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Zhang Y, Miller M, Buttfield A, Burns B, Lawrie K, Gaston J, Ferguson I. Alfentanil versus fentanyl for emergency department rapid sequence induction with ketamine: A-FAKT, a pilot randomized trial. Am J Emerg Med 2024; 84:25-32. [PMID: 39059038 DOI: 10.1016/j.ajem.2024.07.027] [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: 01/03/2024] [Revised: 06/12/2024] [Accepted: 07/14/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND Fentanyl is often administered during rapid sequence induction of anesthesia (RSI) in the emergency department (ED) to ameliorate the hypertensive response that may occur. Due to its more rapid onset, the use of alfentanil may be more consistent with both the onset time of the sedative and the commencement of laryngoscopy. As such, we compared the effect of alfentanil and fentanyl on post-induction hemodynamic changes when administered as part of a standardized induction regimen including ketamine and rocuronium in ED RSI. METHODS This was a double-blind pilot randomized controlled trial of adult patients requiring RSI in the ED of three urban Australian hospitals. Patients were randomized to receive either alfentanil or fentanyl in addition to ketamine and rocuronium for RSI. Non-invasive blood pressure and heart rate were measured immediately before and at two, four, and six minutes after induction. The primary outcome was the occurrence of at least one post-induction systolic blood pressure outside the pre-specified range of 100-160mmHg (with adjustment for patients with baseline hypertension). Secondary outcomes included hypertension, hypotension, hypoxia, first-pass intubation success, 30-day mortality, and the pattern of hemodynamic changes. RESULTS A total of 61 patients were included in the final analysis (31 in the alfentanil group and 30 in the fentanyl group). The primary outcome was met in 58% of the alfentanil group and 50% of the fentanyl group (difference 8%, 95% confidence interval: -17% to 33%). The 30-day mortality rate, first-pass success rate, and incidences of hypertension, hypotension, and hypoxia were similar between the groups. There were no significant differences in systolic blood pressure or heart rate between the groups at any of the measured time-points. CONCLUSION Alfentanil and fentanyl produced comparable post-induction hemodynamic changes when used as adjuncts to ketamine in ED RSI. Future studies could consider comparing different dosages of these opioids.
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Affiliation(s)
- Yichen Zhang
- South Western Sydney Clinical School, University of New South Wales, Warwick Farm, New South Wales, Australia.
| | - Matthew Miller
- Aeromedical Operations, New South Wales Ambulance, Bankstown Aerodrome, New South Wales, Australia; Department of Anaesthesia, St George Hospital, Kogarah, New South Wales, Australia; St George and Sutherland Clinical Schools, University of New South Wales, Kogarah, New South Wales, Australia
| | - Alexander Buttfield
- Emergency Department, Campbelltown Hospital, Campbelltown, New South Wales, Australia; School of Medicine, Western Sydney University, Campbelltown, New South Wales, Australia
| | - Brian Burns
- Aeromedical Operations, New South Wales Ambulance, Bankstown Aerodrome, New South Wales, Australia; Emergency Department, Northern Beaches Hospital, Frenchs Forest, New South Wales, Australia; Faculty of Medicine & Health, University of Sydney, Camperdown, New South Wales, Australia; Macquarie Medical School, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Kimberley Lawrie
- Aeromedical Operations, New South Wales Ambulance, Bankstown Aerodrome, New South Wales, Australia; Emergency Department, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - James Gaston
- Emergency Department, Campbelltown Hospital, Campbelltown, New South Wales, Australia; School of Medicine, Western Sydney University, Campbelltown, New South Wales, Australia
| | - Ian Ferguson
- South Western Sydney Clinical School, University of New South Wales, Warwick Farm, New South Wales, Australia; Aeromedical Operations, New South Wales Ambulance, Bankstown Aerodrome, New South Wales, Australia; Emergency Department, Liverpool Hospital, 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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Fouche PF, Meadley B, StClair T, Winnall A, Stein C, Jennings PA, Bernard S, Smith K. Temporal changes in blood pressure following prehospital rapid sequence intubation. Emerg Med J 2021; 39:451-456. [PMID: 34272210 DOI: 10.1136/emermed-2020-210887] [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: 11/04/2020] [Accepted: 07/09/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Rapid Sequence intubation (RSI) is an airway procedure that uses sedative and paralytic drugs to facilitate endotracheal intubation. It is known that RSI could impact blood pressure in the peri-intubation period. However, little is known about blood pressure changes in longer time frames. Therefore, this analysis aims to describe the changes in systolic blood pressure in a large cohort of paramedic-led RSI cases over the whole prehospital timespan. METHODS Intensive Care Paramedics in Victoria, Australia, are authorised to use RSI in medical or trauma patients with a Glasgow Coma Scale <10. This retrospective cohort study analysed data from patientcare records for patients aged 12 years and above that had received RSI, from 1 January 2008 to 31 December 2019. This study quantifies the systolic blood pressure changes using regression with fractional polynomial terms. The analysis is further stratified by high versus Low Shock Index (LSI). The shock index is calculated by dividing pulse rate by systolic blood pressure. RESULTS During the study period RSI was used in 8613 patients. The median number of blood pressure measurements was 5 (IQR 3-8). Systolic blood pressure rose significantly by 3.4 mm Hg (p<0.001) and then returned to baseline in the first 5 min after intubation for LSI cases. No initial rise in blood pressure is apparent in High Shock Index (HSI) cases. Across the whole cohort, systolic blood pressure decreased by 7.1 mm Hg (95% CI 7.9 to 6.3 mm Hg; p<0.001) from the first to the last blood pressure measured. CONCLUSIONS Our study shows that in RSI patients a small transient elevation in systolic blood pressure in the immediate postintubation period is found in LSI, but this elevation is not apparent in HSI. Blood pressure decreased over the prehospital phase in RSI patients with LSI, but increased for HSI cases.
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Affiliation(s)
- Pieter Francsois Fouche
- Department of Paramedicine, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
| | - Ben Meadley
- Paramedicine, Monash University Faculty of Medicine Nursing and Health Sciences, Frankston, Victoria, Australia.,Air Ambulance, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Toby StClair
- Ambulance Victoria, Melbourne, Victoria, Australia.,Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | | | - Christopher Stein
- Emergency Medical Care, University of Johannesburg, Johannesburg, Gauteng, South Africa
| | - Paul Andrew Jennings
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia.,Ambulance Victoria, Doncaster, Victoria, Australia
| | | | - Karen Smith
- Ambulance Victoria, Doncaster, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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