1
|
Al Hillan A, Curras-Martin D, Carson M, Gor S, Ezeume A, Gupta V, Copcaalvarez A, Beri G, Bermann M, Asif A. Capsule Endoscopy Transit Time to Duodenum: Relation to Patient Demographics. Cureus 2020; 12:e6894. [PMID: 32064217 PMCID: PMC7003722 DOI: 10.7759/cureus.6894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 02/05/2020] [Indexed: 12/15/2022] Open
Abstract
Background Anesthesia guidelines recommend fasting for at least two hours to minimize aspiration risk related to endoscopic procedures, and the American Society for Gastrointestinal Endoscopy (ASGE) states that the final oral preparation liquid can be administered three to eight hours before the procedure. We have observed the cancellation of endoscopy procedures if liquids were consumed within four, six, or eight hours of the start time. Objectively, documenting gastric transit time via a review of pill endoscopy data could address clinician concerns, prevent delays in patient care, and improve the rate at which our clinicians practice within national guidelines. The objective was to utilize capsule endoscopy data from our center to report the relationship between patient factors that could affect gastric transit time (GTT) and small bowel transit time (SBTT) such as chronic kidney disease (CKD), diabetes mellitus (DM), nutritional status, and obesity. Methods This retrospective review obtained data on adult pill endoscopy (PillCam™ SB 3) (Medtronic, Minneapolis MN) studies on in- and outpatients. Past medical history and laboratory data were abstracted from electronic medical records. Mean GTT and SBTT are reported in minutes + standard deviation (SD) and times were compared accounting for conditions that could prolong transit, such as diabetes mellitus or chronic kidney disease (CKD). Results One hundred and sixty-three records reviewed. Four patients were excluded as the pill did not pass out of the stomach. The mean age was 66 years, 57% were female, and 26% were evaluated for gastrointestinal (GI) bleeding. The mean GTT for all patients (n = 159) was 35 + 49 with a median of 19 minutes. There were no statistically significant differences in GTT between the following subgroups: CKD0 (n = 100) 40 + 58 versus CKD5 (n = 11) 35 + 39, albumin > 3.0 (n = 123) 37 + 53 versus albumin < 3.0 (n = 36) 27 + 30, diabetes mellitus (DM) (n = 40) 51 + 71 vs. non-DM (n = 119) 42 + 79, body mass index (BMI) > 30, or aspirin use. The SBTT results in all patients (n = 124) was 238 + 88 minutes. Similarly, there was no relation between SBTT and albumin, any CKD, CKD0 versus CKD5, DM status, or BMI. The patients with the capsule stuck in the stomach did not have any other clinical history to explain this occurrence. Conclusions This analysis of objective data regarding pill endoscopy found that the mean GTT was 44 minutes, and it was < 60 minutes for 85% of the cohort. Patient factors were not associated with longer transit times, and this is the first report to document PillCam times in relation to CKD. These data support recommendations that endoscopic procedures, in accordance with anesthesia and ASGE guidelines, can be safely conducted in the majority of patients within 60 minutes of ingesting liquids.
Collapse
Affiliation(s)
- Alsadiq Al Hillan
- Internal Medicine, Jersey Shore University Medical Center, Neptune, USA
| | | | - Michael Carson
- Internal Medicine, Jersey Shore University Medical Center, Neptune, USA
| | - Shreya Gor
- Internal Medicine, Jersey Shore University Medical Center, Neptune, USA
| | - Adaeze Ezeume
- Internal Medicine, Jersey Shore University Medical Center, Neptune, USA
| | - Varsha Gupta
- Internal Medicine, Jersey Shore University Medical Center, Neptune, USA
| | | | - Gagan Beri
- Gastroenterology, Jersey Shore University Medical Center, Neptune, USA
| | - Mordechai Bermann
- Internal Medicine, Jersey Shore University Medical Center, Neptune, USA
| | - Arif Asif
- Internal Medicine, Jersey Shore University Medical Center, Neptune, USA
| |
Collapse
|
2
|
Green SM, Leroy PL, Roback MG, Irwin MG, Andolfatto G, Babl FE, Barbi E, Costa LR, Absalom A, Carlson DW, Krauss BS, Roelofse J, Yuen VM, Alcaino E, Costa PS, Mason KP. An international multidisciplinary consensus statement on fasting before procedural sedation in adults and children. Anaesthesia 2019; 75:374-385. [PMID: 31792941 PMCID: PMC7064977 DOI: 10.1111/anae.14892] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2019] [Indexed: 01/29/2023]
Abstract
The multidisciplinary International Committee for the Advancement of Procedural Sedation presents the first fasting and aspiration prevention recommendations specific to procedural sedation, based on an extensive review of the literature. These were developed using Delphi methodology and assessment of the robustness of the available evidence. The literature evidence is clear that fasting, as currently practiced, often substantially exceeds recommended time thresholds and has known adverse consequences, for example, irritability, dehydration and hypoglycaemia. Fasting does not guarantee an empty stomach, and there is no observed association between aspiration and compliance with common fasting guidelines. The probability of clinically important aspiration during procedural sedation is negligible. In the post-1984 literature there are no published reports of aspiration-associated mortality in children, no reports of death in healthy adults (ASA physical status 1 or 2) and just nine reported deaths in adults of ASA physical status 3 or above. Current concerns about aspiration are out of proportion to the actual risk. Given the lower observed frequency of aspiration and mortality than during general anaesthesia, and the theoretical basis for assuming a lesser risk, fasting strategies in procedural sedation can reasonably be less restrictive. We present a consensus-derived algorithm in which each patient is first risk-stratified during their pre-sedation assessment, using evidence-based factors relating to patient characteristics, comorbidities, the nature of the procedure and the nature of the anticipated sedation technique. Graded fasting precautions for liquids and solids are then recommended for elective procedures based upon this categorisation of negligible, mild or moderate aspiration risk. This consensus statement can serve as a resource to practitioners and policymakers who perform and oversee procedural sedation in patients of all ages, worldwide.
Collapse
Affiliation(s)
- S M Green
- Department of Emergency Medicine, Loma Linda University, Loma Linda, CA, USA
| | - P L Leroy
- Department of Pediatrics, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - M G Roback
- University of Colorado School of Medicine, Aurora, CO, USA
| | - M G Irwin
- Department of Anaesthesiology, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - G Andolfatto
- University of British, Columbia Department of Emergency Medicine, Lions Gate Hospital, North Vancouver, BC, Canada
| | - F E Babl
- Department of Emergency Medicine, Royal Children's Hospital, Parkville, Vic., Australia
| | - E Barbi
- Department of Pediatrics, Institute for Maternal and Child Health-IRCCS 'Burlo Garofolo', Trieste, Italy
| | - L R Costa
- Department of Pediatric Dentistry, Federal University of Goias, Goiania-Goias, Brazil
| | - A Absalom
- Department of Anaesthesia, University of Groningen, University Medical Center Groningen, the Netherlands
| | - D W Carlson
- Department of Pediatrics, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - B S Krauss
- Department of Pediatrics, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - J Roelofse
- Departments of Anaesthesia, University of the Western Cape, Stellenbosch University, Tygerberg, Republic of South Africa
| | - V M Yuen
- Department of Anaesthesiology, Hong Kong Children's Hospital and Queen Mary Hospital, University of Hong Kong, Hong Kong
| | - E Alcaino
- Department of Paediatric Dentistry, University of Sydney, Westmead Centre for Oral Health, Sydney, NSW, Australia
| | - P S Costa
- Department of Pediatrics, Federal University of Goias, Goiania-Goias, Brazil
| | - K P Mason
- Department of Anesthesia, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | | |
Collapse
|
3
|
Green SM, Mason KP, Krauss BS. Pulmonary aspiration during procedural sedation: a comprehensive systematic review. Br J Anaesth 2018; 118:344-354. [PMID: 28186265 DOI: 10.1093/bja/aex004] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background Although pulmonary aspiration complicating operative general anaesthesia has been extensively studied, little is known regarding aspiration during procedural sedation. Methods We performed a comprehensive, systematic review to identify and catalogue published instances of aspiration involving procedural sedation in patients of all ages. We sought to report descriptively the circumstances, nature, and outcomes of these events. Results Of 1249 records identified by our search, we found 35 articles describing one or more occurrences of pulmonary aspiration during procedural sedation. Of the 292 occurrences during gastrointestinal endoscopy, there were eight deaths. Of the 34 unique occurrences for procedures other than endoscopy, there was a single death in a moribund patient, full recovery in 31, and unknown recovery status in two. We found no occurrences of aspiration in non-fasted patients receiving procedures other than endoscopy. Conclusions This first systematic review of pulmonary aspiration during procedural sedation identified few occurrences outside of gastrointestinal endoscopy, with full recovery typical. Although diligent caution remains warranted, our data indicate that aspiration during procedural sedation appears rare, idiosyncratic, and typically benign.
Collapse
Affiliation(s)
- S M Green
- Department of Emergency Medicine, Loma Linda University Medical Center and Children's Hospital, Loma Linda, CA, USA
| | - K P Mason
- Department of Anesthesia, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - B S Krauss
- Division of Emergency Medicine, Boston Children's Hospital and the Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
4
|
Ketamine sedation for orthopedic procedures in a high complexity emergency service. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2018. [DOI: 10.1097/cj9.0000000000000076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
|
5
|
Bhatt M, Johnson DW, Taljaard M, Chan J, Barrowman N, Farion KJ, Ali S, Beno S, Dixon A, McTimoney CM, Dubrovsky AS, Roback MG. Association of Preprocedural Fasting With Outcomes of Emergency Department Sedation in Children. JAMA Pediatr 2018; 172:678-685. [PMID: 29800944 PMCID: PMC6137504 DOI: 10.1001/jamapediatrics.2018.0830] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE It is not clear whether adherence to preprocedural fasting guidelines prevent pulmonary aspiration and associated adverse outcomes during emergency department (ED) sedation of children. OBJECTIVE To examine the association between preprocedural fasting duration and the incidence of sedation-related adverse outcomes in a large sample of children. DESIGN, SETTING, AND PARTICIPANTS We conducted a planned secondary analysis of a multicenter prospective cohort study of children aged 0 to 18 years who received procedural sedation for a painful procedure in 6 Canadian pediatric EDs from July 2010 to February 2015. The primary risk factor was preprocedural fasting duration. Secondary risk factors were age, sex, American Society of Anesthesiologists classification, preprocedural and sedation medications, and procedure type. MAIN OUTCOMES AND MEASURES Four outcomes were examined: (1) pulmonary aspiration, (2) the occurrence of any adverse event, (3) serious adverse events, and (4) vomiting. RESULTS A total of 6183 children with a median age of 8.0 years (interquartile range, 4.0-12.0 years), of whom 6166 (99.7%) had healthy or mild systemic disease (American Society of Anesthesiologists levels I or II), were included in the analysis. Of these, 2974 (48.1%) and 310 (5.0%) children did not meet American Society of Anesthesiologists fasting guidelines for solids and liquids, respectively. There were no cases of pulmonary aspiration. There were 717 adverse events (11.6%; 95% CI, 10.8%-12.4%), of which 68 (1.1%; 95% CI, 0.9%-1.3%) were serious adverse events and 315 (5.1%; 95% CI, 4.6%-5.7%) were vomiting. The odds ratio (OR) of occurrence of any adverse event, serious adverse events, and vomiting did not change significantly with each additional hour of fasting duration for both solids (any adverse event: OR, 1.00; 95% CI, 0.98 to 1.02; serious adverse events, OR, 1.01; 95% CI, 0.95-1.07; vomiting: OR, 1.00; 95% CI, 0.97-1.03) and liquids (any adverse event: OR, 1.00; 95% CI, 0.98-1.02; serious adverse events: 1.01, 95% CI, 0.95-1.07; vomiting: OR, 1.00; 95% CI, 0.96-1.03). CONCLUSIONS AND RELEVANCE In this study, there was no association between fasting duration and any type of adverse event. These findings do not support delaying sedation to meet established fasting guidelines.
Collapse
Affiliation(s)
- Maala Bhatt
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - David W. Johnson
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada,Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada,Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada,Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jason Chan
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada,Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Nick Barrowman
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Ken J. Farion
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Samina Ali
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Suzanne Beno
- Department of Pediatrics, the Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Dixon
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - C. Michelle McTimoney
- Department of Pediatrics, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada,Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Alexander Sasha Dubrovsky
- Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Mark G. Roback
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis,Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis
| | | |
Collapse
|
6
|
Kim WS, Ku JY, Choi H, Choi HJ, Kim HJ, Lee B. Considerations for physicians using ketamine for sedation of children in emergency departments. Clin Exp Emerg Med 2017; 4:244-249. [PMID: 29306262 PMCID: PMC5758618 DOI: 10.15441/ceem.16.155] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 09/21/2017] [Accepted: 09/26/2017] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Ketamine use in emergency departments (EDs) for procedural sedation and analgesia is becoming increasingly common. However, few studies have examined patient factors related to adverse events associated with ketamine. This study investigated factors for consideration when using ketamine to sedate pediatric ED patients. METHODS The study included pediatric patients receiving ketamine for laceration repair in the ED. Before sedation, information was collected about upper respiratory tract infection symptoms, allergy history, and fasting time. Patients received 2 mg/kg ketamine intravenously or 4 mg/kg ketamine intramuscularly. The primary outcomes were adverse events due to ketamine. RESULTS We studied 116 patients aged 8 months to 7 years (2.8±1.5 years). The group with adverse events was significantly younger on average than the group without adverse events (2.5±1.5 vs. 3.1±1.5, P=0.028). Upper respiratory tract infection symptoms were not significant variables affecting ketamine sedation (48.9% vs. 43.7%, P=0.719). There was no significant association between duration of fasting and adverse events (P=0.073 and P=0.897, respectively), or between food type and adverse events (P=0.734). However, the number of attempts to sedate and ketamine dose correlated with adverse events (P<0.001 and P=0.022, respectively). In multiple logistic regression analysis, intravenous injection and ketamine dose were significant factors (odds ratio, 16.77; 95% confidence interval, 1.78 to 498.54; odds ratio, 4.37; 95% confidence interval, 1.59 to 22.9, respectively). CONCLUSION Emergency medicine physicians should consider injection type and ketamine dose when using ketamine sedation while suturing lacerations.
Collapse
Affiliation(s)
- Woo Sung Kim
- Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Ji Yeon Ku
- Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Hanbyul Choi
- Department of Surgery, Stonybrook University Hospital, New York, USA
| | - Hyo Jeong Choi
- Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Ho Jung Kim
- Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Bora Lee
- Department of Biostatistic Consulting, Clinical Trial Center, Bucheon Hospital of Soonchunhyang University, Bucheon, Korea
| |
Collapse
|
7
|
Gazal G, Fareed WM, Zafar MS, Al-Samadani KH. Pain and anxiety management for pediatric dental procedures using various combinations of sedative drugs: A review. Saudi Pharm J 2016; 24:379-85. [PMID: 27330369 PMCID: PMC4908057 DOI: 10.1016/j.jsps.2014.04.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 04/19/2014] [Indexed: 11/05/2022] Open
Abstract
For fearful and uncooperative children behavioral management techniques are used. In order to control the pain and anxiety in pedodontic patients, pharmacologic sedation, anesthesia and analgesia are commonly used. Midazolam is commonly used as an oral sedation agent in children; it has several features such as safety of use, quick onset and certain degree of amnesia that makes it a desirable sedation agent in children. This review paper discusses various aspects of oral midazolam, ketamine and their combinations in conscious sedation including, advantages of oral route of sedation, pharmacokinetics, range of oral doses, and antagonists for clinical dental treatment procedures.
Collapse
Affiliation(s)
- Giath Gazal
- Department of Oral and Maxillofacial Surgery, College of Dentistry, Taibah University, P.O. Box 2898, Al Madinah Al Munawwarah, Saudi Arabia
| | - Wamiq Musheer Fareed
- Department of Oral and Maxillofacial Surgery, College of Dentistry, Taibah University, P.O. Box 2898, Al Madinah Al Munawwarah, Saudi Arabia
| | - Muhammad Sohail Zafar
- Department of Restorative Dentistry, College of Dentistry, Taibah University, P.O. Box 2898, Al Madinah Al Munawwarah, Saudi Arabia
| | - Khalid H. Al-Samadani
- Department of Restorative Dentistry, College of Dentistry, Taibah University, P.O. Box 2898, Al Madinah Al Munawwarah, Saudi Arabia
| |
Collapse
|
8
|
Demographic Predictors of NPO Violations in Elective Pediatric Surgery. J Perianesth Nurs 2016; 31:36-40. [DOI: 10.1016/j.jopan.2015.01.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 12/29/2014] [Accepted: 01/02/2015] [Indexed: 11/21/2022]
|
9
|
Clark M, Birisci E, Anderson JE, Anliker CM, Bryant MA, Downs C, Dalabih A. The risk of shorter fasting time for pediatric deep sedation. Anesth Essays Res 2016; 10:607-612. [PMID: 27746560 PMCID: PMC5062212 DOI: 10.4103/0259-1162.186598] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Current guidelines adopted by the American Academy of Pediatrics calls for prolonged fasting times before performing pediatric procedural sedation and analgesia (PSA). PSA is increasingly provided to children outside of the operating theater by sedation trained pediatric providers and does not require airway manipulation. We investigated the safety of a shorter fasting time compared to a longer and guideline compliant fasting time. We tried to identify the association between fasting time and sedation-related complications. METHODS This is a prospective observational study that included children 2 months to 18 years of age and had an American Society of Anesthesiologists physical status classification of I or II, who underwent deep sedation for elective procedures, performed by pediatric critical care providers. Procedures included radiologic imaging studies, electroencephalograms, auditory brainstem response, echocardiograms, Botox injections, and other minor surgical procedures. Subjects were divided into two groups depending on the length of their fasting time (4-6 h and >6 h). Complication rates were calculated and compared between the three groups. RESULTS In the studied group of 2487 subjects, 1007 (40.5%) had fasting time of 4-6 h and the remaining 1480 (59.5%) subjects had fasted for >6 h. There were no statistically significant differences in any of the studied complications between the two groups. CONCLUSIONS This study found no difference in complication rate in regard to the fasting time among our subjects cohort, which included only healthy children receiving elective procedures performed by sedation trained pediatric critical care providers. This suggests that using shorter fasting time may be safe for procedures performed outside of the operating theater that does not involve high-risk patients or airway manipulation.
Collapse
Affiliation(s)
- Mathew Clark
- Division of Critical Care Medicine, St. Louis University, St. Louis, MO, USA
| | - Esma Birisci
- Department of Statistics, University of Missouri, Columbia, MO, USA
| | - Jordan E Anderson
- Women's and Children's Hospital Campus, University of Missouri Health Care, Columbia, MO, USA
| | - Christina M Anliker
- Women's and Children's Hospital Campus, University of Missouri Health Care, Columbia, MO, USA
| | - Micheal A Bryant
- Women's and Children's Hospital Campus, University of Missouri Health Care, Columbia, MO, USA
| | - Craig Downs
- Department of Child Health, Division of Critical Care Medicine, University of Missouri School of Medicine, Columbia, MO, USA
| | - Abdallah Dalabih
- Department of Child Health, Division of Critical Care Medicine, University of Missouri School of Medicine, Columbia, MO, USA
| |
Collapse
|
10
|
Coté CJ. Paediatric sedation guidelines: where we came from, where we are now, and current drug controversies. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2014. [DOI: 10.1080/22201173.2010.10872646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
11
|
Godwin SA, Burton JH, Gerardo CJ, Hatten BW, Mace SE, Silvers SM, Fesmire FM. Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department. Ann Emerg Med 2014; 63:247-58.e18. [DOI: 10.1016/j.annemergmed.2013.10.015] [Citation(s) in RCA: 202] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
12
|
Lee JY, Jo YY. Preoperative fasting in emergencies: choice for preventing aspiration pneumonitis. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2014. [DOI: 10.5124/jkma.2014.57.5.429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Ji Yeon Lee
- Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Youn Yi Jo
- Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center, Incheon, Korea
| |
Collapse
|
13
|
Orliaguet G. Sédation et analgésie en structure d’urgence. Pédiatrie : quelle sédation et analgésie pour l’intubation trachéale chez l’enfant ? ACTA ACUST UNITED AC 2012; 31:377-83. [DOI: 10.1016/j.annfar.2012.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
|
14
|
Orliaguet G. [Sedation and analgesia in emergency structure. Paediatry: Which sedation and analgesia for pediatric patients? Pharmacology]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2012; 31:359-368. [PMID: 22445224 DOI: 10.1016/j.annfar.2012.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- G Orliaguet
- Département d'anesthésie-réanimation, hôpital Necker-Enfants-malades, université Paris Descartes, Paris 5, 149, rue de Sèvres, 75730 Paris cedex 15, France.
| |
Collapse
|
15
|
Bell A, Taylor DM, Holdgate A, MacBean C, Huynh T, Thom O, Augello M, Millar R, Day R, Williams A, Ritchie P, Pasco J. Procedural sedation practices in Australian Emergency Departments. Emerg Med Australas 2011; 23:458-65. [DOI: 10.1111/j.1742-6723.2011.01418.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
16
|
Taylor DM, Bell A, Holdgate A, MacBean C, Huynh T, Thom O, Augello M, Millar R, Day R, Williams A, Ritchie P, Pasco J. Risk factors for sedation-related events during procedural sedation in the emergency department. Emerg Med Australas 2011; 23:466-73. [PMID: 21824314 DOI: 10.1111/j.1742-6723.2011.01419.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the nature, incidence and risk factors for sedation-related events during ED procedural sedation, with particular focus on the drugs administered. METHODS Eleven Australian EDs enrolled consecutive adult and paediatric patients between January 2006 and December 2008. Patients were included if a sedative drug was administered for an ED procedure. Data collection was prospective and employed a specifically designed form. Multivariate logistic regression was employed to determine risk factors for sedation-related events. RESULTS Two thousand, six hundred and twenty-three patients were enrolled (60.3% male, mean age 39.2 years). Reductions of fracture/dislocations of shoulders, wrists and ankles were most common. Four hundred and sixty-one (17.6%) cases experienced at least one airway event that required intervention. Airway obstruction, hypoventilation and desaturation occurred in 12.7%, 6.4% and 3.7% of all patients, respectively. Two thousand, one hundred and forty-six cases had complete datasets for further analyses. Increasing age and level of sedation, pre-medication with fentanyl, and sedation with propofol, midazolam or fentanyl were risk factors for an airway event (P < 0.05). Ketamine was a protective factor. Hypotension (systolic pressure <80 mmHg) occurred in 34 (1.6%) cases with midazolam being a significant risk factor (P < 0.001). Vomiting also occurred in 34 (1.6%) cases, 12 of whom required an intervention. One patient aspirated. Vomiting occurred after administration of all drugs but was not associated with fasting status. Other events were rare. CONCLUSIONS Sedation-related events, especially airway events, are common but very rarely have an adverse outcome. Elderly patients, deeply sedated with short-acting agents, are at particular risk. The results will help tailor sedation to individual patients.
Collapse
|
17
|
Green SM, Roback MG, Kennedy RM, Krauss B. Clinical Practice Guideline for Emergency Department Ketamine Dissociative Sedation: 2011 Update. Ann Emerg Med 2011; 57:449-61. [DOI: 10.1016/j.annemergmed.2010.11.030] [Citation(s) in RCA: 276] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Revised: 11/17/2010] [Accepted: 11/22/2010] [Indexed: 10/18/2022]
|
18
|
Treston G, Bell A, Cardwell R, Fincher G, Chand D, Cashion G. What is the nature of the emergence phenomenon when using intravenous or intramuscular ketamine for paediatric procedural sedation? Emerg Med Australas 2009; 21:315-22. [PMID: 19682018 DOI: 10.1111/j.1742-6723.2009.01203.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Ketamine has become the drug most favoured by emergency physicians for sedation of children in the ED. Some emergency physicians do not use ketamine for paediatric procedural sedation (PPS) because of concern about emergence delirium on recovery. The present study set out to determine the true incidence and nature of this phenomenon. METHODS Prospective data relating to any emergence agitation, crying, hallucinations, dreams, altered perceptions, delirium and necessary interventions were recorded in consecutive cases of ketamine PPS from March 2002 to June 2007, and analysed. Standard inclusion and exclusion criteria for the use of ketamine were followed. RESULTS A total of 745 prospective data collection records were available for analysis over the 5 year period. Of all, 93 (12.5%) children cried on awakening when recovering from PPS, 291 (39%) experienced pleasant altered perceptions and 16 (2.1%) experienced what was called 'emergence delirium'. None required any active treatment and all except one settled within 20 min. There was no evidence of an increased rate of nightmares on telephone follow up in the weeks post procedure. CONCLUSION The belief that ketamine, in the doses used for ED PPS, causes frequent emergence delirium is flawed. A pleasant emergence phenomenon is common, but is not distressing for the child, and has no long-term (up to 30 days) negative sequelae. Rarely, there is anxiety or distress on awakening from ketamine sedation, which settles spontaneously. This should not deter emergency physicians from using ketamine for PPS.
Collapse
|
19
|
Green SM, Coté CJ. Ketamine and Neurotoxicity: Clinical Perspectives and Implications for Emergency Medicine. Ann Emerg Med 2009; 54:181-90. [DOI: 10.1016/j.annemergmed.2008.10.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2008] [Revised: 09/23/2008] [Accepted: 10/01/2008] [Indexed: 10/21/2022]
|
20
|
Green SM, Roback MG, Krauss B, Brown L, McGlone RG, Agrawal D, McKee M, Weiss M, Pitetti RD, Hostetler MA, Wathen JE, Treston G, Garcia Pena BM, Gerber AC, Losek JD. Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children. Ann Emerg Med 2009; 54:158-68.e1-4. [PMID: 19201064 DOI: 10.1016/j.annemergmed.2008.12.011] [Citation(s) in RCA: 185] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2008] [Revised: 11/18/2008] [Accepted: 12/09/2008] [Indexed: 02/07/2023]
Abstract
STUDY OBJECTIVE Although ketamine is one of the most commonly used sedatives to facilitate painful procedures for children in the emergency department (ED), existing studies have not been large enough to identify clinical factors that are predictive of uncommon airway and respiratory adverse events. METHODS We pooled individual-patient data from 32 ED studies and performed multiple logistic regressions to determine which clinical variables would predict airway and respiratory adverse events. RESULTS In 8,282 pediatric ketamine sedations, the overall incidence of airway and respiratory adverse events was 3.9%, with the following significant independent predictors: younger than 2 years (odds ratio [OR] 2.00; 95% confidence interval [CI] 1.47 to 2.72), aged 13 years or older (OR 2.72; 95% CI 1.97 to 3.75), high intravenous dosing (initial dose > or =2.5 mg/kg or total dose > or =5.0 mg/kg; OR 2.18; 95% CI 1.59 to 2.99), coadministered anticholinergic (OR 1.82; 95% CI 1.36 to 2.42), and coadministered benzodiazepine (OR 1.39; 95% CI 1.08 to 1.78). Variables without independent association included oropharyngeal procedures, underlying physical illness (American Society of Anesthesiologists class >or = 3), and the choice of intravenous versus intramuscular route. CONCLUSION Risk factors that predict ketamine-associated airway and respiratory adverse events are high intravenous doses, administration to children younger than 2 years or aged 13 years or older, and the use of coadministered anticholinergics or benzodiazepines.
Collapse
Affiliation(s)
- Steven M Green
- Department of Emergency Medicine, Loma Linda University Medical Center and Children's Hospital, Loma Linda, CA, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Bell A, Treston G, McNabb C, Monypenny K, Cardwell R. Profiling adverse respiratory events and vomiting when using propofol for emergency department procedural sedation. Emerg Med Australas 2008; 19:405-10. [PMID: 17919212 DOI: 10.1111/j.1742-6723.2007.00982.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To evaluate the rate of adverse respiratory events and vomiting among ED patients undergoing procedural sedation with propofol. METHODS This was a prospective, observational series of patients undergoing procedural sedation. Titrated i.v. propofol was administered via protocol. Fasting status was recorded. RESULTS Four hundred patients undergoing sedation were enrolled. Of these 282 (70%, 95% confidence interval [CI] 66-75%) had eaten or drunken within 6 and 2 h, respectively. Median fasting times from a full meal, snack or drink were 7 h (interquartile range [IQR] 5-9 h), 6 h (IQR 4-8 h) and 4 h (IQR 2-6 h), respectively. Overall a respiratory event occurred in 86 patients (22%, 95% CI 18-26%). An airway intervention occurred in 123 patients (31%, 95% CI 26-35%). In 111 cases (90%, 95% CI 60-98%) basic airway manoeuvres were all that was required. No patients were intubated. Two patients vomited (0.5%, 95% CI 0.0-1.6%), one during sedation, one after patient became conversational. One patient developed transient laryngospasm (0.25%, 95% CI 0-1.2%) unrelated to vomiting. There were nil aspiration events (0%, 95% CI 0-0.74%). CONCLUSIONS Seventy per cent of patients undergoing ED procedural sedation are not fasted. No patient had a clinically evident adverse outcome. Transient respiratory events occur but can be managed with basic airway interventions making propofol a safe alternative for emergency physicians to provide emergent procedural sedation.
Collapse
Affiliation(s)
- Anthony Bell
- Department of Emergency Medicine, Redcliffe Hospital, Redcliffe, Queensland, Australia.
| | | | | | | | | |
Collapse
|
22
|
|
23
|
Herd D, Anderson BJ. Ketamine disposition in children presenting for procedural sedation and analgesia in a children's emergency department. Paediatr Anaesth 2007; 17:622-9. [PMID: 17564643 DOI: 10.1111/j.1460-9592.2006.02145.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The aim of this study was to describe ketamine pharmacokinetics in children to simulate time-concentration profiles to predict duration of concentrations associated with anesthesia, arousal and analgesia. METHODS Children presenting for painful procedures in the Emergency Dept were given ketamine 1-1.5 mgxkg(-1) i.v. Blood was assayed for ketamine on 3-6 occasions (median 3) over the subsequent 14-152 min (median 28.5). A population pharmacokinetic analysis was undertaken by using nonlinear mixed effects models (NONMEM). Simulation was used to predict time-concentration profiles in this cohort RESULTS There were 188 observations from 54 children (age 8.3 sd 3.5 years, weight 32.5 sd 15.6 kg). A two-compartment (central, peripheral) linear disposition model fitted data better than a one-compartment model. Population parameter estimates and their between subject variability (BSV), standardized to a 70-kg person using allometric models, were central volume (V1) 38.7 (BSV 64%) l.70 kg(-1), peripheral volume of distribution (V2) 102 (51.7%) l.70 kg(-1), clearance (CL) 90 (38.1%) l.h(-1) 70 kg(-1) and intercompartment clearance (Q) 215 (19%) l.h(-1) 70 kg(-1). At 10 min half of the children given 1 mgxkg(-1) will have a serum concentration below 0.75 mgxl(-1). This is a concentration associated with 'awakening' in adults. However, almost all the children will still have a serum concentration above 0.1 mgxl(-1), a level associated with analgesia in adults. CONCLUSIONS Ketamine 1 mgxkg(-1) i.v. provides satisfactory serum concentrations for children undergoing sedation for painful procedures of <5-min duration and produces concentrations associated with analgesic effect for more than 10 min. Clearance increases with decreasing age in children. The relationship between serum concentration and effect is poorly defined in children.
Collapse
Affiliation(s)
- David Herd
- Department of Paediatrics, Starship Children's Hospital, Auckland, New Zealand.
| | | |
Collapse
|
24
|
Green SM, Roback MG, Miner JR, Burton JH, Krauss B. Fasting and Emergency Department Procedural Sedation and Analgesia: A Consensus-Based Clinical Practice Advisory. Ann Emerg Med 2007; 49:454-61. [PMID: 17083995 DOI: 10.1016/j.annemergmed.2006.08.017] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2006] [Revised: 08/06/2006] [Accepted: 08/23/2006] [Indexed: 11/27/2022]
Abstract
Emergency physicians frequently administer procedural sedation and analgesia to nonfasted patients; however, they currently have no specific guidelines to aid them in preprocedural risk stratification. We assembled a committee of leading emergency physician sedation researchers to develop a consensus-based clinical practice advisory for this purpose. Our goal was to create a tool to permit emergency physicians to identify prudent limits of sedation depth and timing in light of fasting status and individual patient risk factors. The advisory is not intended to assert a legal standard of practice or absolute requirement. It is expected that emergency physicians will at times appropriately deviate from it according to individualized judgment and unique clinical circumstances.
Collapse
Affiliation(s)
- Steven M Green
- Department of Emergency Medicine, Loma Linda University Medical Center and Children's Hospital, Loma Linda, CA 92354, USA.
| | | | | | | | | |
Collapse
|
25
|
Coté CJ, Wilson S. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update. Pediatrics 2006; 118:2587-602. [PMID: 17142550 DOI: 10.1542/peds.2006-2780] [Citation(s) in RCA: 476] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical supervision; careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications; appropriate fasting for elective procedures and a balance between depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure; a focused airway examination for large tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction; a clear understanding of the pharmacokinetic and pharmacodynamic effects of the medications used for sedation, as well as an appreciation for drug interactions; appropriate training and skills in airway management to allow rescue of the patient; age- and size-appropriate equipment for airway management and venous access; appropriate medications and reversal agents; sufficient numbers of people to carry out the procedure and monitor the patient; appropriate physiologic monitoring during and after the procedure; a properly equipped and staffed recovery area; recovery to presedation level of consciousness before discharge from medical supervision; and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.
Collapse
|
26
|
Cheung KW, Watson ML, Field S, Campbell SG. Aspiration pneumonitis requiring intubation after procedural sedation and analgesia: a case report. Ann Emerg Med 2006; 49:462-4. [PMID: 17084944 DOI: 10.1016/j.annemergmed.2006.09.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2006] [Revised: 09/06/2006] [Accepted: 09/07/2006] [Indexed: 11/22/2022]
Abstract
Emergency department (ED) procedural sedation and analgesia is widely and routinely performed; serious complications are rare. We describe the first reported case of aspiration during procedural sedation in the ED. Although our patient required endotracheal intubation and critical care admission, there was no adverse long-term outcome. Given that there were no apparent predisposing factors, we believe it is crucial for emergency physicians to routinely anticipate the possibility of such a complication during each sedation event.
Collapse
Affiliation(s)
- Ka Wai Cheung
- Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
| | | | | | | |
Collapse
|
27
|
Green SM, Krauss B. Should I Give Ketamine IV or IM? Ann Emerg Med 2006; 48:613-4. [PMID: 17052564 DOI: 10.1016/j.annemergmed.2006.05.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2006] [Revised: 05/25/2006] [Accepted: 05/30/2006] [Indexed: 11/16/2022]
|
28
|
Babl F, Priestley S, Krieser D, Miller J, Tully M, Spicer M, McGowan V, Dilla N. Development and implementation of an education and credentialing programme to provide safe paediatric procedural sedation in emergency departments. Emerg Med Australas 2006; 18:489-97. [PMID: 17083639 DOI: 10.1111/j.1742-6723.2006.00904.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE In the conduct of paediatric procedural sedation (PPS) within the ED the combination of powerful drugs, variable competency levels and high staff turnover carry the potential for sedation-associated adverse events. Yet, currently, there is no set programme for education and accreditation of ED staff in PPS. We set out to develop such a programme. METHODS We outline the development process of a comprehensive multidisciplinary PPS programme and present its key educational elements (sedation manual, lecture, treatment order form and checklist, parent information handout) and credentialing through multiple-choice questions and competency assessments. We describe issues associated with the implementation of the programme at a metropolitan mixed ED and the ED of a major tertiary paediatric centre. RESULTS Since its inception a total of 294 emergency staff have either completed or have partially completed the programme. Staff feedback showed that the majority of staff scored the elements of the programme as very good to excellent, and felt that their sedation skills had improved and their practice was safer. The development and implementation of the PPS programme raised many issues and posed a number of challenges. We describe the strategies we used to overcome such challenges and barriers. CONCLUSION We present the development and implementation of a comprehensive PPS programme for emergency staff. As a result of the multicentre development process involving a community and a tertiary paediatric ED the programme will likely have broad applicability in different types of ED caring for children.
Collapse
Affiliation(s)
- Franz Babl
- Emergency Department, Royal Children's Hospital, Parkville, Victoria, Australia.
| | | | | | | | | | | | | | | |
Collapse
|
29
|
Abstract
Children often present with painful conditions that require painful interventions. Procedural sedation and analgesia refers to the pharmacologic technique of managing a child's pain and anxiety. Procedural sedation is a safe, effective, and humane way to facilitate appropriate medical care. It is important to distinguish the goals for the procedural sedation, pain relief or anxiolysis or both. Different medications and combinations of medications can be used to achieve the desired effect. It is also important to keep in mind the possible adverse reactions and side effects associated with each medication when choosing the sedation cocktail.
Collapse
Affiliation(s)
- Lisa Doyle
- Department of Emergency Medicine, University of Arizona University Physicians Hospital, Tucson, 85713, USA.
| | | |
Collapse
|
30
|
Abstract
Procedural sedation and analgesia for children--the use of sedative, analgesic, or dissociative drugs to relieve anxiety and pain associated with diagnostic and therapeutic procedures--is now widely practised by a diverse group of specialists outside the operating theatre. We review the principles underlying safe and effective procedural sedation and analgesia and the spectrum of procedures for which it is currently done. We discuss the decision-making process used to determine appropriate drug selection, dosing, and sedation endpoint. We detail the pharmacopoeia for procedural sedation and analgesia, reviewing the pharmacology and adverse effects of these drugs. International differences in practice are described along with current areas of controversy and future directions.
Collapse
Affiliation(s)
- Baruch Krauss
- Division of Emergency Medicine, Children's Hospital and Harvard Medical School, 300 Longwood
| | | |
Collapse
|
31
|
Sehdev RS, Symmons DAD, Kindl K. Ketamine for rapid sequence induction in patients with head injury in the emergency department. Emerg Med Australas 2006; 18:37-44. [PMID: 16454773 DOI: 10.1111/j.1742-6723.2006.00802.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the evidence regarding the use of ketamine for induction of anaesthesia in patients with head injury in the ED. METHOD A literature review using the key words ketamine, head injury and intracranial pressure. RESULTS Advice from early literature guiding against the use of ketamine in head injury has been met with widespread acceptance, as reflected by current practice. That evidence is conflicting and inconclusive in regards to the safety of using ketamine in head injury. A review of the literature to date suggests that ketamine could be a safe and useful addition to our available treatment modalities. The key to this argument rests on specific pharmacological properties of ketamine, and their effects on the cerebral haemodynamics and cellular physiology of brain tissue that has been exposed to traumatic injury. CONCLUSION In the modern acute management of head-injured patients, ketamine might be a suitable agent for induction of anaesthesia, particularly in those patients with potential cardiovascular instability.
Collapse
Affiliation(s)
- Rajesh S Sehdev
- Emergency Department, The Townsville Hospital, Townsville, Queensland, Australia.
| | | | | |
Collapse
|
32
|
Affiliation(s)
- Peter Barnett
- Emergency Department, Royal Children's Hospital, Parkville, Victoria, Australia.
| |
Collapse
|