Propofol–fentanyl versus propofol–ketamine for procedural sedation and analgesia in patients with trauma

Pharmacological agents for procedural sedation and analgesia in the emergency department and intensive care unit: a systematic review and network meta-analysis of randomised trials

BACKGROUND

We aimed to evaluate the comparative effectiveness and safety of various i.v. pharmacologic agents used for procedural sedation and analgesia (PSA) in the emergency department (ED) and ICU. We performed a systematic review and network meta-analysis to enable direct and indirect comparisons between available medications.

METHODS

We searched Medline, EMBASE, Cochrane, and PubMed from inception to 2 March 2023 for RCTs comparing two or more procedural sedation and analgesia medications in all patients (adults and children >30 days of age) requiring emergent procedures in the ED or ICU. We focused on the outcomes of sedation recovery time, patient satisfaction, and adverse events (AEs). We performed frequentist random-effects model network meta-analysis and used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to rate certainty in estimates.

RESULTS

We included 82 RCTs (8105 patients, 78 conducted in the ED and four in the ICU) of which 52 studies included adults, 23 included children, and seven included both. Compared with midazolam-opioids, recovery time was shorter with propofol (mean difference 16.3 min, 95% confidence interval [CI] 8.4-24.3 fewer minutes; high certainty), and patient satisfaction was better with ketamine-propofol (mean difference 1.5 points, 95% CI 0.3-2.6 points, high certainty). Regarding AEs, compared with midazolam-opioids, respiratory AEs were less frequent with ketamine (relative risk [RR] 0.55, 95% CI 0.32-0.96; high certainty), gastrointestinal AEs were more common with ketamine-midazolam (RR 3.08, 95% CI 1.15-8.27; high certainty), and neurological AEs were more common with ketamine-propofol (RR 3.68, 95% CI 1.08-12.53; high certainty).

CONCLUSION

When considering procedural sedation and analgesia in the ED and ICU, compared with midazolam-opioids, sedation recovery time is shorter with propofol, patient satisfaction is better with ketamine-propofol, and respiratory adverse events are less common with ketamine.

Low-dose ketamine or opioids combined with propofol for procedural sedation in the emergency department: a systematic review

Procedural sedation is routinely performed for procedures in the emergency department (ED). Propofol is a commonly used sedative, frequently combined with an opioid or low-dose ketamine as an analgesic. However, there is still controversy on the optimal combination of agents in current guidelines. The objective of this systematic review is to identify and present studies comparing low-dose ketamine to opioids when combined with propofol for procedural sedation in the ED and to describe the dosing regimen, observed efficacy, and side effects. For this systematic review, following the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines, EMBASE and PubMed databases were searched. Studies comparing propofol with opioids versus propofol with low-dose (es)ketamine in patients undergoing procedural sedation for procedures in the ED were included. Analyses were descriptive because of the high heterogeneity among included studies. The outcomes were dosing regimen, efficacy of analgesia, efficacy of sedation depth, efficacy of recovery and (adverse) events. We included four out of 2309 studies found in the literature search. Overall, the studies had a low risk of bias, but the Grading of Recommendations Assessment, Development, and Evaluation evidence profile was downgraded due to the imprecision and inconsistency of the studies. All studies compared low-dose ketamine with fentanyl. Dosing ranged from 0.3 to 1.0 mg/kg (ketamine), 1.0-1.5 μg/kg (fentanyl) and 0.4-1.0 mg/kg (propofol). The efficacy of analgesia was measured by two studies, one favoring the fentanyl group, and one favoring the ketamine group. The efficacy of sedation depth was measured by one study, with the fentanyl group having a deeper sedation score. Two studies showed shorter recovery time with low-dose ketamine. One study showed a higher incidence of cardio-respiratory clinical events and interventions in the fentanyl group. Two studies showed significant differences of overall sedation events in the fentanyl group. One study did not find any significant differences of the incidence of sedation events. This systematic review did not provide sufficient evidence that the combination of low-dose ketamine and propofol is associated with a shorter recovery time and fewer sedation events compared to the combination of opioids and propofol.

Comparison of the Effect of Intravenous Fentanyl with Low-Dose Ketamine on Pain Relief in Patients Taking Methadone and Suffering from Limb Fractures

Background

Given the significance of pain control in addicted patients and the prominence of not using opioids due to patient's drug dependence, the present study aimed at comparing and evaluating the effect of intravenous fentanyl with low-dose ketamine on pain relief in patients taking methadone and suffering from limb fractures.

Materials and Methods

The present double-blind randomized clinical trial was performed on 100 patients taking methadone and suffering from limb fractures. The patients were divided into two groups receiving 1 μg/kg single dose of fentanyl and 0.3 mg/kg single dose of ketamine (low-dose ketamine). Patients' pain scores and the incidence rate of complications were recorded before the intervention, and 15, 30, and 60 min after drug administration and were then compared between the two groups.

Results

The mean pain score of patients 15 min after the intervention was significantly lower in the low-dose ketamine group with a mean of 2.50 ± 1.34 as compared with the fentanyl group with a mean of 7.10 ± 1.43 (P < 0.001). However, the mean pain score was not significantly different between the two groups 30 and 60 min after the intervention (P > 0.05). In addition, the incidence rate of complications was not significantly different between the two groups (P > 0.05).

Conclusion

According to the results of this study, low-dose ketamine as compared with fentanyl relieves pain in the mentioned patients with a faster effect and in a shorter time although no difference can be found between the pain scores of the two groups 30 and 60 min after the intervention.

The Influence of Age on Propofol Dosing Requirements During Procedural Sedation in the Emergency Department

Propofol is a frequently used agent for procedural sedation in the emergency department (ED). Some have suggested that propofol dosing in this setting should be adjusted in elderly patients; however, limited data exist supporting this recommendation. Additional factors that may contribute to altered propofol dose requirements in this setting have not been thoroughly explored. The objective of this analysis was to ascertain the effect age may have on the propofol dose required during procedural sedation in the ED. This retrospective study was conducted at a Level 1 academic medical center ED and included patients 18 years or older who received propofol for procedural sedation from 2015 to 2017. Those patients who were 18-64 years of age were compared with those 65 years or older. Between the two groups, total and weight-based propofol requirements for sedation, opioid doses, and adverse events were compared. This analysis included 101 procedural sedations. The median induction dose and opioid requirements before or during the procedure were not significantly different between the two groups. Compared with patients 18-64 years of age, those 65 years or older had significantly less total weight-based propofol requirements (p = 0.024) and required less total propofol for sedation (p = 0.007). In addition, patients 65 years or older required fewer repeat doses of propofol during the procedure than younger patients (p = 0.043). The incidence of adverse effects, including respiratory suppression, was not significantly different between the two groups. Patients 65 years or older may have lower weight-based propofol dosing requirements than younger patients. Utilizing a reduced total dose and repeat dosing strategy for propofol in this setting may be indicated. Further investigations are recommended to clarify factors that signal the need for more tailored dosing.