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Engstrom K, Brown CS, Mattson AE, Lyons N, Rech MA. Pharmacotherapy optimization for rapid sequence intubation in the emergency department. Am J Emerg Med 2023; 70:19-29. [PMID: 37196592 DOI: 10.1016/j.ajem.2023.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 05/04/2023] [Accepted: 05/04/2023] [Indexed: 05/19/2023] Open
Abstract
PURPOSE Rapid-sequence intubation (RSI) is the process of administering a sedative and neuromuscular blocking agent (NMBA) in rapid succession to facilitate endotracheal intubation. It is the most common and preferred method for intubation of patients presenting to the emergency department (ED). The selection and use of medications to facilitate RSI is critical for success. The purpose of this review is to describe pharmacotherapies used during the RSI process, discuss current clinical controversies in RSI medication selection, and review pharmacotherapy considerations for alternative intubation methods. SUMMARY There are several steps to the intubation process requiring medication considerations, including pretreatment, induction, paralysis, and post-intubation sedation and analgesia. Pretreatment medications include atropine, lidocaine, and fentanyl; but use of these agents in clinical practice has fallen out of favor as there is limited evidence for their use outside of select clinical scenarios. There are several options for induction agents, though etomidate and ketamine are the most used due to their more favorable hemodynamic profiles. Currently there is retrospective evidence that etomidate may produce less hypotension than ketamine in patients presenting with shock or sepsis. Succinylcholine and rocuronium are the preferred neuromuscular blocking agents, and the literature suggests minimal differences between succinylcholine and high dose rocuronium in first-pass success rates. Selection between the two is based on patient specific factors, half-life and adverse effect profiles. Finally, medication-assisted preoxygenation and awake intubation are less common methods for intubation in the ED but require different considerations for medication use. AREAS FOR FUTURE RESEARCH The optimal selection, dosing, and administration of RSI medications is complicated, and further research is needed in several areas. Additional prospective studies are needed to determine optimal induction agent selection and dosing in patients presenting with shock or sepsis. Controversy exists over optimal medication administration order (paralytic first vs induction first) and medication dosing in obese patients, but there is insufficient evidence to significantly alter current practices regarding medication dosing and administration. Further research examining awareness with paralysis during RSI is needed before definitive and widespread practice changes to medication use during RSI can be made.
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Affiliation(s)
- Kellyn Engstrom
- Department of Pharmacy, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, United States of America.
| | - Caitlin S Brown
- Department of Pharmacy, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Alicia E Mattson
- Department of Pharmacy, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Neal Lyons
- Loyola University Chicago, Loyola University Medical Center, Stritch School of Medicine, Department of Emergency Medicine, S 1st Ave, Maywood, IL 60153, United States of America; Loyola University Medical Center, Department of Pharmacy, S 1st Ave, Maywood, IL 60153, United States of America
| | - Megan A Rech
- Loyola University Chicago, Loyola University Medical Center, Stritch School of Medicine, Department of Emergency Medicine, S 1st Ave, Maywood, IL 60153, United States of America; Loyola University Medical Center, Department of Pharmacy, S 1st Ave, Maywood, IL 60153, United States of America
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Ferguson I, Bliss J, Aneman A. Does the addition of fentanyl to ketamine improve haemodynamics, intubating conditions or mortality in emergency department intubation: A systematic review. Acta Anaesthesiol Scand 2019; 63:587-593. [PMID: 30644096 DOI: 10.1111/aas.13314] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 11/09/2018] [Accepted: 11/25/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Ketamine is an induction agent frequently used for general anaesthesia in emergency medicine. Generally regarded as haemodynamically stable, it can cause hypertension and tachycardia and may cause or worsen shock. The effects of ketamine may be improved by the addition of fentanyl to the induction regime. We conducted a systematic review to identify evidence with regard to the effect of adding fentanyl to an induction regime of ketamine and a paralysing agent on post-induction haemodynamics, intubating conditions and mortality. METHODS We conducted a search of the Cochrane library, EMBASE, MEDLINE, PROQUEST, OpenGrey and clinical trial registries. Prominent authors were contacted in order to identify additional literature pertinent to the research question. Studies were included if they pertained to intubation of adult patients in the prehospital or emergency department environments and included an induction regime of ketamine and a paralysing agent, with at least one outcome measure of haemodynamics, intubating conditions or mortality. Search results were reviewed by two investigators independently, adjudicated by a third investigator where disagreement occurred. RESULTS One observational study was identified that partially answered the research question. DISCUSSION Only one observational study was identified that partially answered the research question. This paper demonstrated that the use of fentanyl as a pretreatment increases the incidence of post-induction hypotension, a phenomenon that was seen with propofol, midazolam and ketamine. The difference in hypotension between these agents was not statistically significant. The impact of this on patient-orientated outcomes is unclear.
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Affiliation(s)
- Ian Ferguson
- Emergency Department Liverpool Hospital Liverpool New South Wales Australia
- Greater Sydney Area HEMSAmbulance NSW Sydney New South Wales Australia
- South West Sydney Clinical School University of New South Wales Sydney New South Wales Australia
| | - James Bliss
- Emergency Department Liverpool Hospital Liverpool New South Wales Australia
- Greater Sydney Area HEMSAmbulance NSW Sydney New South Wales Australia
| | - Anders Aneman
- South West Sydney Clinical School University of New South Wales Sydney New South Wales Australia
- Department of Intensive Care Medicine Liverpool Hospital Sydney New South Wales Australia
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Ducharme J. Propofol in the emergency department: another interpretation of the evidence. CAN J EMERG MED 2015; 3:311-2. [PMID: 17610775 DOI: 10.1017/s1481803500005820] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- J Ducharme
- Emergency Medicine, Atlantic Health Sciences Corporation, Saint John, New Brunswick, Canada
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Efficacy, safety and patient satisfaction of propofol for procedural sedation and analgesia in the emergency department: a prospective study. CAN J EMERG MED 2015; 9:421-7. [DOI: 10.1017/s148180350001544x] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ABSTRACT
Objective:
We evaluated the efficacy, safety and patient satisfaction with the use of propofol for procedural sedation and analgesia in the emergency department (ED).
Methods:
All patients receiving propofol for procedural sedation and analgesia in the ED between December 1, 2003, and November 30, 2005, were prospectively assessed. Propofol was administered using a standardized protocol, which included an initial dose of 0.25–0.5 mg/kg followed by 10–20 mg/minute until sedated. Efficacy was evaluated using procedural success rate, recovery time and physician satisfaction. Adverse respiratory effects were defined as apnea for more than 30 seconds or an oxygen saturation of less than 90%. Hypotension was defined as systolic blood pressure < 90 mm Hg or > 20% decrease from baseline. Patient and physician satisfaction were determined using 5-point Likert scales.
Results:
Our study included 113 patients with a mean age of 50 (standard deviation [SD] 19) years; 62% were male. The most common procedures were orthopedic manipulation (44%), cardioversion (37%), and abscess incision and drainage (13%). The mean total propofol dose required was 1.6 (SD 0.9) mg/kg. Procedural success was achieved in 90% of cases and the mean patient recovery time was 7.6 (SD 3.4) minutes. No patient (0%, 95% confidence interval [CI] 0%–3%) experienced apnea; however, 1 patient (1%, 95% CI 0%–5%) experienced emesis, which resulted in an oxygen saturation <90%. Nine patients (8%, 95% CI 4%–15%) experienced hypotension and 7 (6%, 95% CI 3%–12%) experienced pain on injection. All patients were very satisfied (92%, 95% CI 85%–96%) or satisfied (8%, 95% CI 4%–15%), and 94% (95% CI 88%–98%) reported no recollection of the procedure. The majority of physicians were very satisfied (85%, 95% CI 77%–91%) or satisfied (6%, 95% CI 3%–12%) with the sedation and the conditions achieved.
Conclusion:
When administered as part of a standardized protocol, propofol appears to be a safe and effective agent for performing procedural sedation and analgesia in the ED, and is associated with high patient and physician satisfaction.
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Stollings JL, Diedrich DA, Oyen LJ, Brown DR. Rapid-sequence intubation: a review of the process and considerations when choosing medications. Ann Pharmacother 2013; 48:62-76. [PMID: 24259635 DOI: 10.1177/1060028013510488] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To summarize published data regarding the steps of rapid-sequence intubation (RSI); review premedications, induction agents, neuromuscular blockers (NMB), and studies supporting use or avoidance; and discuss the benefits and deficits of combinations of induction agents and NMBs used when drug shortages occur. DATA SOURCE A search of Medline databases (1966-October 2013) was conducted. STUDY SELECTION AND DATA EXTRACTION Databases were searched using the terms rapid-sequence intubation, fentanyl, midazolam, atropine, lidocaine, phenylephrine, ketamine, propofol, etomidate thiopental, succinylcholine, vecuronium, atracurium, and rocuronium. Citations from publications were reviewed for additional references. DATA SYNTHESIS Data were reviewed to support the use or avoidance of premedications, induction agents, and paralytics and combinations to consider when drug shortages occur. CONCLUSIONS RSI is used to secure a definitive airway in often uncooperative, nonfasted, unstable, and/or critically ill patients. Choosing the appropriate premedication, induction drug, and paralytic will maximize the success of tracheal intubation and minimize complications.
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Coadministration of the AMPAKINE CX717 with propofol reduces respiratory depression and fatal apneas. Anesthesiology 2013; 118:1437-45. [PMID: 23542802 DOI: 10.1097/aln.0b013e318291079c] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Propofol (2,6-diisopropylphenol) is used for the induction and maintenance of anesthesia in human and veterinary medicine. Propofol's disadvantages include the induction of respiratory depression and apnea. Here, the authors report a clinically feasible pharmacological solution for reducing propofol-induced respiratory depression via a mechanism that does not interfere with anesthesia. Specifically, they test the hypothesis that the AMPAKINE CX717, which has been proven metabolically stable and safe for human use, can prevent and rescue from propofol-induced severe apnea. METHODS The actions of propofol and the AMPAKINE CX717 were measured via (1) ventral root recordings from newborn rat brainstem-spinal cord preparations, (2) phrenic nerve recordings from an adult mouse in situ working heart-brainstem preparation, and (3) plethysmographic recordings from unrestrained newborn and adult rats. RESULTS In vitro, respiratory depression caused by propofol (2 μM, n = 11, mean ± SEM, 41 ± 5% of control frequency, 63 ± 5% of control duration) was alleviated by CX717 (n = 4, 50-150 μM). In situ, a decrease in respiratory frequency (44 ± 9% of control), phrenic burst duration (66 ± 7% of control), and amplitude (78 ± 5% of control) caused by propofol (2 μM, n = 5) was alleviated by coadministration of CX717 (50 μM, n = 5). In vivo, pre- or coadministration of CX717 (20-25mg/kg) with propofol markedly reduced propofol-induced respiratory depression (n = 7; 20mg/kg) and propofol-induced lethal apnea (n = 6; 30 mg/kg). CONCLUSIONS Administration of CX717 before or in conjunction with propofol provides an increased safety margin against profound apnea and death.
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Randomised Comparative Study on Propofol and Diazepam as a Sedating Agent in Day Care Surgery. J Maxillofac Oral Surg 2013. [PMID: 26225032 DOI: 10.1007/s12663-013-0537-0] [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] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE The study was conducted to assess the usefulness by qualitative comparison between the two intravenous sedative drugs, Diazepam and Propofol and to provide sedation in apprehensive and uncooperative patients undergoing day care oral surgical procedures. METHODS The present study was conducted on 20 adult patients, 10 in each group (Propofol and Diazepam) irrespective of age and sex. Intravenous sedation of Propofol compared with Diazepam in terms of onset of action, recovery, and anterograde amnesia, patient co-operation, surgeon's convenience and side effects and other parameters. RESULTS Propofol was found to be the superior sedating agent compared to Diazepam, having rapid onset and predictability of action, profoundness of amnesia and a faster recovery period, offering advantages of early patient discharge and better patient compliance. CONCLUSION Propofol was found to be an ideal sedating agent in day care oral surgical procedures.
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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.
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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
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Nemeth J, Maghraby N, Kazim S. Emergency Airway Management: the Difficult Airway. Emerg Med Clin North Am 2012; 30:401-20, ix. [DOI: 10.1016/j.emc.2011.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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de La Coussaye JE, Adnet F. Sédation et analgésie en structure d’urgence. Quelles sont les modalités de sédation et/ou d’analgésie pour la réalisation d’un choc électrique externe ? ACTA ACUST UNITED AC 2012; 31:343-6. [DOI: 10.1016/j.annfar.2012.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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[Sedation and analgesia in emergency structure. Which sedation and/or analgesia for tracheal intubation?]. ACTA ACUST UNITED AC 2012; 31:313-21. [PMID: 22440814 DOI: 10.1016/j.annfar.2012.01.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Bajwa SJS, Kulshrestha A. Renal endocrine manifestations during polytrauma: A cause of concern for the anesthesiologist. Indian J Endocrinol Metab 2012; 16:252-7. [PMID: 22470863 PMCID: PMC3313744 DOI: 10.4103/2230-8210.93744] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Nowadays, an increasing number of patients get admitted with polytrauma, mainly due to road traffic accidents. These polytrauma victims may exhibit associated renal injuries, in addition to bone injuries and injuries to other visceral organs. Nevertheless, even in cases of polytrauma, renal tissue is hyperfunctional as part of the normal protective responses of the body to external insults. Both polytrauma and renal injuries exhibit widespread renal, endocrine, and metabolic responses. The situation is very challenging for the attending anesthesiologist, as he is expected to contribute immensely, not only in the resuscitation of such patients, but if required, to allow the operative procedures in case of life-threatening injuries. During administration of anesthesia, care has to be taken, not only to maintain hemodynamic stability, but equal attention has to be paid to various renal protection strategies. At the same time, various renoendocrine manifestations have to be taken into account, so that a judicious use of anesthesia drugs can be made, to minimize the renal insults.
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Affiliation(s)
- Sukhminder Jit Singh Bajwa
- Department of Anesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab, India
| | - Ashish Kulshrestha
- Department of Anesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab, India
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Scarponcini TR, Edwards CJ, Rudis MI, Jasiak KD, Hays DP. The role of the emergency pharmacist in trauma resuscitation. J Pharm Pract 2011; 24:146-59. [PMID: 21712210 DOI: 10.1177/0897190011400550] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The clinical pharmacist in the emergency department is now commonly incorporated as a member of the emergency department trauma team. As such, the emergency pharmacist needs to have detailed knowledge of the pharmacotherapy of resuscitation and be able to apply the skills needed to function as a valuable member of this team. In addition to the traditional skills of the discipline of clinical pharmacy, the emergency pharmacist must be familiar with the intricacies of treating life-threatening injuries in an emergent setting and be able to anticipate the direction of the patient's care. The ability to provide valuable pharmacological interventions throughout the resuscitation and stabilization process requires familiarity with the process of resuscitation, including rapid sequence induction, analgesia and sedation, seizure prophylaxis, appropriate antibiotic and tetanus prophylaxis, intracranial pressure control, hemodynamic stabilization, and any other specific drug therapy that the clinical situation demands. This article discusses the aforementioned pharmacotherapeutic topics and describes the role of the Emergency Pharmacist on the ED trauma team.
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David H, Shipp J. A randomized controlled trial of ketamine/propofol versus propofol alone for emergency department procedural sedation. Ann Emerg Med 2011; 57:435-41. [PMID: 21256626 DOI: 10.1016/j.annemergmed.2010.11.025] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Revised: 11/15/2010] [Accepted: 11/19/2010] [Indexed: 01/12/2023]
Abstract
STUDY OBJECTIVE We compare the frequency of respiratory depression during emergency department procedural sedation with ketamine plus propofol versus propofol alone. Secondary outcomes are provider satisfaction, sedation quality, and total propofol dose. METHODS In this randomized, double-blind, placebo-controlled trial, healthy children and adults undergoing procedural sedation were pretreated with intravenous fentanyl and then randomized to receive either intravenous ketamine 0.5 mg/kg or placebo. In both groups, this procedure was immediately followed by intravenous propofol 1 mg/kg, with repeated doses of 0.5 mg/kg as needed to achieve and maintain sedation. Respiratory depression was defined according to any of 5 predefined markers. Provider satisfaction was scored on a 5-point scale, sedation quality with the Colorado Behavioral Numerical Pain Scale, and propofol dose according to the total number of milligrams of propofol administered. RESULTS The incidence of respiratory depression was similar between the ketamine/propofol (21/97; 22%) and propofol-alone (27/96; 28%) groups, difference 6% (95% confidence interval -6% to 18%). With ketamine/propofol compared with propofol alone, treating physicians and nurses were more satisfied, less propofol was administered, and there was a trend toward better sedation quality. CONCLUSION Compared with procedural sedation with propofol alone, the combination of ketamine and propofol did not reduce the incidence of respiratory depression but resulted in greater provider satisfaction, less propofol administration, and perhaps better sedation quality.
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Affiliation(s)
- Henry David
- Department of Emergency Medicine, University of Missouri–Columbia, Columbia, MO 65212, USA.
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Slavik VC, Zed PJ. Combination Ketamine and Propofol for Procedural Sedation and Analgesia. Pharmacotherapy 2007; 27:1588-98. [DOI: 10.1592/phco.27.11.1588] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Loh G, Dalen D. Low-dose ketamine in addition to propofol for procedural sedation and analgesia in the emergency department. Ann Pharmacother 2007; 41:485-92. [PMID: 17341533 DOI: 10.1345/aph.1h522] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy and safety of low-dose intravenous ketamine in addition to intravenous propofol for procedural sedation and analgesia in the emergency department (ED). DATA SOURCES Articles were identified using PubMed (1949-February 2007), MEDLINE (1966-February 2007), EMBASE (1980-February 2007), BioMed Central (to February 2007), the Cochrane Library (to February 2007), International Pharmaceutical Abstracts, and Google Scholar (until February 2007). Reference citations from retrieved publications were also reviewed. Search terms included ketamine, propofol, ketamine-propofol, ketofol, combination, sedation, procedural sedation, conscious sedation, and emergency department. STUDY SELECTION AND DATA EXTRACTION All articles on prospective procedural sedation that were published or translated into English and that compared combination ketamine-propofol with an appropriate comparator group were included. Clinically relevant safety endpoints included the frequency of significant hemodynamic and respiratory compromise warranting medical intervention, nausea, vomiting, and emergence reactions. Time until hospital discharge criteria were met and patient satisfaction scores were efficacy endpoints of interest. DATA SYNTHESIS Of the 11 trials included in this review, most had small sample sizes and were conducted in non-ED settings. The ketamine-propofol combination demonstrated no additional efficacy over propofol in terms of time to discharge. Although fewer patients given the ketamine-propofol combination experienced significant hemodynamic and respiratory compromise, need for active interventions, including fluid or vasopressor administration, supplemental oxygen, or assisted ventilation did not differ between groups. Patients who received higher doses of adjuvant ketamine reported an increased incidence of nausea, vomiting, and emergence reactions following the procedure. Few studies reported patient satisfaction scores postprocedure, and effect of ketaminepropofol on time-to-discharge criteria met was inconclusive. CONCLUSIONS At this time, insufficient clinical evidence exists to recommend the routine use of low-dose ketamine with propofol for procedural sedation in the ED setting.
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Affiliation(s)
- Gabriel Loh
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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Abstract
OBJECTIVE To review the current efficacy and safety evidence for the use of etomidate for procedural sedation in the emergency department (ED). DATA SOURCES MEDLINE (1966-December 2003), EMBASE (1980-December 2003), PubMED (1966-December 2003), and Cochrane Database of Systemic Reviews (up to December 2003) were searched for full-text reports published in English on the use of etomidate in humans. Search terms included etomidate, procedural sedation, conscious sedation, relocation, dislocation, abscess incision, abscess drainage, and cardioversion. STUDY SELECTION AND DATA EXTRACTION Prospective and retrospective studies evaluating efficacy or safety endpoints using etomidate for procedural sedation in the ED were included. All studies were evaluated independently by both authors. For clinical outcomes (efficacy, safety), the definitions specified by each study were used. DATA SYNTHESIS Three observational studies and 5 prospective, randomized controlled trials were included in this review. Onset of action and time to recovery following etomidate were rapid and found to be comparable to that of propofol and thiopental but significantly faster than that of midazolam. The dose of etomidate for procedural sedation ranged from 0.15 to 0.22 mg/kg. No significant hemodynamic effects were observed; however, respiratory depression resulting in oxygen desaturation to <90% or apnea appears to occur in approximately 10% of patients undergoing procedural sedation with etomidate with or without analgesia. The most prominent adverse effect reported with etomidate was myoclonus, occurring in 20-45% of patients. CONCLUSIONS Etomidate is an appropriate and valuable agent for performing procedural sedation in the ED. The rapid onset and recovery time and relative lack of significant hemodynamic and respiratory effects may facilitate optimal and safe conditions for procedural sedation in the ED.
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Affiliation(s)
- Jamie Falk
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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