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Tamsett Z, Douglas N, King C, Johnston T, Bentley C, Hao B, Prinsloo D, Bourke EM. Does the choice of induction agent in rapid sequence intubation in the emergency department influence the incidence of post-induction hypotension? Emerg Med Australas 2024; 36:340-347. [PMID: 38018391 DOI: 10.1111/1742-6723.14355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 10/26/2023] [Accepted: 11/14/2023] [Indexed: 11/30/2023]
Abstract
OBJECTIVE To describe the effects of different induction agents on the incidence of post-induction hypotension (PIH) and its associated interventions during rapid sequence intubation (RSI) in the ED. METHODS A single centre retrospective study of patients intubated between 2018 and 2021 was conducted in a regional Australian ED. The impact of induction agent choice, in addition to demographic and clinical factors on the incidence of PIH were determined using descriptive statistics and a multivariate analysis presented as adjusted odds ratios (aORs) and their 95% confidence intervals (CIs). RESULTS Ketamine and propofol, used either individually or in conjunction with fentanyl, were significantly associated with PIH (ketamine aOR 4.5, 95% CI 1.35-14.96; propofol aOR 4.88, 95% CI 1.46-16.29). Age >60 years was associated with a greater requirement for vasopressors (aOR 4.46, 95% CI 2.49-7.97) and a higher risk of mortality after RSI (aOR 4.2, 95% CI 1.87-9.40). Patients with a shock index >1.0 were significantly more likely to require vasopressors (aOR 5.13, 95% CI 2.35-11.2) and have a cardiac arrest within 15 min of RSI (aOR 3.56, 95% CI 1.07-11.8). CONCLUSIONS Exposure to both propofol and ketamine is significantly associated with PIH after RSI, alongside age and shock index. PIH is likely multifactorial in nature, and this data supports the sympatholytic effect of induction agents as the underlying cause of PIH rather than the choice of agent itself. Further prospective work including a randomised controlled trial between induction agents is justified to further clarify this important clinical question.
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Affiliation(s)
- Zacchary Tamsett
- Department of Emergency Medicine, Grampians Health, Ballarat, Victoria, Australia
| | - Ned Douglas
- Department of Anaesthesia, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Cathy King
- Department of Emergency Medicine, Grampians Health, Ballarat, Victoria, Australia
- School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Tanya Johnston
- Department of Emergency Medicine, Grampians Health, Ballarat, Victoria, Australia
| | - Connor Bentley
- Department of Emergency Medicine, Grampians Health, Ballarat, Victoria, Australia
| | - Brian Hao
- Department of Emergency Medicine, Grampians Health, Ballarat, Victoria, Australia
| | - Duron Prinsloo
- Department of Emergency Medicine, Grampians Health, Ballarat, Victoria, Australia
| | - Elyssia M Bourke
- Department of Emergency Medicine, Grampians Health, Ballarat, Victoria, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Emergency Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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2
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Ferguson IMC, Miller MR, Partyka C, Bliss J, Aneman A, Harris IA. The effect of ketamine and fentanyl on haemodynamics during intubation in pre-hospital and retrieval medicine. Acta Anaesthesiol Scand 2023; 67:364-371. [PMID: 36495319 DOI: 10.1111/aas.14177] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/14/2022] [Accepted: 11/26/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Ketamine use for rapid sequence intubation (RSI) is frequent in pre-hospital and retrieval medicine (PHARM) and is associated with potentially deleterious haemodynamic changes, which may be ameliorated by concurrent use of fentanyl. OBJECTIVES To describe the frequency with which fentanyl is used in conjunction with ketamine in a system where its use is discretionary, and to explore any observed changes in haemodynamics with its use. METHODS A retrospective observational study of over 800 patients undergoing RSI with ketamine ± fentanyl in the PHARM setting between 2015 and 2019. The primary outcome was the proportion of patients in each group who had a systolic blood pressure (SBP) outside a pre-specified target range, with adjustment for baseline abnormality, within 10 min of anaesthetic induction. RESULTS Eight hundred and seventy-six patients were anaesthetised with ketamine, of whom 804 were included in the analysis. 669 (83%, 95% CI 80%-86%) received ketamine alone, and 135 (17%, 95% CI 14%-20%) received both fentanyl and ketamine. Median fentanyl dose was 1.1 mcg/kg (IQR 0.75-1.5 mcg/kg). Systolic blood pressure (SBP) at induction was consistently associated with SBP after intubation in multivariable logistic regression, but fentanyl use was not associated with a change in odds of meeting the primary outcome (OR 1.08; 95% CI 0.72-1.60), becoming hypertensive (OR 1.35; 95% CI 0.88-2.07) or hypotensive (OR 0.76; 95% CI 0.47-1.21). CONCLUSIONS The addition of fentanyl to ketamine for RSI was not associated with an alteration of the odds of post-induction haemodynamic stability, although the doses used were low. These findings justify further study into the optimal dosing of fentanyl during RSI in pre-hospital and retrieval medicine.
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Affiliation(s)
- Ian M C Ferguson
- Aeromedical Retrieval Service, New South Wales Ambulance, Rozelle, New South Wales, Australia.,South West Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Emergency Department, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Matthew R Miller
- Aeromedical Retrieval Service, New South Wales Ambulance, Rozelle, New South Wales, Australia.,St George Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Department of Anesthesiology, St George Hospital, Sydney, New South Wales, Australia
| | - Christopher Partyka
- Aeromedical Retrieval Service, New South Wales Ambulance, Rozelle, New South Wales, Australia.,South West Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - James Bliss
- Aeromedical Retrieval Service, New South Wales Ambulance, Rozelle, New South Wales, Australia.,South West Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Emergency Department, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Anders Aneman
- South West Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Intensive Care Unit, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Ian A Harris
- South West Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Whitlam Orthopaedic Research Centre, Liverpool, New South Wales, Australia
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Ferguson I, Buttfield A, Burns B, Reid C, Shepherd S, Milligan J, Harris IA, Aneman A. Fentanyl versus placebo with ketamine and rocuronium for patients undergoing rapid sequence intubation in the emergency department: The FAKT study-A randomized clinical trial. Acad Emerg Med 2022; 29:719-728. [PMID: 35064992 PMCID: PMC9314707 DOI: 10.1111/acem.14446] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/30/2021] [Accepted: 01/10/2022] [Indexed: 01/21/2023]
Abstract
Objective The objective was to determine whether the use of fentanyl with ketamine for emergency department (ED) rapid sequence intubation (RSI) results in fewer patients with systolic blood pressure (SBP) measurements outside the pre‐specified target range of 100–150 mm Hg following the induction of anesthesia. Methods This study was conducted in the ED of five Australian hospitals. A total of 290 participants were randomized to receive either fentanyl or 0.9% saline (placebo) in combination with ketamine and rocuronium, according to a weight‐based dosing schedule. The primary outcome was the proportion of patients in each group with at least one SBP measurement outside the prespecified range of 100–150 mm Hg (with adjustment for baseline abnormality). Secondary outcomes included first‐pass intubation success, hypotension, hypertension and hypoxia, mortality, and ventilator‐free days 30 days following enrollment. Results A total of 142 in the fentanyl group and 148 in the placebo group commenced the protocol. A total of 66% of patients receiving fentanyl and 65% of patients receiving placebo met the primary outcome (difference = 1%, 95% CI = −10 to 12). Hypotension (SBP ≤ 99 mm Hg) was more common with fentanyl (29% vs. 16%; difference = 13%, 95% CI = 3% to 23%), while hypertension (≥150 mm Hg) occurred more with placebo (69% vs. 55%; difference = 14%, 95% CI = 3 to 24). First‐pass success rate, 30 day mortality, and ventilator‐free days were similar. Conclusions and Relevance There was no difference in the primary outcome between groups, although lower blood pressures were more common with fentanyl. Clinicians should consider baseline hemodynamics and postinduction targets when deciding whether to use fentanyl as a coinduction agent with ketamine.
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Affiliation(s)
- Ian Ferguson
- South West Clinical School University of New South Wales Sydney New South Wales Australia
- Emergency Department Liverpool Hospital Sydney New South Wales Australia
- GSA‐HEMS, NSW Ambulance Bankstown Aerodrome Sydney New South Wales Australia
| | - Alexander Buttfield
- University of Western Sydney Sydney New South Wales Australia
- Campbelltown Hospital Sydney New South Wales Australia
| | - Brian Burns
- GSA‐HEMS, NSW Ambulance Bankstown Aerodrome Sydney New South Wales Australia
- University of Sydney, Discipline of Emergency Medicine Sydney New South Wales Australia
- Northern Beaches Hospital Sydney New South Wales Australia
| | - Cliff Reid
- GSA‐HEMS, NSW Ambulance Bankstown Aerodrome Sydney New South Wales Australia
- University of Sydney, Discipline of Emergency Medicine Sydney New South Wales Australia
- Northern Beaches Hospital Sydney New South Wales Australia
| | - Shamus Shepherd
- Orange Health Service Orange New South Wales Australia
- University of New South Wales Rural Clinical School Orange New South Wales Australia
| | - James Milligan
- Royal North Shore Hospital, St Leonards Sydney New South Wales Australia
- CareFlight Ltd Sydney New South Wales Australia
| | - Ian A. Harris
- South West Clinical School University of New South Wales Sydney New South Wales Australia
- Ingham Institute for Applied Medical Research Liverpool New South Wales Australia
| | - Anders Aneman
- South West Clinical School University of New South Wales Sydney New South Wales Australia
- Intensive Care Unit, Liverpool Hospital Liverpool New South Wales Australia
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Freeman J, Alkhouri H, Knipp R, Fogg T, Gillett M. Mapping haemodynamic changes with rapid sequence induction agents in the emergency department. Emerg Med Australas 2021; 34:237-243. [PMID: 34553502 DOI: 10.1111/1742-6723.13867] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/27/2021] [Accepted: 08/30/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Patients intubated in the ED are at an increased risk of post-intubation hypotension. However, evidence regarding the most appropriate induction agent is lacking. The present study aims to describe and compare the haemodynamic effect of propofol, ketamine and thiopentone during rapid sequence induction. METHODS This is an observational study using data prospectively collected from the Australian and New Zealand Emergency Department Airway Registry between June 2012 and March 2019. The distribution of induction agents across medical and trauma patients were obtained with descriptive statistics. The relationship between induction agent, dose and change in pre- and post-intubation systolic blood pressure (SBP) was described using multivariable logistic regression. The SBP pre- and post-intubation was the primary measure of haemodynamic stability. RESULTS From the 5063 intubation episodes, 2229 met the inclusion criteria. Of those, 785 (35.2%) patients were induced with thiopentone, 773 (34.7%) with propofol and 671 (30.1%) with ketamine. Of the included population, 396 (17.8%) patients experienced a reduction in pre-intubation SBP exceeding 20%. Both propofol (P = 0.01) and ketamine (P = 0.01) had an independent and dose-dependent association with hypotension, noting that a higher proportion of patients induced with ketamine had a shock index exceeding 0.9. CONCLUSION Propofol was associated with post-intubation hypotension and it is recommended clinicians consider using the lowest effective dose to reduce this risk. Reflecting its perceived haemodynamic stability, patients who received ketamine were more likely to have a higher shock index; however, there was also an association with post-intubation hypotension.
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Affiliation(s)
- Jessica Freeman
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Hatem Alkhouri
- Emergency Care Institute, Agency for Clinical Innovation, Sydney, New South Wales, Australia.,Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Robert Knipp
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Toby Fogg
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Mark Gillett
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
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Arnold I, Alkhouri H, Badge H, Fogg T, McCarthy S, Vassiliadis J. Current airway management practices after a failed intubation attempt in Australian and New Zealand emergency departments. Emerg Med Australas 2021; 33:808-816. [PMID: 33543598 DOI: 10.1111/1742-6723.13729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/05/2021] [Accepted: 01/10/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The aims of the present study were to describe current airway management practices after a failed intubation attempt in Australian and New Zealand EDs and to explore factors associated with second attempt success. METHODS Data were collected from a multicentre airway registry (The Australian and New Zealand Emergency Department Airway Registry). All intubation episodes that required a second attempt between March 2010 and November 2015 were analysed. Analysis for association with success at the second attempt was undertaken for patient factors including predicted difficulty of laryngoscopy, as well as for changes in laryngoscope type, adjunct devices, intubator and intubating manoeuvres. RESULTS Of the 762 patients with a failed first intubation attempt, 603 (79.1%) were intubated successfully at the second attempt. The majority of second attempts were undertaken by emergency consultants (36.8%) and emergency registrars (34.2%). A change in intubator occurred in 56.5% of intubation episodes and was associated with higher second attempt success (unadjusted odds ratio [OR] 1.85; 95% confidence interval [CI] 1.29-2.65). In 69.7% of second attempts at intubation, there was no change in laryngoscope type. Changes in laryngoscope type, adjunct devices and intubation manoeuvres were not significantly associated with success at the second attempt. In adjusted analyses, second attempt success was higher for a change from a non-consultant intubator to a consultant intubator from any specialty (adjusted OR 2.31; 95% CI 1.35-3.95) and where laryngoscopy was not predicted to be difficult (adjusted OR 2.58; 95% CI 1.58-4.21). CONCLUSIONS The majority of second intubation attempts were undertaken by emergency consultants and registrars. A change from a non-consultant intubator to a consultant intubator of any specialty for the second attempt and intubation episodes where laryngoscopy was predicted to be non-difficult were associated with a higher success rate at intubation. Participation in routine collection and monitoring of airway management practices via a Registry may enable the introduction of appropriate improvements in airway procedures and reduce complication rates.
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Affiliation(s)
- Isaac Arnold
- Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Hatem Alkhouri
- Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia.,Emergency Care Institute, Agency for Clinical Innovation, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Helen Badge
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia.,School of Allied Health, Faculty of Health Science, Australian Catholic University, Sydney, New South Wales, Australia
| | - Toby Fogg
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia.,CareFlight, Sydney, New South Wales, Australia
| | - Sally McCarthy
- Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia.,Emergency Care Institute, Agency for Clinical Innovation, Sydney, New South Wales, Australia.,Emergency Department, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - John Vassiliadis
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Discipline of Emergency Medicine, Northern Clinical School, The University of Sydney Medical School, Sydney, New South Wales, Australia
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6
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Baekgaard JS, Eskesen TG, Moo Lee J, Ikast Ottosen C, Bennett Gyldenkærne K, Garoussian J, Ejlersgaard Christensen R, Sillesen M, King DR, Velmahos GC, Rasmussen LS, Steinmetz J. Ketamine for rapid sequence intubation in adult trauma patients: A retrospective observational study. Acta Anaesthesiol Scand 2020; 64:1234-1242. [PMID: 32531068 DOI: 10.1111/aas.13651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 05/24/2020] [Accepted: 05/30/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND In the trauma population, ketamine is commonly used during rapid sequence induction. However, as ketamine has been associated with important side effects, this study sought to compare in-hospital mortality in trauma patients after induction with ketamine versus other induction agents. METHODS We retrospectively identified adult trauma patients intubated in the pre-hospital phase or initially in the trauma bay at two urban level-1 trauma centers during a 2-year period using local trauma registries and medical records. In-hospital mortality was compared for patients intubated with ketamine versus other agents using logistic regression with adjustment for age, gender, Injury Severity Score (ISS), systolic blood pressure (SBP) < 90 mm Hg, and pre-hospital Glasgow Coma Scale (GCS) score. RESULTS A total of 343 trauma patients were included with a median ISS of 25 [17-34]. The most frequently used induction agents were ketamine (36%) and propofol (36%) followed by etomidate (9%) and midazolam (5%). There was no difference in ISS or the presence of SBP <90 mm Hg according to the agent of choice, but the pre-hospital GCS score was higher for patients intubated with ketamine (median 8 vs 5, P = .001). The mortality for patients intubated with ketamine was 18% vs 27% for patients intubated with other agents (P = .14). This remained statistically insignificant in the multivariable logistic regression analysis (odds ratio 0.68 [0.33-1.41], P = .30). CONCLUSIONS We found no statistically significant difference in mortality among patients intubated in the initial phase post-trauma with the use of ketamine compared with other agents (propofol, etomidate, or midazolam).
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Affiliation(s)
- Josefine S. Baekgaard
- Department of Anesthesia Center of Head and Orthopedics, Rigshospitalet University of Copenhagen Copenhagen Denmark
- Department of Trauma Emergency Surgery & Surgical Critical Care Massachusetts General HospitalHarvard University Boston USA
| | - Trine G. Eskesen
- Department of Anesthesia Center of Head and Orthopedics, Rigshospitalet University of Copenhagen Copenhagen Denmark
- Department of Trauma Emergency Surgery & Surgical Critical Care Massachusetts General HospitalHarvard University Boston USA
| | - Jae Moo Lee
- Department of Trauma Emergency Surgery & Surgical Critical Care Massachusetts General HospitalHarvard University Boston USA
| | - Camilla Ikast Ottosen
- Department of Anesthesia Center of Head and Orthopedics, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Katrine Bennett Gyldenkærne
- Department of Anesthesia Center of Head and Orthopedics, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Jasmin Garoussian
- Department of Anesthesia Center of Head and Orthopedics, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | | | - Martin Sillesen
- Department of Surgical Gastroenterology Copenhagen University Hospital Rigshospitalet Denmark
| | - David R. King
- Department of Trauma Emergency Surgery & Surgical Critical Care Massachusetts General HospitalHarvard University Boston USA
| | - George C. Velmahos
- Department of Trauma Emergency Surgery & Surgical Critical Care Massachusetts General HospitalHarvard University Boston USA
| | - Lars S. Rasmussen
- Department of Anesthesia Center of Head and Orthopedics, Rigshospitalet University of Copenhagen Copenhagen Denmark
- Institute of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Jacob Steinmetz
- Department of Anesthesia Center of Head and Orthopedics, Rigshospitalet University of Copenhagen Copenhagen Denmark
- Institute of Clinical Medicine University of Copenhagen Copenhagen Denmark
- Trauma Center Center of Head and Orthopedics, Rigshospitalet University of Copenhagen Copenhagen Denmark
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7
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Algın A, Yıldırım Ç, Hökenek NM. The Use of Ketamine in Trauma Patients. ANKARA MEDICAL JOURNAL 2019. [DOI: 10.17098/amj.652006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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8
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DiRago M, Gerostamoulos D, Morris C, Fredericksen T, Woodford NW, Drummer OH. Prevalence of drugs in injured drivers in Victoria, Australia. AUST J FORENSIC SCI 2019. [DOI: 10.1080/00450618.2019.1687753] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Matthew DiRago
- Victorian Institute of Forensic Medicine, Southbank, Australia
- Department of Forensic Medicine, School of Public Health and Preventive Medicine, Monash University, Southbank, Australia
| | - Dimitri Gerostamoulos
- Victorian Institute of Forensic Medicine, Southbank, Australia
- Department of Forensic Medicine, School of Public Health and Preventive Medicine, Monash University, Southbank, Australia
| | - Carla Morris
- Victoria Police, Road Policing Drug and Alcohol Section, Victoria, Australia
| | - Tania Fredericksen
- Victoria Police, Road Policing Drug and Alcohol Section, Victoria, Australia
| | - Noel W. Woodford
- Victorian Institute of Forensic Medicine, Southbank, Australia
- Department of Forensic Medicine, School of Public Health and Preventive Medicine, Monash University, Southbank, Australia
| | - Olaf H. Drummer
- Victorian Institute of Forensic Medicine, Southbank, Australia
- Department of Forensic Medicine, School of Public Health and Preventive Medicine, Monash University, Southbank, Australia
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Ferguson I, Milligan J, Buttfield A, Shepherd S, Burns B, Reid C, Aneman A, Harris I. FentAnyl or placebo with KeTamine for emergency department rapid sequence intubation: The FAKT study protocol. Acta Anaesthesiol Scand 2019; 63:693-699. [PMID: 30656637 DOI: 10.1111/aas.13309] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 12/09/2018] [Accepted: 12/14/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Some critically ill patients require rapid sequence intubation in the emergency department, and ketamine is one sedative agent employed, due to its relative haemodynamic stability. Tachycardia and hypertension are frequent side effects, and in less stable patients, shock can be unmasked or exacerbated. The use of fentanyl as a co-induction agent may lead to a smoother haemodynamic profile post-induction, which may lead to reduced mortality in this critically ill cohort. This randomised controlled trial aims to compare the effect of administering fentanyl vs placebo in a standardised induction regimen with ketamine and rocuronium on (a) the percentage of patients in each group with a systolic blood pressure outside the range of 100-150 mm Hg within 10 minutes of induction, (b) the laryngoscopic view, and (c) 30-day mortality. METHODS/DESIGN Three hundred patients requiring rapid sequence intubation in participating emergency departments will be randomised to receive either fentanyl or placebo (0.9% saline) in addition to ketamine and rocuronium according to a standardised, weight-based induction regimen. The primary outcome measure is the percentage of patients in each group with a systolic blood pressure outside the range of 100-150 mm Hg within 10 minutes of induction. Secondary outcome measures include the laryngoscopic view, percentage of first pass success, 30-day mortality and number of ventilator-free days at 30 days. DISCUSSION The effect of adding fentanyl to an induction regimen of ketamine and rocuronium will be evaluated, both in terms of post-intubation physiology, the effect on intubating conditions, and 30-day mortality.
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Affiliation(s)
- Ian Ferguson
- Liverpool Hospital Liverpool BC New South Wales Australia
| | - James Milligan
- Royal North Shore Hospital St Leonards New South Wales Australia
| | - Alex Buttfield
- Campbelltown Hospital Campbelltown New South Wales Australia
| | | | - Brian Burns
- The Northern Beaches Hospital Frenchs Forest New South Wales Australia
| | - Cliff Reid
- The Northern Beaches Hospital Frenchs Forest New South Wales Australia
| | - Anders Aneman
- Liverpool Hospital Liverpool BC New South Wales Australia
| | - Ian Harris
- Liverpool Hospital Liverpool BC New South Wales Australia
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