EDs (3). These agents allow patients to maintain their airway reflexes and respond to verbal stim- uli. In this regard, the use of short-acting sedative agents that provide adequate sedation with minimum adverse ef- fects is optimal (5). Propofol is a non-opioid, non-barbiturate, sedative- hypnotic agent that has a rapid onset of action and short recovery time (6). The onset time of propofol action is ap- proximately 45 seconds, and its redistribution time from the blood to the fat and muscles ranges 3 - 5 minutes (5, 7, 8). Ketamine is an analgesic and sedative agent with amnestic properties, derived from phencyclidine. This agent facili- tates the preservation of the muscle tone and protection of the airway reflexes and spontaneous respiration (9). More- over, ketamine is effective in preventing injection pain (10, 11) and improving hemodynamic depression caused by propofol (12). The possible side effects of ketamine include emergence phenomena, postoperative dysphoria, vomit- ing, or laryngospasm (13-15). However, the combined use of ketamine and propofol can decrease the dose-dependent side effects of these agents (15). Ketofol is commonly used in the bolus form in EDs, operating rooms, and ambulatory settings (15-17). Etomidate is another ultrashort-acting sedative agent with an action onset of approximately one minute and an action duration of 5 - 15 minutes. This sedative has the least hemodynamic effect in comparison with other PSA agents (5). The main problems of this agent include Copyright © 2020, Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.