T HE I NCIDENCE AND T REATMENT OF P REHOSPITAL M OTION S ICKNESS

Objectives. The authors' objectives were: 1) to determine the incidence of motion sickness during ambulance transport on a mountainous route in healthy volunteers, and 2) to determine if droperidol alleviated the signs and symptoms of motion sickness in those volunteers who developed it. Methods. This was a prospective, randomized, double-blind, placebo-controlled trial. Subjects were healthy volunteers over age 18 and not currently taking an antiemetic. Participants were transported in the back of an ambulance over a mountainous road. Those who developed motion sickness rated their nausea on a 100-mm visual analog scale (VAS) and were randomized to receive placebo (saline) or 2.5?mg droperidol intravenously. Symptoms were recorded on a VAS every 5 minutes until the end of the transport. Incidence of motion sickness was calculated as a percentage with 95% confidence intervals (CIs). Pretreatment characteristics were compared with chi-square tests, and mean VAS scores were compared using t-tests. Results. Thirty-seven subjects completed the study. Sixteen (43%, 95% CI = 27%?59%) developed motion sickness. Fifteen were randomized and completed data collection. Eight received droperidol (mean baseline VAS, 45) and seven received placebo (mean baseline VAS, 40). Droperidol trended toward a greater mean reduction of nausea than placebo at 5 minutes (20 versus 4, p = 0.077). Conclusions. The incidence of motion sickness during ambulance transport in a mountainous setting is substantial. There was a strong trend toward a positive treatment effect with droperidol. Further prospective study in an actual patient setting is warranted.     

Do oxygen-enriched atmospheres exist beneath surgical drapes and contribute to fire hazard potential in the operating room?

The purposes of this study were to (1) describe the microenvironment in terms of oxygen concentration beneath the drapes of healthy subjects who were simulating patients undergoing minor surgical procedures with supplemental oxygen and to (2) evaluate the efficacy of using a scavenger system beneath the drapes. A convenience sample of 12 healthy volunteer subjects was studied in an ambulatory surgery center operating room, which was ventilated with 25 air exchanges per hour. The study was carried out in 2 parts. Each subject was supine, and oxygen was applied by a standard nondivided nasal cannula. The subjects were draped as routinely done for ophthalmic procedures. Oxygen concentrations were measured by using an Ohmeda Rascal II gas analyzer beneath the drapes and at the hypothetical surgical site with oxygen flow rates of 0, 1, 2, 3, and 4 L/min, allowing 5 minutes to elapse after a change in flow rate was made. Following a 10-minute break, the subjects were redraped, and the procedure was repeated using a scavenger system consisting of a suctioning system connected to wall suction at 170 to 190 mm Hg. Although the mean +/- SD oxygen saturation never fell below 95% (97.75% +/- 1.54%), mean +/- SD oxygen concentrations beneath the drapes were lower than normal room air concentrations (19.08% +/- 0.51%) when no oxygen was delivered to the patient. With supplemental oxygen and no scavenger system, oxygen concentrations beneath the drapes were consistently elevated (as high as 45% with 4 L/min) compared with normal ambient concentrations (21%) or with concentrations obtained at the surgical site (as high as 23.4%). With the scavenger system in place, mean +/- SD oxygen concentrations reached 34.08% +/- 5.52% beneath the drapes. Statistical analyses revealed that significantly higher oxygen concentrations occurred beneath the drapes with each incremental change in oxygen flow rate, and regardless of the oxygen flow rate used, oxygen concentrations beneath the drapes were significantly reduced with the use of the scavenger system.     

Motion sickness: comparison of metoclopramide and diphenhydramine to placebo

Objectives: This is an evaluation of the efficacy of metoclopramide (MTCP) or diphenhydramine (DPH) to relieve symptoms of motion sickness in patients being transported via ambulance in a mountainous setting.Methods: This is a prospective, randomized, double-blinded, placebo-controlled study of patients transported by ambulance in the Sierra Nevada mountains of Fresno County. Consenting patients who met the inclusion criteria were asked to rate their motion sickness every five minutes using a visual analog scale (VAS) during transport. If motion sickness occurred, they were randomized to receive MTCP (20 mg IV), DPH (50 mg IV), or placebo (normal saline), and remaining symptoms were recorded every five minutes. If signs and symptoms of motion sickness persisted after 15 minutes, a rescue dose of MTCP was offered.Results: Twenty-six patients were enrolled in the study. Twenty-two (84.6%) developed motion sickness and were randomized to MTCP, DPH, or placebo. Eight patients received MTCP, seven received DPH, and seven received placebo. The MTCP group showed a statistically significant decrease in the mean VAS score at 15 minutes compared to the DPH and placebo groups. There was no significant difference in the decrease in VAS score between the placebo and the DPH group. Twelve out of 22 patients requested a rescue dose of MTCP after 15 minutes. At 25 minutes, there was no significant difference in the VAS score between the three groups.Conclusion: During ambulance transport in a mountainous setting, the administration of MTCP is superior to both DPH and placebo in the treatment of motion sickness. Diphenhydramine is not superior to placebo.     

Measurement of minute ventilation in ventilator-dependent patients: need for standardization

OBJECTIVES: a) To determine the variation in methods used to measure minute ventilation (VE) in patients who receive mechanical ventilation; b) to determine the effect of supplemental oxygen on VE, respiratory rate (RR), and tidal volume (VT) measurements. DESIGN: Telephone survey of hospitals, and a randomized control trial. SETTING: Medical and surgical ICUs in a university hospital. PATIENTS: Thirty-three patients who had required mechanical ventilation because of the inability to sustain adequate spontaneous ventilation. All patients were considered ready to undergo a weaning trial by their physicians. INTERVENTIONS: Spontaneous VE, RR, VT, and SaO2 were measured both in the presence and absence of supplemental oxygen; measurements were obtained in a randomized manner. MEASUREMENTS AND MAIN RESULTS: a) In a telephone survey of hospitals throughout the country, we found that the measurement of VE is variably obtained during room air breathing or in the presence of supplemental oxygen. b) Measurements of VE increased from 11.0 +/- 0.8 L/min while patients received supplemental oxygen to 13.5 +/- 1.1 L/min while patients breathed room air (p less than .001). Of 15 patients who had a VE less than 10 L/min while receiving supplemental oxygen, seven developed a value greater than 10 L/min while breathing room air; thus, a weaning trial might have been inappropriately deferred in these patients. c) Mean SaO2 decreased from 95.0 +/- 0.6% while breathing supplemental oxygen to 90.2 +/- 1.1% while breathing room air (p less than .001). CONCLUSIONS: Measurements of VE in patients being considered for a weaning trial can result in significant oxygen desaturation if obtained during room air breathing, and the values obtained can significantly overestimate the patient's true ventilatory requirements, since most patients receive supplemental oxygen during a weaning trial. Standardized methods of measuring VE in critically ill patients need to be developed.     

Influence of transdermal scopolamine on motion sickness during 7 days' exposure to heavy seas

We conducted a double-blind, placebo-controlled study to evaluate the efficacy and tolerability of transdermal scopolamine in the prevention of motion sickness (MS) aboard a frigate during 7 days of continuously moderate or heavy seas. Forty-nine healthy sailors with a previous history of MS were randomly assigned to receive a transdermal therapeutic system of scopolamine (TTS-S) or transdermal placebo (TD-P). Patches were placed behind the ears at least 4 hours before departure and were removed 72 hours later. Subjects were observed on days 1 to 4 and 6. In the TTS-S group, both subjective feeling of MS and the incidence of nausea were reduced during the first 2 days. Because of adaptation, differences in signs and symptoms of MS between subjects receiving TTS-S and TD-P disappeared after the second day. During the first 3 days, vomiting occurred less often in the TTS-S group. On day 6, 3 days after removal of the patch, vomiting occurred in 23% of the TTS-S group, probably due to delay in adaptation, but none of the subjects in the TD-P group vomited. Concentration was not adversely influenced, since the ability to work increased in the TTS-S group. During prolonged continuous exposure to heavy and moderate seas, 2.5 cm2 TTS-S discs proved to be efficacious in preventing MS, with xerostomia as a tolerable side effect and no significant ocular side effects.     

Supplemental oxygen is not required in trauma patients treated with IV opiates

The risk of respiratory depression can prevent the proper use of opioids in trauma patients and lead to use of supplemental oxygen. However, high FiO(2) might contribute to atelectasis formation and consequently to relative hypoxia. Supplemental oxygen also can cause a risk of fire. In a randomized, controlled study we evaluated the need and effects of supplemental oxygen in 13 patients with extremity trauma who were treated pain-free with an intravenous opioid, oxycodone (dose range 6.75-13.6 mg). After opioid injection, 7 patients received 40% supplemental oxygen and 6 were breathing room air. Pulse oxygen saturation (SpO(2)), arterial blood gases, and hemodynamic parameters were monitored for 30 minutes. Atelectasis formation was evaluated with a computed tomography scan. No hypoxia, hypoventilation, or significant atelectasis formation was detected in any of the patients. Accordingly, routinely given supplemental oxygen was not considered necessary in these patients because no complications were seen.     

Hyperoxic attenuation of exercise-induced bronchospasm in asthmatics.

To investigate the mechanism of exercise-induced bronchospasm, we measured specific airway conductance before and after exercise in 7 healthy normals, 12 asthmatics with intact carotid bodies, and 5 asthmatics who had had bilateral carotid body resection. The subjects breathed either air or oxygen (randomly assigned) during cycle ergometer exercise. Post-exercise bronchodilation was the usual pattern in normals, whereas post-exercise bronchospasm occurred in all asthmatics who breathed air during exercise. Oxygen breathing during exercise markedly attenuated the post-exercise bronchospasm in those asthmatics with intact carotid bodies, but had no significant effect in those without effect in those without carotid bodies. The attenuation of the bronchospasm with oxygen occurred with either incremental or constant load exercise of high intensity. The degree of attenuation did not correlate significantly with changes in end-tidal PCO2, maximum work rate, maximum exercise ventilation, or maximum heart rate. These studies indicate that oxygen attenuates exercise-induced bronchospasm in asthmatics through its action on the carotid bodies.     

Visual-vestibular habituation and balance training for motion sickness.

BACKGROUND AND PURPOSE: This case report describes physical therapy for motion sickness in a 34-year-old woman. The purpose of the report is twofold: (1) to provide an overview of the literature regarding motion sickness syndrome, causal factors, and rationale for treatment and (2) to describe the evaluation and treatment of a patient with motion sickness. CASE DESCRIPTION AND OUTCOMES: The patient initially had moderate to severe visually induced motion sickness, which affected her functional abilities and prevented her from working. Following 10 weeks of a primarily home-based program of visual-vestibular habituation and balance training, her symptoms were alleviated and she could resume all work-related activities. DISCUSSION: Although motion sickness affects nearly one third of all people who travel by land, sea, or air, little documentation exists regarding prevention or management.     

Meclizine in combination with ondansetron for prevention of postoperative nausea and vomiting in a high-risk population

Postoperative nausea and vomiting (PONV) is prevalent in surgical patients with known risk factors: general anesthesia, female, nonsmoker, motion sickness history, and PONV history. Common treatment involves ondansetron; however, the effects are short-lived, and supplemental medication may be required. Meclizine, a long-acting drug with a low side-effect profile, may be ideal in combination with ondansetron for at-risk patients. We randomized 77 subjects scheduled for general anesthesia and screened for 4 of 5 PONV risk factors for experimental or control group assignment. Severity of PONV was measured using a 0 to 10 verbal numeric rating scale (VNRS). Other measured variables included time to onset and incidence of PONV and total antiemetic requirements. No significant differences in demographics (excluding weight), surgical or anesthesia time, analgesic requirements, or nausea incidence in the postanesthesia care unit (PACU) and same-day surgery unit were noted. The meclizine group had lower VNRS scores in the PACU at 15 (P = .013) and 45 (P = .006) minutes following rescue treatment. The incidence of nausea was lower in the meclizine vs. placebo group (10% vs. 29%) following discharge (P = .038). Prophylactic meclizine resulted in lower incidence and severity of PONV in a high-risk population, especially after rescue treatment.     

Erythropoietic response to acute anemia.

Reliance on a brisk erythropoietic response to untreated blood loss is an alternative to transfusion of homologous blood. Slow erythropoiesis has been observed in ICU patients who refused blood. Many of these patients received supplemental oxygen therapy and Fluosol-DA, a temporary red cell substitute. This study reports the erythropoietic response, in the baboon, to moderate (Hct 20%) and severe (Hct 10%) anemia. In addition, the effect of oxygen therapy (FIO2 0.6 for 1 wk) and fluorocarbon emulsions (Oxypherol) on erythropoiesis was evaluated. Baboons uniformly survived acute normovolemic anemia with Hct 10%. In all cases, the response to anemia was characterized by a lag period (with no change in Hct), and a nonlinear recovery period. A lag period of 3 days was observed in both moderate and severe anemia for baboons breathing room air or FIO2 0.6. The lag period was prolonged to 1 wk in the presence of Oxypherol. The recovery period exhibited a uniform and negative correlation between the rate of Hct change and the Hct, in all cases. The theoretical maximum rate of increase of Hct was 2.6%/day. In untreated blood loss, shortening the lag period and increasing the slope of the recovery period will decrease the length of time that the patient is anemic.     

The dependence of maximal flow in man on the airway gas physical properties

The changes in maximum expiratory flow rates after washing out lung air with a helium/oxygen mixture (He/O2, 80 : 20) were measured in 24 patients with chronic irreversible airflow obstruction (FEV1 1.77 +/- SD 0.39 litres; FVC 3.62 +/- 0.59 litres), and in six normal subjects. The percentage increase in flow breathing He/O2 was variable; however, it was similar in normal subjects and in patients with airflow obstruction, and in both groups decreased at low lung volumes. Contrary to previous studies, only three patients with chronic airflow obstruction failed consistently to increase flow rates by greater than or equal to 20% when breathing He/O2 at all lung volumes measured. In six normal subjects and 12 patients with chronic airflow obstruction airway gas viscosity was increased by breathing a neon/oxygen mixture (Ne/O2, 80 : 20). The response to Ne/O2 was again variable (normal subjects delta Vmax.40 4 +/- SD 14%; patients delta Vmax.40 18 +/- 8%). Only two normal subjects and one patient with airflow obstruction consistently reduced their flow rates when breathing Ne/O2. These results indicate either that there is no difference in the distribution of airflow resistance in normal subjects and in patients with chronic airflow obstruction, or that density as well as viscosity is an important determinant of flow in very small airways. In either case, He/O2 breathing is not a good discriminator of the site of airflow obstruction.     

Oxygen supplementation increases glucose tolerance during euglycaemic hyperinsulinaemic glucose clamp procedure in patients with severe COPD and chronic hypoxaemia

Investigations in chronic obstructive pulmonary disease (COPD) patients have shown impaired glucose tolerance in hypoxic COPD patients, compared with COPD patients with normal arterial blood gases. In healthy subjects, hypoxaemia or stay at altitude, have been shown to alter glucose metabolism. At altitude the effect seems to be dependent on duration of stay. A short stay is associated with insulin resistance, a longer stay gives rise to increased glucose uptake. The euglycaemic hyperinsulinaemic glucose clamp technique is a method to study glucose tolerance and enables determinations of glucose clearance in peripheral tissues. We investigated six COPD patients [forced expiratory volume in 1 s 0.7 +/- 0.2 l (mean +/- SD)] with chronic hypoxaemia (PaO(2) 7.9 +/- 0.6 kPa at rest, breathing air), with and without oxygen supplementation, using the glucose clamp technique. Net peripheral glucose uptake was 5.5 +/- 1.2 and 7.1 +/- 1.6 mg (kg*min)(-1) (+29%) breathing air and supplemental oxygen, respectively (P = 0.03). The tissue sensitivity to insulin increased 32% (P = 0.03) with oxygen supplementation. The results indicate that normalization of oxygen saturation in COPD patients with chronic hypoxaemia may have an immediate effect on glucose tolerance and tissue sensitivity to insulin in these patients.     

Arterial oxygen saturation and breathlessness in patients with chronic obstructive airways disease

Nine patients with chronic obstructive airways disease performed a 6 min self-paced walk (breathing air) on a treadmill and then identical (but operator-controlled) treadmill walks breathing either air or supplemental oxygen sufficient to just prevent arterial oxygen desaturation during the exercise. During the exercises, ventilation was recorded and patients recorded their sensation of breathlessness on a visual analogue scale (VAS) every 30 s. Breathing supplemental oxygen produced a small fall in mean exercise ventilation and a large and consistent reduction in mean exercise breathlessness. In seven patients the VAS scores were higher on air than with supplemental oxygen, at similar levels of ventilation. An analysis of covariance, to control for reduction in ventilation, showed a decrease in mean breathlessness when breathing supplemental oxygen, significant at the 8% level. The reduction in breathlessness produced by preventing exercise desaturation cannot be explained by the decrease in ventilation. This suggests that hypoxia may be a stimulus for breathlessness. The mechanism is unknown.     

Suppression of pain and the R2 component of the blink reflex during optokinetic stimulation

The effect of exposure to a rotating optokinetic drum on the electrically evoked blink reflex was investigated in 20 healthy volunteers. Pain ratings and the area under the curve of the R2 component of the blink reflex to innocuous and nociceptive trigeminal stimulation decreased substantially during and after optokinetic stimulation. At low shock intensities, R2 decreased most during optokinetic stimulation in subjects who did not develop symptoms of motion sickness. In contrast, during the recovery period after optokinetic stimulation, suppression of R2 to moderate and intense stimuli was greatest in the most nauseated subjects. These findings suggest that a mechanism that suppresses symptoms of motion sickness during sensory conflict also inhibits activity in wide dynamic range neurones in the trigeminal nucleus caudalis. Nausea in the absence of sensory conflict may inhibit R2 to intense electrical stimulation by provoking diffuse noxious inhibitory controls.     

A randomized controlled trial of oxygen for reducing nausea and vomiting during emergency transport of patients older than 60 years with minor trauma.

OBJECTIVE: To test the hypothesis that oxygen administration reduces nausea and vomiting in patients with minor trauma during ambulance transport. PATIENTS AND METHODS: This study, conducted from January to April 2000, consisted of 100 patients older than 60 years with minor trauma, who were randomly assigned to breathe air or 100% oxygen at 10 L/min through a facemask during ambulance transport. A paramedic, blinded to treatment, recorded vomiting episodes during transport. Patients, also blinded to treatment, rated their levels of pain, nausea, vomiting, anxiety, and overall satisfaction with their care on 100-mm visual analog scales, with greater values indicating more intense sensation. Results from the 2 groups were compared with chi2 or unpaired 2-tailed t tests and presented as means +/- SDs. RESULTS: Before randomization, patients subsequently assigned to receive oxygen had significantly greater pain and nausea. On arrival at the hospital, oxygen saturation was higher in the 50 patients given oxygen (99% +/- 1 % vs 96% +/- 2%; P<.001) than in the 50 patients who breathed air. Reported pain remained greater in the oxygen group. However, those given oxygen had less nausea (22 +/- 29 vs 54 +/- 38 mm; P<.001) and vomiting (4 vs 19 episodes; P<.001), lower heart rates (86 +/- 12 vs 94 +/- 13 beats/min; P<.001), and higher overall satisfaction scores (54 +/- 33 vs 33 +/- 23 mm; P<.001). CONCLUSION: Our results indicate that supplemental oxygen during ambulance transport reduced nausea scores by 50% and decreased vomiting 4-fold. Consequently, patients reported greater satisfaction with their care. Thus, we recommend that patients be given supplemental oxygen during ambulance transport.     

Effect of respiratory rate, respiratory depth, and open versus closed mouth breathing on sublingual temperature

The effect of open mouth breathing, tachypnea, and hyperpnea, either alone or in combination, on sublingual and tympanic membrane temperature in healthy adults was investigated. Seventy-eight subjects maintained randomly assigned breathing patterns for 15 minutes. Temperatures were monitored immediately prior to and for 5 minutes following the breathing protocol. The only statistically significant finding (p less than .01) was a lower sublingual temperature with open mouth breathing. No significant changes in tympanic membrane temperature were seen.     

Influence of spontaneous pursed lips breathing on walking endurance and oxygen saturation in patients with moderate to severe chronic obstructive pulmonary disease

OBJECTIVE: To evaluate how spontaneously used pursed lips breathing influences walking endurance, oxygen saturation and dyspnoea in patients with moderate to severe chronic obstructive pulmonary disease. DESIGN: A randomized open-label, cross-over study of chronic obstructive pulmonary disease patients participating in a rehabilitation programme. SETTING: Outpatient pulmonary rehabilitation centre at a university hospital. SUBJECTS: Thirty-two patients with moderate to severe chronic obstructive pulmonary disease. INTERVENTION: All patients performed two endurance shuttle walking tests in random order. During endurance shuttle walking test I a mouthpiece was used in order to prevent spontaneous pursed lips breathing. During endurance shuttle walking test II spontaneous pursed lips breathing was used freely. Heart rate, oxygen saturation and the patients' estimated dyspnoea and leg fatigue on a Borg Category Ratio 10 scale were recorded before, directly after, and 5 and 10 minutes after the tests. RESULTS: When spontaneous pursed lips breathing was used the patients walked on an average for 37 seconds (16%) longer (P<0.01) than when pursed lips breathing was prevented. The patients desaturated considerably during both walking tests but the average drop in oxygen saturation was 1.2% less when spontaneous pursed lips breathing was employed. There were no significant differences in rated degree of dyspnoea or leg fatigue with or without pursed lips breathing. CONCLUSION: Spontaneous pursed lips breathing can be a useful technique to increase walking endurance and reduce oxygen desaturation during walking in patients with moderate to severe chronic obstructive pulmonary disease.     

Arterial oxygen values achieved by COPD patients breathing oxygen alternately via nasal mask and nasal cannula.

Ten patients with known but clinically stable chronic obstructive pulmonary disease (COPD) were studied while breathing low-flow (1-2 L/min) supplemental oxygen by nasal cannula and by biflow nasal mask. Although the increase in inspired oxygen when breathing with the cannula has been documented, the nasal mask has not been tested by measurement of PaO2 change. The mean age of the group was 64.6 years, and their mean PaO2 was 54 +/- 10.5 torr while they were at rest and breathing room air. Patients were each given oxygen alternately with the mask and cannula, with no change in flowrate; time was allowed between the two for equilibration and return to baseline values. PaO2 values were compared by t test for nonindependent samples, which provided a t value of 1.893, with P = 0.09. Differences in measured arterial saturation (SaO2) and PaCO2 also proved to be insignificant when patients breathed via the two devices. The conclude that the nasal cannula and the biflow nasal mask produce comparable PaO2 in patients who may need low-flow supplemental oxygen at rest. The mask can be considered an alternative oxygen appliance if preferred by patients because of comfort.     

Randomized Clinical Trial of Propofol With and Without Alfentanil for Deep Procedural Sedation in the Emergency Department

Objectives: The objectives were to compare the efficacy, occurrence of adverse events, and recovery duration of propofol with and without alfentanil for use in procedural sedation in the emergency department (ED). Methods: This was a randomized nonblinded prospective trial of adult patients undergoing procedural sedation for painful procedures in the ED. Patients with pain before the procedure were given intravenous (IV) morphine sulfate until their pain was adequately treated at least 20 minutes before starting the procedure. Patients received 1 mg/kg propofol either with or without a supplemental dose of 10 μg/kg alfentanil for deep procedural sedation. Doses, vital signs, nasal end‐tidal CO₂ (ETCO₂), pulse oximetry, and bispectral electroencephalographic (EEG) analysis scores were recorded. Subclinical respiratory depression was defined as a change in ETCO₂ of >10 mmHg, an oxygen saturation of <92% at any time, or an absent ETCO₂ waveform at any time. Clinical events related to respiratory depression were noted during the procedure, including the addition of or increase in the flow rate of supplemental oxygen, the use of a bag‐valve mask apparatus, airway repositioning, or stimulation to induce breathing. After the procedure, patients were asked if they experienced pain during the procedure or had recall of the procedure. Results: A total of 150 patients were enrolled; 146 underwent sedation and were included in the analysis. Seventy‐four patients received propofol, and 71 received propofol with alfentanil. No clinically significant complications were noted. Subclinical respiratory depression was seen in 24/74 patients in the propofol group and 30/71 patients in the propofol/alfentanil group (effect size = 9.8%, 95% CI = –5.8% to 25.5%). Clinical signs of respiratory depression included an increase in supplemental oxygen use in 25 of the 74 propofol patients and 31 of the 71 propofol/alfentanil patients (effect size 9.9%, 95% CI = –5.9% to 25.7%), the use of bag‐valve mask apparatus in seven patients in the propofol group and 12 in the propofol/alfentanil group (effect size = 5.6%, 95% CI = –3.5% to 18.4%), airway repositioning in 13 propofol patients and 20 propofol/alfentanil patients (effect size = 10.6%, 95% CI = –3.0% to 24.2%), and stimulation to induce breathing in 11 propofol patients and 20 propofol/alfentanil patients (effect size = 13.3%, 95% CI = 0.1% to 26.5%). The total time of the procedure was longer for the alfentanil/propofol group (median = 11 minutes, range = 5–22 minutes) than for the propofol group (median = 9 minutes, range = 1 to 43 minutes; effect size = 1.93 minutes, 95% CI = 0.73 to 2.58, p = 0.02). Pain during the procedure was reported by 10 of the 74 patients in the propofol group and 7 of the 71 patients in the propofol/alfentanil group (effect size = 4.5%, 95% CI = –6.8% to 14.1%). Recall of some part of the procedure was reported by 12 patients in the propofol group and 9 in the propofol/alfentanil group (effect size = 3.5%, 95% CI = –7.9% to 15.0%). All procedures were successfully completed. Conclusions: The use of supplemental alfentanil with propofol for procedural sedation did not result in a difference in reported pain or recall immediately after the procedure. There was an increase in the proportion of patients who required stimulation to induce respiration during the procedure in patients who received propofol with supplemental alfentanil. The addition of supplemental opioid to procedural sedation with propofol does not appear beneficial.