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Khan MT, Khan AR, Rohail S, Raza FA, Ahmed S, Siddiqui A, Kumar J, Yasinzai AQK, Sohail AH, Goyal A. Safety of procedural sedation in emergency department settings among the adult population: a systematic review and meta-analysis of randomized controlled trials. Intern Emerg Med 2024; 19:1385-1403. [PMID: 39102153 DOI: 10.1007/s11739-024-03697-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 06/25/2024] [Indexed: 08/06/2024]
Abstract
Procedural sedation and analgesia (PSA) are a common practice in emergency departments (EDs), aiming to alleviate pain, anxiety, and discomfort during various medical procedures. We have undertaken a systematic review and meta-analysis with the aim of assessing the incidence of adverse events associated with PSA, including those related to individual drugs and various drug combinations. The study adhered to PRISMA guidelines for a systematic review and meta-analysis of adverse events in ED sedation. A comprehensive search strategy was employed across ten databases, supplemented by searches on clinicaltrials.gov and manual reviews of reference lists. Data extraction focused on medication administration and adverse events. The study considered four types of adverse events: cardiac, respiratory, gastrointestinal, and neurological. Only randomized controlled trials (RCTs) focusing on PSA administered to adult patients within the ED setting were included. The statistical analysis employed OpenMeta Analyst to conduct a one-arm meta-analysis, with findings presented alongside their corresponding 95% Confidence Intervals. Forest plots were constructed to combine and evaluate results, and sensitivity analyses were performed to identify sources of heterogeneity. From a literature search of 4246 records, 32 RCTs were deemed suitable for this meta-analysis. The analysis included 6377 procedural sedations. The most common adverse event was hypoxia, with an incidence rate of 78.5 per 1000 sedations (95% CI = 77.5-133.5). This was followed by apnea and hypotension, with incidence rates of 31 (95% CI = 19.5-41.8) and 28.1 (95% CI = 17.4-38.9) per 1,000 sedations, respectively. Agitation and vomiting each occurred in 15.6 per 1,000 sedations (95% CI = 8.7-22.6). Severe adverse events were rare, with bradycardia observed in 16.7 per 1,000 sedations, laryngospasm in 2.9 per 1,000 sedations (95% CI = - 0.1 to 6), intubation in 10.8 per 1,000 sedations (95% CI = 4-17), and aspiration in 2.7 per 1,000 sedations (95% CI = - 0.3 to 5.7). Ketamine is found to be the safest option in terms of respiratory adverse events, with the lowest rates of apnea and hypoxia, making it the least respiratory depressant among the evaluated drugs. Etomidate has the least occurrence of hypotension when used alone. Propofol has the highest incidence of hypotension when used alone and ranks second in hypoxia-related adverse events after midazolam. Using combinations of sedating agents, such as propofol and ketamine, has been found to offer several advantages over single drugs, especially in reducing adverse events like vomiting, intubation difficulty, hypotension, bradycardia, and laryngospasm. The combination significantly reduces the incidence of hypotension compared to using propofol or ketamine individually. Despite the regular use of procedural sedation, it can sometimes lead to serious adverse events. Respiratory issues like apnea and hypoxia, while not common, do occur more often than cardiovascular problems such as hypotension. However, the least frequent respiratory complications, which can also pose a threat to life, include laryngospasm, aspiration, and intubation. These incidents are extremely rare.
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Affiliation(s)
- Muhammad Taha Khan
- Department of Internal Medicine, Karachi Medical and Dental College, Karachi, Pakistan
| | - Ayesha Rahman Khan
- Department of Internal Medicine, Karachi Medical and Dental College, Karachi, Pakistan
| | - Samia Rohail
- Department of Internal Medicine, Karachi Medical and Dental College, Karachi, Pakistan
| | - Fatima Ali Raza
- Department of Internal Medicine, Karachi Medical and Dental College, Karachi, Pakistan
| | - Shahzaib Ahmed
- Department of Internal Medicine, Fatima Memorial Hospital College of Medicine and Dentistry, Lahore, Pakistan
| | - Amna Siddiqui
- Department of Internal Medicine, Karachi Medical and Dental College, Karachi, Pakistan
| | - Jai Kumar
- Department of Internal Medicine, Karachi Medical and Dental College, Karachi, Pakistan
| | | | - Amir Humza Sohail
- Department of Surgery, University of New Mexico, Albuquerque, NM, USA
| | - Aman Goyal
- Department of Internal Medicine, Seth GS Medical College and KEM Hospital, Mumbai, India, 400012.
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Sharif S, Kang J, Sadeghirad B, Rizvi F, Forestell B, Greer A, Hewitt M, Fernando SM, Mehta S, Eltorki M, Siemieniuk R, Duffett M, Bhatt M, Burry L, Perry JJ, Petrosoniak A, Pandharipande P, Welsford M, Rochwerg B. 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. Br J Anaesth 2024; 132:491-506. [PMID: 38185564 DOI: 10.1016/j.bja.2023.11.050] [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: 08/07/2023] [Revised: 09/29/2023] [Accepted: 11/30/2023] [Indexed: 01/09/2024] Open
Abstract
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.
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Affiliation(s)
- Sameer Sharif
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada; Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
| | - Jasmine Kang
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Fayyaz Rizvi
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ben Forestell
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Alisha Greer
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada; Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Mark Hewitt
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada; Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Shannon M Fernando
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada; Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Sangeeta Mehta
- Department of Medicine, Sinai Health System; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Mohamed Eltorki
- Department of Pediatrics, Division of Pediatric Emergency Medicine, McMaster University, Ottawa, ON, Canada
| | - Reed Siemieniuk
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Mark Duffett
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Maala Bhatt
- Department of Medicine, Sinai Health System, Interdepartmental Division of Critical Care Medicine, Toronto, ON, Canada
| | - Lisa Burry
- Department of Medicine, Sinai Health System; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Pharmacy, Sinai Health System, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Jeffrey J Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Andrew Petrosoniak
- Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada
| | - Pratik Pandharipande
- Department of Anesthesiology, Division of Critical Care, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Michelle Welsford
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Bram Rochwerg
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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Henao Zapata JA, Herrera Echeverry C, Montealegre Arturo JS, Ordoñez Lizarralde RA, Valbuena Pabón JC. Inducción Anestésica: Propofol, Ketamina o Ketofol ¿Cuándo utilizarlos? UNIVERSITAS MÉDICA 2023. [DOI: 10.11144/javeriana.umed63-4.prop] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Introducción: La anestesia general se subdivide en diferentes etapas donde una de las más importantes es la etapa de la inducción anestésica y los fármacos que se utilizan en ella, siendo el Propofol y la Ketamina los más nombrados
Objetivo: Realizar una revisión de las propiedades farmacocinéticas y farmacodinámicas de estos dos medicamentos, para la toma de decisiones sobre en qué situaciones debería usarse cada uno de ellos o de forma concomitante
Materiales y métodos: Se realizaron 4 búsquedas separadas en la base de datos de PUBMED, obteniendo un total de 27 bibliografías utilizadas para la revisión.
Resultados: El propofol es un agente hipnótico útil para procedimientos cortos, en pacientes estables hemodinámicamente. La ketamina tiene un perfil farmacodinámico ideal para pacientes con inestabilidad hemodinámica. El ketofol es una alternativa que logra adecuado sinergismo permitiendo mantener los beneficios de cada uno de estos medicamentos y disminuyendo la probabilidad de efectos adversos.
Conclusión: Dependiendo de la cirugía que se vaya a realizar y de la estabilidad hemodinámica de cada paciente se puede preferir un medicamento sobre otro.
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Grégoire C, De Kock M, Henrie J, Cren R, Lavand'homme P, Penaloza A, Verschuren F. Procedural Sedation With Dexmedetomidine in Combination With Ketamine in the Emergency Department. J Emerg Med 2022; 63:283-289. [PMID: 35550843 DOI: 10.1016/j.jemermed.2022.01.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 12/30/2021] [Accepted: 01/25/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Dexmedetomidine is an alternative agent for procedural sedation in the emergency department thanks to its ability to maintain hemodynamic and respiratory stability. Dexmedetomidine must, however, be combined with a powerful analgesic. OBJECTIVE Our aim was to evaluate the quality and safety of procedural sedation using the combination of dexmedetomidine and ketamine for patients undergoing painful procedures in the emergency department. METHODS This prospective interventional single-center study was conducted in an academic emergency department of an urban hospital in Brussels, Belgium. Patients received a bolus injection of 1 µg/kg dexmedetomidine over 10 min and then a continuous infusion of 0.6 µg/kg/h followed by a bolus of 1 mg/kg ketamine. The painful procedure was carried out 1 min later. The level of pain was evaluated with a numerical rating scale from 0 (no pain) to 10 (maximal pain). The level of patient comfort for the procedure was measured using a comfort scale. RESULTS Thirty patients were included. Overall, 90% of patients felt little or no pain (n = 29 of 30) or discomfort (n = 28 of 30) during the procedure. One patient experienced apnea with desaturation, which was resolved by a jaw-thrust maneuver. Although 23% of patients had significant arterial hypertension, none required drug treatment. CONCLUSIONS The combination of dexmedetomidine and ketamine provides conscious sedation, bringing comfort and pain relief to patients in optimal conditions for respiratory and hemodynamic safety. However, sedation and recovery times are longer than with conventional drug combinations. The dexmedetomidine-ketamine combination should therefore be recommended for nonurgent procedures and fragile patients.
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Affiliation(s)
- Charles Grégoire
- Emergency Department, Cliniques Universitaires Saint-Luc, Brussels Belgium.
| | - Marc De Kock
- Anesthesia Intensive Care, Centre Hospitalier de Wallonie Picarde, Tournai, Belgium
| | - Julie Henrie
- Emergency Department, Cliniques Universitaires Saint-Luc, Brussels Belgium
| | - Rosen Cren
- Emergency Department, Cliniques Universitaires Saint-Luc, Brussels Belgium
| | | | - Andrea Penaloza
- Emergency Department, Cliniques Universitaires Saint-Luc, Brussels Belgium
| | - Franck Verschuren
- UCLouvain, Experimental and Clinical Research Institute, Acute Medicine Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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Midega TD, Chaves RCDF, Ashihara C, Alencar RM, Queiroz VNF, Zelezoglo GR, Vilanova LCDS, Olivato GB, Cordioli RL, Bravim BDA, Corrêa TD. Ketamine use in critically ill patients: a narrative review. Rev Bras Ter Intensiva 2022; 34:287-294. [PMID: 35946660 DOI: 10.5935/0103-507x.20220027-pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 05/08/2022] [Indexed: 11/20/2022] Open
Abstract
Ketamine is unique among anesthetics and analgesics. The drug is a rapid-acting general anesthetic that produces an anesthetic state characterized by profound analgesia, preserved pharyngeal-laryngeal reflexes, normal or slightly enhanced skeletal muscle tone, cardiovascular and respiratory stimulation, and occasionally a transient and minimal respiratory depression. Research has demonstrated the efficacy of its use on anesthesia, pain, palliative care, and intensive care. Recently, it has been used for postoperative and chronic pain, as an adjunct in psychotherapy, as a treatment for depression and posttraumatic stress disorder, as a procedural sedative, and as a treatment for respiratory and/or neurologic clinical conditions. Despite being a safe and widely used drug, many physicians, such as intensivists and those practicing in emergency care, are not aware of the current clinical applications of ketamine. The objective of this narrative literature review is to present the theoretical and practical aspects of clinical applications of ketamine in intensive care unit and emergency department settings.
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Affiliation(s)
- Thais Dias Midega
- Departamento de Medicina Intensiva, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | | | - Carolina Ashihara
- Departamento de Anestesiologia, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | - Roger Monteiro Alencar
- Departamento de Medicina Intensiva, Hospital Municipal Dr. Moysés Deutsch - São Paulo (SP), Brasil
| | | | | | | | | | - Ricardo Luiz Cordioli
- Departamento de Medicina Intensiva, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | - Bruno de Arruda Bravim
- Departamento de Medicina Intensiva, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | - Thiago Domingos Corrêa
- Departamento de Medicina Intensiva, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
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Walravens S, Buylaert W, Steen E, De Paepe P. Implementation of a protocol using ketamine-propofol ('ketofol') in a 1 to 4 ratio for procedural sedation in adults at a university hospital emergency department - report on safety and effectiveness. Acta Clin Belg 2021; 76:359-364. [PMID: 32174247 DOI: 10.1080/17843286.2020.1741228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objectives: To test the feasibility of an evidence-based protocol for procedural sedation in adults at our emergency department, using a mixture of ketamine and propofol ('ketofol') in a 1 to 4 ratio. We hypothesize that the protocol is safe and effective and can facilitate procedural sedation.Methods: During 14 months, adults in need of procedural sedation at our university hospital emergency department were included in a prospective convenience sample study. Patients with important comorbidity were discussed with the anaesthesiology department for feasibility of sedation in the emergency department setting. Outcome measures were procedural success, respiratory and hemodynamic events, vomiting, agitation or hallucinations, recall and physician's satisfaction.Results: Sixty-one patients between 18 and 89 years were included. All but one procedure were successful. Six respiratory events were registered in 6 patients (9.8%). These consisted of airway obstruction alleviated by airway repositioning and without influence on vital signs except for one brief episode of desaturation. Neither hemodynamic events nor vomiting were reported. Five patients (8.2%) experienced pleasant hallucinations and one patient (1.6%) became agitated upon awakening but recovered rapidly without medication. Three patients (4.9%) had recall and physician satisfaction rate was 93.4%.Conclusion: A feasibility trial of an implemented protocol for ketofol procedural sedation in adults showed only minor respiratory events, a low incidence of agitation or hallucinations, minimal recall and a high success and physician satisfaction rate. Despite a non-consecutive and limited sample used, ketofol in a 1 to 4 ratio appears safe and effective for use in the emergency department.
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Affiliation(s)
- Stig Walravens
- Department of Emergency Medicine, Ghent University Hospital, Ghent, Belgium
| | - Walter Buylaert
- Department of Emergency Medicine, Ghent University Hospital, Ghent, Belgium
| | - Evi Steen
- Department of Emergency Medicine, Ghent University Hospital, Ghent, Belgium
| | - Peter De Paepe
- Department of Emergency Medicine, Ghent University Hospital, Ghent, Belgium
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Abstract
TOPIC Ketamine is beneficial in clinical settings ranging from procedural sedation to the treatment of chronic pain. This article describes the clinical benefits of ketamine for treatment of acute pain and for sedation of patients undergoing mechanical ventilation. CLINICAL RELEVANCE Ketamine causes analgesic and amnestic effects by noncompetitive inhibition of the N-methyl-D-aspartate receptor and activation of the opioid μ and κ receptors. Unlike other sedatives, ketamine provides analgesia and amnesia without causing hypotension or respiratory depression. Several studies have elucidated the clinical benefits of ketamine. The use of ketamine has extended beyond critical care areas such as the operating room and intensive care units. Nurses must be familiar with optimal clinical scenarios, monitoring parameters, and contraindications of ketamine. PURPOSE To highlight the clinical utility and pharmacological properties of ketamine through a literature review. Current studies of ketamine in acute pain and sedation management are summarized. CONTENT COVERED This narrative review describes pharmacological properties, dosing strategies, adminis-tration considerations, and adverse effects of ketamine.
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Affiliation(s)
- Kyle Brown
- Kyle Brown is a critical care pharmacy specialist, Memorial Healthcare System, Pembroke Pines, Florida
| | - Calvin Tucker
- Calvin Tucker is a coordinator, Acute Care Surgery Pharmacy Services, University of Florida Health Shands Hospital, Jacksonville, Florida
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Dilip TS, Chandy GM, Hazra D, Selvan J, Ganesan P. The adverse effects of Ketamine on Procedural Sedation and Analgesia (PSA) in the Emergency Department. J Family Med Prim Care 2021; 10:2279-2283. [PMID: 34322425 PMCID: PMC8284211 DOI: 10.4103/jfmpc.jfmpc_2140_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 12/02/2020] [Accepted: 01/05/2021] [Indexed: 12/05/2022] Open
Abstract
Background: Procedural sedation and analgesia (PSA) in the emergency department (ED) is mainly used for wound irrigation, reduction of fractures, and wound closure. Ketamine is one of the most commonly used drugs for PSA in the ED. The study was conducted in the ED of a large tertiary care hospital in southern India to evaluate the adverse effects of Ketamine on PSA. Materials and Methods: This is a prospective observational study performed in the ED for 6 months (October 2019–March 2020) in 151 patients who required Ketamine for PSA. Titrated doses of Ketamine was administered in all patients; hemodynamic variables and adverse events were recorded at timed intervals. Results: During the study period, a total of 151 patients in the ED required PSA. The mean age of the study Cohort was 37 ± 15 years, and males accounted for 83%. All individuals obtained adequate sedation and pain relief. It was found that the incidence of adverse reactions to Ketamine was higher in young people (18- to 40-year-old), which was 63%. The most common adverse reaction in the study population was 39 cases of hypertension (44.8%), followed by vomiting in 25 cases (28.7%) and delusion in 6 cases (4%). There was no significant adverse effect in any patients which necessitated admission. Conclusion: Ketamine is a drug with good analgesic, sedative properties and has been shown to have a good safety profile with minimal adverse events for use as PSA in ED. Side effects were most common in the younger adult age group and hypertension was the most common side effect.
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Affiliation(s)
- T S Dilip
- Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Gina Maryann Chandy
- Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Darpanarayan Hazra
- Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Jagadesha Selvan
- Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Priya Ganesan
- Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India
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Khandelwal A, Chaturvedi A, Sokhal N, Singh A, Sharma HB. Comparison of Propofol and Ketofol on Transcranial Motor Evoked Potentials in Patients Undergoing Thoracolumbar Spine Surgery. Asian Spine J 2021; 16:183-194. [PMID: 34000799 PMCID: PMC9066259 DOI: 10.31616/asj.2020.0562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 03/08/2021] [Indexed: 11/23/2022] Open
Abstract
Study Design This was a double-blind randomized study. Purpose The primary purpose was to compare the effects of propofol and ketofol on amplitudes and latencies of transcranial motor evoked potentials (TcMEPs) during thoracolumbar spine surgery. In addition, intraoperative hemodynamics and muscle power were compared. Overview of Literature Propofol is commonly used during intraoperative TcMEP monitoring. However, propofol inhibits TcMEP amplitudes and causes hypotension in a dose-dependent fashion. Methods Amplitude and latency of TcMEPs were recorded bilaterally from the abductor pollicis brevis (APB) and abductor hallucis (AH) muscles in 38 adult American Society of Anesthesiologists I and II patients undergoing thoracolumbar spine surgery. Baseline recordings of TcMEPs in both groups were recorded under propofol infusion. Group X patients then received propofol and fentanyl (1 mcg/kg/hr), and group Y patients received ketofol and fentanyl (1 mcg/kg/hr). Bispectral index was maintained at 40-60 in both groups. Amplitude and latency were recorded at 30 minutes intervals for 2 hours. Results Propofol caused no significant changes in amplitude and latency in any muscle. In contrast, amplitude increased significantly at all time points in the bilateral APB muscles and 60, 90, and 120 minutes in the left AH muscle without changes in latency in response to ketofol. When the two groups were compared, ketofol induced significantly higher amplitudes at 60, 90, and 120 minutes in the (left) APB, at all time points in the (right) APB, and at 120 minutes in both AH muscles, compared with propofol. Blood pressures were lower and fluid and vasopressor requirements were higher in group X. Muscle power was similar between the two groups. Conclusions Ketofol facilitates TcMEP amplitudes without affecting latency. Use of ketofol resulted in a better and more stable hemodynamic profile than did use of propofol.
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Affiliation(s)
- Ankur Khandelwal
- Department of Anaesthesia and Critical Care, Sharda University School of Medical Sciences and Research, Greater Noida, India
| | - Arvind Chaturvedi
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Navdeep Sokhal
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Akanksha Singh
- Department of Physiology, All India Institute of Medical Sciences, New Delhi, India
| | - Hanjabam Barun Sharma
- Department of Physiology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India Study
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Ali SA, Aweke Z, Jemal B. Evidence based guideline on use of ketofol (Ketamine and Propofol admixture) for procedural sedation and analgesia (PSA) in pediatrics surgery: Review article. INTERNATIONAL JOURNAL OF SURGERY OPEN 2020. [DOI: 10.1016/j.ijso.2020.06.008] [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]
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Ebru TK, Resul K. Comparison of ketamine-propofol mixture (ketofol) and midazolam-meperidine in endoscopic retrograde cholangiopancretography (ERCP) for oldest old patients. Ther Clin Risk Manag 2019; 15:755-763. [PMID: 31417263 PMCID: PMC6592063 DOI: 10.2147/tcrm.s201441] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 05/06/2019] [Indexed: 01/28/2023] Open
Abstract
Background and aim: Endoscopic retrograde cholangiopancreatography (ERCP) requires moderate-to-deep conscious sedation. Combinations of ketamine and propofol (ketofol) and of midazolam and meperidine were analyzed using the bispectral index (BIS). There is no research on the use of ketofol on very elderly patients. The aim of this study is to use BIS and offer insight into the use and safety of ketofol sedation for oldest old patients undergoing ERCP. Materials and methods: For the ERCP procedure, 168 patients aged 85+ years were enrolled in a 2-year retrospective single center study. Seventy-five patients received midazolam-meperidine (MM) sedation in 2016, while 75 patients received ketofol (KP) sedation in 2018. The two groups were compared for patient data, procedure duration, Ramsay Sedation Score (RSS), heart rate (HR), blood pressure (BP), and pulse oximetry (SpO2), BIS, facial pain score (FPS), time to achieve BIS, recovery time, and complications. The total amount of rescue medication was recorded. Results: The two groups did not differ by patient data or procedure duration (p>0.05). Group KP had significantly higher systolic and diastolic BP, HR, and SpO2 values and lower BIS scores than Group MM (p=0.0001). The two groups did not differ by time to achieve BIS scores (p>0.05). Group KP had significantly fewer complications and a shorter recovery time than Group MM (p<0.001). Conclusion: Ketofol induced sedation results in more stable vital signs and fewer complications than the midazolam-meperidine sedation regimen during ERCP in oldest old patients, indicating that ketofol can be an alternative to midazolam-meperidine.
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Affiliation(s)
- Tarıkçı Kılıç Ebru
- Department of Anesthesiology, Ümraniye Training and Research Hospital, İstanbul, Turkey
| | - Kahraman Resul
- Department of Gastroenterology, Ümraniye Training and Research Hospital, İstanbul, Turkey
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Brendt P, Mathews A, Greenberg R, Arnold M. Autistic Man Falling Through the Cracks: Advanced Patient Transport and the "Pop-up" Recovery Ward. PREHOSP EMERG CARE 2018; 23:578-579. [PMID: 30501448 DOI: 10.1080/10903127.2018.1555296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The Royal Flying Doctor Service was tasked to relocate a 19 year-old autistic patient with severe social anxiety, agoraphobia, and morbid obesity from one residential location to another. The retrieval team was confronted with two main challenges: 1) Continuous risk elevation in an elective patient transportation as distinct from other urgent prehospital transfers of mental health patients; and 2) prehospital ketamine/propofol sedation of an aggressive/combative patient with recovery from sedation in a private property. The transfer accomplished the successful relocation of the patient.
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Miner J. Ketamine or Ketofol: Do We Have Enough Evidence to Know Which One to Use? Acad Emerg Med 2017; 24:1511-1513. [PMID: 28802082 DOI: 10.1111/acem.13276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- James Miner
- Department of Emergency Medicine; Hennepin County Medical Center; Department of Emergency Medicine; University of Minnesota; Minneapolis MN
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