51
|
Sanatkar M, Abianeh SH, Ghazizadeh S, Rahmati J, Ghanbarzadeh K, Fathi HR, Najafi A, Sadrossadat H, Shahriyari A. The Comparison of Infusion of Two Different Sedation Regimens with Propofol and Ketamine Combination During Plastic and Reconstructive Surgery. Aesthetic Plast Surg 2015; 39:141-6. [PMID: 25552328 DOI: 10.1007/s00266-014-0419-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Accepted: 10/16/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Anesthetic agents are often combined to enhance their therapeutic effects while minimizing adverse events. The aim of this study was to evaluate the effects of two different sedation regimens of ketamine and propofol combination via infusion on perioperative variables in patients who underwent plastic and reconstructive surgery. METHODS This randomized double-blind clinical trial was done on 80 patients who were randomized to two groups; group 1 (n = 40) received a 2:1 mixture of 9 mg/ml propofol and 4.5 mg/ml ketamine, and group 2 (n = 40) received a 4:1 mixture of 9 mg/ml propofol and 2.25 mg/ml ketamine. After premedication and before local anesthetic injection, the infusion of mixtures was adjusted to attain the Ramsay sedation scores of 5 in both groups. We recorded induction time, sedation efficacy, cardiovascular and respiratory events, recovery time, and incidence of adverse events during and after the procedure. RESULTS The mean of volume infusion of mixtures in the beginning of the procedure was higher in group 2 (3.2 ± 1. 2 ml) than in group 1 (2.4 ± 0.8 ml) (p < 0.001). The induction time for sedation was 2.8 ± 0.8 min and 2.6 ± 0.4 min in group 1 and group 2, respectively (p = 0. 92). The number of oversedated patients was greater in group 2 compared to group 1 but not statistically significant (p = 0. 80). The sedation efficacy was similar between the two groups. The hemodynamic changes during the procedure were greater in group 2 compared to group 1 (p = 0. 001). The recovery time was not significantly different between the two groups (p = 0.43). The mean pain score in the recovery room was lower in group 1 than group 2 (1.2 ± 0.8 vs 2.8 ± 1.8, p = 0. 01). Moreover, 4 (10 %) patients in group 1 and 10 (25 %) patients in group 2 needed opioid administration (p = 0. 02). Other postoperative adverse events were similar between the two groups. CONCLUSION We recommend the use of a 2:1 combination of propofol-ketamine, because it reduced the rescue propofol requirement and consequently produced lower cardiovascular and respiratory depression effects and also less postoperative pain.
Collapse
|
52
|
Sédation–analgésie avant procédure douloureuse chez l’enfant par association kétamine–propofol (kétofol) en camp de réfugiés. ANNALES FRANCAISES DE MEDECINE D URGENCE 2015. [DOI: 10.1007/s13341-015-0505-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
53
|
Green SM, Andolfatto G, Krauss BS. Ketofol for procedural sedation revisited: pro and con. Ann Emerg Med 2014; 65:489-91. [PMID: 25544732 DOI: 10.1016/j.annemergmed.2014.12.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Indexed: 11/19/2022]
Affiliation(s)
- Steven M Green
- Department of Emergency Medicine, Loma Linda University Medical Center and Children's Hospital, Loma Linda, CA.
| | - Gary Andolfatto
- Emergency Department, Lions Gate Hospital, North Vancouver, British Columbia, Canada
| | - Baruch S Krauss
- Division of Emergency Medicine, Children's Hospital Boston and Department of Pediatrics, Harvard Medical School, Boston, MA
| |
Collapse
|
54
|
|
55
|
|
56
|
|
57
|
Gulec H, Sahin S, Ozayar E, Degerli S, Bercin F, Ozdemir O. [Ketamine-propofol sedation in circumcision]. Rev Bras Anestesiol 2014; 65:367-70. [PMID: 26363694 DOI: 10.1016/j.bjan.2014.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 03/10/2014] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE to compare the therapeutic effects of ketamine alone or ketamine plus propofol on analgesia, sedation, recovery time, side effects in premedicated children with midazolam-ketamine-atropin who are prepared circumcision operation. METHODS 60 American Society of Anaesthesiologists physical status I-II children, aged between 3 and 9 years, undergoing circumcision operations under sedation were recruited according to a randomize and double-blind institutional review board-approved protocol. Patients were randomized into two groups via sealed envelope assignment. Both groups were administered a mixture of midazolam 0.05mg/kg+ketamine 3mg/kg+atropine 0.02mg/kg intramuscularly in the presence of parents in the pre-operative holding area. Patients were induced with propofol-ketamine in Group I or ketamine alone in Group II. RESULTS in the between-group comparisons, age, weight, initial systolic blood pressure, a difference in terms of the initial pulse rate was observed (p>0.050). Initial diastolic blood pressure and subsequent serial measurements of 5, 10, 15, 20thmin, systolic blood pressure, diastolic blood pressure and pulse rate in ketamine group were significantly higher (p<0.050). CONCLUSION propofol-ketamine (Ketofol) provided better sedation quality and hemodynamy than ketamine alone in pediatric circumcision operations. We did not observe significant complications during sedation in these two groups. Therefore, ketofol appears to be an effective and safe sedation method for circumcision operation.
Collapse
|
58
|
Abstract
BACKGROUND Propofol mixed with racemic ketamine (or "ketofol") is popular for short procedural sedation and analgesia, yet the optimal combination is unknown. We aimed to determine a ketofol dosing regimen for short procedural sedation and analgesia of 5- to 20-minute duration in healthy patients (2-20 y). METHODS Pharmacokinetic-pharmacodynamic parameters were used to simulate drug concentration and effect profiles over time for different ketamine-to-propofol ratios (1:1-1:10). The target effect was a Children's Hospital of Wisconsin Sedation Scale score of less than 2. Combined effects were additive, with a propofol EC50 of 1.54 μg/mL (concentration required to produce hypnosis in 50% of patients), a ketamine EC50 of 0.44 μg/mL, and a slope of 5.3. Emergence threshold concentrations for propofol were 2.0 μg/mL in children and 1.8 μg/mL in adults as well as 0.5 μg/mL for ketamine (children and adults). The EC50 for propofol antiemesis was 0.343 μg/mL. RESULTS A ketamine-to-propofol ratio of 1:3 was the best combination for intermittent dosing, achieving a rapid onset of a Children's Hospital of Wisconsin Sedation Scale score of less than 2 within 1 minute and a time to emergence of 9 to 19 minutes in all ages after a 10-minute sedation. The optimal ketofol dosing in children (2-11 y) was 0.1 mL/kg initially followed by 0.05 mL/kg at 2 minutes and then 0.025 mL/kg for the subsequent doses. The adults (12-20 y) received 0.05 mL/kg of ketofol initially followed by 0.025 mL/kg for the subsequent doses. These regimens maintain a propofol antiemesis for 30 to 40 minutes after the last dose. CONCLUSIONS We suggest an optimal ratio of racemic ketamine to propofol of 1:3 for boluses during short procedures (5-20 minutes). A short ketofol infusion, ratio 1:4, is a suitable alternative to intermittent boluses. Ratios greater than 1:3 result in delayed recovery after 20 minutes.
Collapse
|
59
|
Gulec H, Sahin S, Ozayar E, Degerli S, Bercin F, Ozdemir O. Ketamine-propofol sedation in circumcision. Braz J Anesthesiol 2014; 65:367-70. [PMID: 26323735 DOI: 10.1016/j.bjane.2014.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 03/10/2014] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND AND OBJECTIVE To compare the therapeutic effects of ketamine alone or ketamine plus propofol on analgesia, sedation, recovery time, side effects in premedicated children with midazolam-ketamine-atropin who are prepared circumcision operation. METHODS 60 American Society of Anaesthesiologists physical status I-II children, aged between 3 and 9 years, undergoing circumcision operations under sedation were recruited according to a randomize and double-blind institutional review board-approved protocol. Patients were randomized into two groups via sealed envelope assignment. Both groups were administered a mixture of midazolam 0.05mg/kg+ketamine 3mg/kg+atropine 0.02mg/kg intramuscularly in the presence of parents in the pre-operative holding area. Patients were induced with propofol-ketamine in Group I or ketamine alone in Group II. RESULTS In the between-group comparisons, age, weight, initial systolic blood pressure, a difference in terms of the initial pulse rate was observed (p>0.050). Initial diastolic blood pressure and subsequent serial measurements of 5, 10, 15, 20thmin, systolic blood pressure, diastolic blood pressure and pulse rate in ketamine group were significantly higher (p<0.050). CONCLUSION Propofol-ketamine (Ketofol) provided better sedation quality and hemodynamy than ketamine alone in pediatric circumcision operations. We did not observe significant complications during sedation in these two groups. Therefore, ketofol appears to be an effective and safe sedation method for circumcision operation.
Collapse
|
60
|
Godwin SA, Burton JH, Gerardo CJ, Hatten BW, Mace SE, Silvers SM, Fesmire FM. Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department. Ann Emerg Med 2014; 63:247-58.e18. [DOI: 10.1016/j.annemergmed.2013.10.015] [Citation(s) in RCA: 202] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
61
|
Cavalli P, Vial M, Henniche A, Plenier C, Moine L, Kottmann V, Noirmain L, Maakel A, Champly F, Guerin T. Évaluation prospective d’une analgésie-sédation par l’association kétamine-propofol pour la prise en charge des gestes douloureux en urgence. ANNALES FRANCAISES DE MEDECINE D URGENCE 2013. [DOI: 10.1007/s13341-013-0365-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
62
|
Newstead B, Bradburn S, Appelboam A, Reuben A, Harris A, Hudson A, Jones L, McLauchlan C, Riou P, Jadav M, Lloyd G. Propofol for adult procedural sedation in a UK emergency department: safety profile in 1008 cases. Br J Anaesth 2013; 111:651-5. [DOI: 10.1093/bja/aet168] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
63
|
Abstract
PURPOSE OF REVIEW The need for sedation for procedures performed outside the operating room has increased dramatically, and pediatric procedural sedation (PPS) is increasingly performed by practitioners who are not anesthesiologists. With 'sedationists' emerging from various specialties, there are differences in practice and guidelines with regards to presedation assessment, targeted depths of sedation, monitoring requirements, and the training required. Our aim is to identify some of the recent advances in PPS and to describe progress towards greater standardization of practice. RECENT FINDINGS Several studies report attempts to optimize the efficacy of specific pharmaceuticals used in PPS. Ketamine, a dissociative agent, functions uniquely and requires its own sedation practice guidelines. Utilizing less invasive administration of sedation via transmucosal and inhaled routes is gaining popularity. Additionally, replacing subjective measurement of depths of the sedation continuum and the nonstandardized definitions of adverse events with alternatives based on physiological parameters and/or required rescue interventions is underway. Finally, the use of presedation family-centered counseling and adjuncts that provide visual and auditory distraction are enhancing pharmaceutical methods. SUMMARY Further multispecialty collaboration and formation of greater consensus with regards to sedation practice are essential to the development of universal guidelines that optimize patient care.
Collapse
|
64
|
Black E, Campbell SG, Magee K, Zed PJ. Propofol for Procedural Sedation in the Emergency Department: A Qualitative Systematic Review. Ann Pharmacother 2013; 47:856-68. [DOI: 10.1345/aph.1r743] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE: To evaluate the efficacy and safety of propofol compared to other agents for procedural sedation of adults in the emergency department (ED) and to review the use of opioids in conjunction with propofol for procedural sedation in the ED. DATA SOURCES: PubMed (1949-December 2012) and EMBASE (1980-December 2012) were searched using combinations of the following search terms: (procedural sedation or conscious sedation [MESH]) and propofol. A manual search of references was also performed. STUDY SELECTION AND DATA EXTRACTION: English-language, full reports of randomized controlled trials (RCTs) and observational studies evaluating propofol use in adults undergoing procedural sedation in the ED were included if they reported efficacy or safety outcomes. Two reviewers independently assessed each article for inclusion, data extraction, and study limitations. DATA SYNTHESIS: Thirteen RCTs and 20 observational studies meeting our inclusion criteria were retrieved. Regardless of the agent used for sedation, procedural success was greater than 80% and most trials demonstrated no statistically significant difference in the incidence of respiratory depression with propofol compared to alternatives. One RCT showed a significantly greater percent decrease in systolic blood pressure from baseline in those who received propofol compared to ketamine. Where reported, no significant difference was found in patient recall, pain, and satisfaction when opioids were added to propofol compared to propofol alone; the addition of opioids may have resulted in a higher incidence of respiratory adverse events. CONCLUSIONS: Propofol for procedural sedation is a reasonable alternative for use in the ED, with comparative efficacy and safety to other alternatives. Use of opioids in addition to propofol may not provide added benefit but does contribute to increased rates of adverse events.
Collapse
Affiliation(s)
- Emily Black
- Emily Black BSc (Pharm) ACPR PharmD, Assistant Professor, College of Pharmacy, Qatar University, Doha
| | - Samuel G Campbell
- Samuel G Campbell MD, Associate Professor, Departments of Emergency Medicine and Anesthesia, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kirk Magee
- Kirk Magee MD MSc FRCPC, Associate Professor, Department of Emergency Medicine, Dalhousie University
| | - Peter J Zed
- Peter J Zed BSc BSc (Pharm) ACPR PharmD FCSHP, Associate Professor and Associate Dean, Practice Innovation, Faculty of Pharmaceutical Sciences; Associate Member, Department of Emergency Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
65
|
Marland S, Ellerton J, Andolfatto G, Strapazzon G, Thomassen O, Brandner B, Weatherall A, Paal P. Ketamine: use in anesthesia. CNS Neurosci Ther 2013; 19:381-9. [PMID: 23521979 DOI: 10.1111/cns.12072] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 01/07/2013] [Accepted: 01/07/2013] [Indexed: 12/23/2022] Open
Abstract
The role of ketamine anesthesia in the prehospital, emergency department and operating theater settings is not well defined. A nonsystematic review of ketamine was performed by authors from Australia, Europe, and North America. Results were discussed among authors and the final manuscript accepted. Ketamine is a useful agent for induction of anesthesia, procedural sedation, and analgesia. Its properties are appealing in many awkward clinical scenarios. Practitioners need to be cognizant of its side effects and limitations.
Collapse
|
66
|
Vinson DR, Hoehn CL. Sedation-assisted Orthopedic Reduction in Emergency Medicine: The Safety and Success of a One Physician/One Nurse Model. West J Emerg Med 2013; 14:47-54. [PMID: 23447756 PMCID: PMC3582522 DOI: 10.5811/westjem.2012.4.12455] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Revised: 04/09/2012] [Accepted: 04/30/2012] [Indexed: 02/01/2023] Open
Abstract
Introduction Much of the emergency medical research on sedation-assisted orthopedic reductions has been undertaken with two physicians––one dedicated to the sedation and one to the procedure. Clinical practice in community emergency departments (EDs), however, often involves only one physician, who both performs the procedure and simultaneously oversees the crendentialed registered nurse who administers the sedation medication and monitors the patient. Although the dual-physician model is advocated by some, evidence in support of its superiority is lacking. Methods: In this electronic health records review we describe sedation-assisted closed reductions of major joints and forearm fractures in three suburban community EDs. The type of procedure and sedation medication, need for specialty assistance, success rates, and intervention-requiring adverse events are reported. Results: During the 18-month study period, procedural sedation was performed 457 times on 442 patients undergoing closed reduction for shoulder dislocations (n = 111), elbow dislocations (n = 29), hip dislocations (n = 101), and forearm fractures (n = 201). In the vast majority of this cohort (98.4% [435/442]), a single emergency physician simultaneously managed both the procedural sedation and the initial orthopedic reduction without the assistance of a second physician. The reduction was successful or satisfactory in 96.6% (425/435; 95% confidence interval [CI], 95.8–98.8%) of these cases, with a low incidence of intervention-requiring adverse events (2.8% [12/435]; 95% CI, 1.5–4.8%). Conclusion: Sedation-assisted closed reduction of major joint dislocations and forearm fractures can be performed effectively and safely in the ED using a one physician/one nurse model. A policy that requires a separate physician (or nurse anesthetist) to administer medications for all sedation-assisted ED procedures appears unwarranted. Further research is needed to determine which specific clinical scenarios might benefit from a dual-physician approach.
Collapse
Affiliation(s)
- David R Vinson
- Kaiser Permanente Roseville Medical Center, Department of Emergency Medicine, Roseville, California ; The Permanente Medical Group, Oakland, California
| | | |
Collapse
|
67
|
In reply. Ann Emerg Med 2013; 61:257-8. [DOI: 10.1016/j.annemergmed.2012.07.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2012] [Revised: 07/29/2012] [Accepted: 07/30/2012] [Indexed: 11/20/2022]
|
68
|
|
69
|
Campoy L, Martin-Flores M, Ludders JW, Gleed RD. Procedural sedation combined with locoregional anesthesia for orthopedic surgery of the pelvic limb in 10 dogs: case series. Vet Anaesth Analg 2012; 39:436-40. [DOI: 10.1111/j.1467-2995.2012.00712.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
70
|
Sahyoun C, Krauss B. Clinical implications of pharmacokinetics and pharmacodynamics of procedural sedation agents in children. Curr Opin Pediatr 2012; 24:225-32. [PMID: 22245909 DOI: 10.1097/mop.0b013e3283504f88] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Procedural sedation has become the standard of care for managing pain and anxiety in children in the emergency department. RECENT FINDINGS Numerous articles have been published on pediatric procedural sedation with, however, little in-depth discussion of the pharmacodynamics and pharmacokinetics of the sedation agents utilized. SUMMARY We review the pharmacokinetics and pharmacodynamics of the pediatric procedural sedation pharmacopeia from a clinical perspective with emphasis on the practical implications for drug titration and dosing.
Collapse
Affiliation(s)
- Cyril Sahyoun
- Division of Emergency Medicine, Children's Hospital Boston, Boston, Massachusetts 02115, USA.
| | | |
Collapse
|
71
|
Andolfatto G, Abu-Laban RB, Zed PJ, Staniforth SM, Stackhouse S, Moadebi S, Willman E. Ketamine-propofol combination (ketofol) versus propofol alone for emergency department procedural sedation and analgesia: a randomized double-blind trial. Ann Emerg Med 2012; 59:504-12.e1-2. [PMID: 22401952 DOI: 10.1016/j.annemergmed.2012.01.017] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2011] [Revised: 01/01/2012] [Accepted: 01/17/2012] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE We determine whether a 1:1 mixture of ketamine and propofol (ketofol) for emergency department (ED) procedural sedation results in a 13% or more absolute reduction in adverse respiratory events compared with propofol alone. METHODS Participants were randomized to receive either ketofol or propofol in a double-blind fashion. Inclusion criteria were aged 14 years or older and American Society of Anesthesiology class 1 to 3 status. The primary outcome was the number and proportion of patients experiencing an adverse respiratory event as defined by the Quebec Criteria. Secondary outcomes were sedation consistency, efficacy, and time; induction time; and adverse events. RESULTS A total of 284 patients were enrolled, 142 per group. Forty-three (30%) patients experienced an adverse respiratory event in the ketofol group compared with 46 (32%) in the propofol group (difference 2%; 95% confidence interval -9% to 13%; P=.80). Three ketofol patients and 1 propofol patient received bag-valve-mask ventilation. Sixty-five (46%) patients receiving ketofol and 93 (65%) patients receiving propofol required repeated medication dosing or progressed to a Ramsay Sedation Score of 4 or less during their procedure (difference 19%; 95% confidence interval 8% to 31%; P=.001). Six patients receiving ketofol were treated for recovery agitation. Other secondary outcomes were similar between the groups. Patients and staff were highly satisfied with both agents. CONCLUSION Ketofol for ED procedural sedation does not result in a reduced incidence of adverse respiratory events compared with propofol alone. Induction time, efficacy, and sedation time were similar; however, sedation depth appeared to be more consistent with ketofol.
Collapse
Affiliation(s)
- Gary Andolfatto
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
| | | | | | | | | | | | | |
Collapse
|
72
|
Thomas MC, Jennett-Reznek AM, Patanwala AE. Combination of ketamine and propofol versus either agent alone for procedural sedation in the emergency department. Am J Health Syst Pharm 2012; 68:2248-56. [PMID: 22095813 DOI: 10.2146/ajhp110136] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The safety of using ketamine-propofol combinations as an alternative to using either agent alone for procedural sedation is discussed. SUMMARY A total of 10 trials comparing the combination of ketamine and propofol with either agent alone for procedural sedation in the emergency department were examined. The evidence reviewed suggests that combining these agents may help to minimize adverse effects such as hypotension and respiratory depression. Ketamine is not commonly used as a single agent in adults because of the risk for emergence reactions; however, when combined with propofol, no significant increase in this adverse effect was found compared with propofol monotherapy. Administering ketamine and propofol can be accomplished by using a two-syringe technique or combining both medications into a single syringe. When two syringes are used, a ketamine 0.3-0.5-mg/kg i.v. bolus dose is administered, followed by a propofol 0.4-1-mg/kg i.v. bolus dose. Sedation is maintained with intermittent i.v. boluses of propofol 0.1-0.5 mg/kg. A 1:1 ratio of ketamine and propofol can also be combined into a single syringe by using the same concentration (10 mg/mL) and equal volumes of each drug, yielding a final concentration of 5 mg/mL for each component. CONCLUSION The combined use of ketamine and propofol is a reasonable alternative to propofol alone for procedural sedation in patients at higher risk for respiratory depression or hypotension. Use of the combination requires the development of standardized protocols for drug preparation and dosage to minimize the potential for errors.
Collapse
|
73
|
Sih K, Campbell SG, Talion JM, Magee K, Zed PJ. Ketamine in Adult Emergency Medicine: Controversies and Recent Advances. Ann Pharmacother 2011; 45:1525-34. [PMID: 22147144 DOI: 10.1345/aph.1q370] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: To review the evidence for the use of ketamine in adult emergency medicine for procedural sedation and analgesia (PSA) and rapid sequence intubation (RSI), as well as to focus on the issues of recovery agitation, combination with propofol for PSA, and the use of ketamine as an induction agent in patients with acute head injury in need of definitive airway management. Data Sources: PubMed (1949-July 2011), EMBASE (1980-July 2011), Google Scholar (to July 2011), International Pharmaceutical Abstracts (1964-July 2011), and Cochrane databases were searched independently. A manual search of references was also performed, Study Selection: English-language, full reports of experimental and observational studies evaluating ketamine in adults undergoing PSA and RSI in the emergency department (ED) were Included if they reported efficacy or safety outcomes. Data Extraction: Two reviewers independently assessed each article for inclusion, data extraction, and study limitations. Data Synthesis: Six studies that used ketamine for PSA were included. The majority reported adequate sedation with high patient satisfaction and lack of pain and procedural recall. There is no evidence to support the superiority of a combination of ketamine and propofol compared to propofol alone for PSA in adults. Recovery agitation is common but can be minimized with premedication with midazolam (number needed to treat 6). Two studies were identified that evaluated the role of ketamine for induction during RSI in the ED, Although ketamine is not a first-line agent for RSI, it is an alternative and may be used as an induction agent in patients requiring endotracheal intubation. Conclusions: Ketamine is an effective agent in adults undergoing PSA and RSI in the ED. The best available evidence provides sufficient confidence to consider use of this agent in the ED.
Collapse
Affiliation(s)
- Kendra Sih
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada; Pediatrics, BC Women's & Children's Hospital, Vancouver
| | - Samuel G Campbell
- Department of Emergency Medicine and Anesthesia, Dalhousie University, Halifax, Nova Scotia, Canada
| | - John M Talion
- Nova Scotia Trauma Program and Queen Elizabeth II Health Sciences Centre Trauma Services, Halifax; Departments of Emergency Medicine, Anesthesia, Surgery, Community Health and Epidemiology, Dalhousie University
| | - Kirk Magee
- RCPS Residency Program, Department of Emergency Medicine, Dalhousie University
| | - Peter J Zed
- College of Pharmacy and Department of Emergency Medicine, Dalhousie University; Clinical Coordinator, Department of Pharmacy, and Pharmacotherapeutic Specialist—Emergency Medicine, Queen Elizabeth II Health Sciences Centre, Halifax; Practice Innovation, Faculty of Pharmaceutical Sciences, University of British Columbia
| |
Collapse
|
74
|
Menchine M, Arora S, Schriger D. Procedural sedation: is two better than one? Answers to the May 2011 Journal Club questions. Ann Emerg Med 2011; 58:383-94. [PMID: 21943576 DOI: 10.1016/j.annemergmed.2011.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Michael Menchine
- Keck School of Medicine of the University of Southern California, Department of Emergency Medicine, Los Angeles, CA, USA
| | | | | |
Collapse
|
75
|
Green SM, Andolfatto G, Krauss B. Ketofol for Procedural Sedation? Pro and Con. Ann Emerg Med 2011; 57:444-8. [DOI: 10.1016/j.annemergmed.2010.12.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Revised: 12/01/2010] [Accepted: 12/07/2010] [Indexed: 10/18/2022]
|
76
|
Arora S, Menchine M, Schriger DL. Procedural sedation: is two better than one? Ann Emerg Med 2011; 57:442-3. [PMID: 21513826 DOI: 10.1016/j.annemergmed.2011.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|