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Romano F, Brändle G, Abplanalp-Marti O, Gualtieri R, Sahyoun C. Procedural sedation and analgesia in Swiss Pediatric Emergency Departments: a national subgroup analysis of a European cross-sectional survey. Eur J Pediatr 2024; 183:4579-4583. [PMID: 39096384 DOI: 10.1007/s00431-024-05701-5] [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: 04/25/2024] [Revised: 07/02/2024] [Accepted: 07/24/2024] [Indexed: 08/05/2024]
Abstract
This study aims to provide a national overview of procedural sedation and analgesia practices within Pediatric Emergency Departments in Switzerland, focusing on the availability of pharmacologic agents, the presence of safety protocols, the utilization of non-pharmacological interventions, and to identify specific local limitations. We conducted a detailed subgroup analysis of Swiss data from a European cross-sectional survey on emergency department pediatric Procedural Sedation and Analgesia (PSA) practice, isolating data from Swiss sites. The survey, conducted between November 2019 and March 2020, covered various aspects of procedural sedation and analgesia practices. The survey included nine Swiss sites, treating a total of 252,786 patients in 2019. Topical analgesia, inhaled equimolar nitrous oxide-oxygen mixture, and ketamine were largely available. All sites had nurse-directed triage protocols in place; however, opioid administration was included in the protocols in only 66% of sites. Only 33% of hospitals reported common use of intravenous sedation. Barriers to procedural sedation and analgesia implementation included staffing shortages (89% of sites) and lack of dedicated spaces (78%).Conclusions: Despite a broad array of pharmacological and options available in Swiss Pediatric Emergency Departments, challenges remain in standardizing practices across the country. Limited space and staffing and enhancing training on non-pharmacological interventions were identified as potential areas for improving pain and anxiety management in pediatric emergency care. This study underscores the need for national guidelines to harmonize emergency department PSA practices across Switzerland, ensuring all children have access to effective and evidence-based procedural comfort. What is Known: • Recent research, conducted in European emergency departments, suggests that in pediatric Procedural Sedation and Analgesia (PSA) resources are limited, and practice is heterogeneous What is New: • Swiss pediatric hospitals offer a wide range of pharmacological options for pain and anxiety management. However, significant barriers to PSA were identified. These include external control of intravenous sedation and insufficient integration of non-pharmacological interventions, such as child life specialists and procedural hypnosis. National guidelines are needed to harmonize PSA practices.
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Affiliation(s)
- Fabrizio Romano
- Pediatric Emergency Department, Inselspital, University Hospital, University of Bern, Bern, Switzerland
| | - Gabriel Brändle
- Division of Pediatric Emergency Medicine, Children's Hospital of Geneva, Geneva University Hospitals, Rue Willy Donzé, 6, 1205, Geneva, Switzerland
- Division of Pediatric Emergency Medicine, Hirslanden Clinique Des Grangettes, Geneva, Switzerland
| | - Olivia Abplanalp-Marti
- Pediatric Emergency Department, Inselspital, University Hospital, University of Bern, Bern, Switzerland
| | - Renato Gualtieri
- Division of Pediatric Emergency Medicine, Children's Hospital of Geneva, Geneva University Hospitals, Rue Willy Donzé, 6, 1205, Geneva, Switzerland.
- Department of Pediatrics, Gynecology and Obstetrics, Geneva University, Geneva, Switzerland.
| | - Cyril Sahyoun
- Division of Pediatric Emergency Medicine, Children's Hospital of Geneva, Geneva University Hospitals, Rue Willy Donzé, 6, 1205, Geneva, Switzerland
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Clark JR, Batra A, Tessier RA, Greathouse K, Dickson D, Ammar A, Hamm B, Rosenthal LJ, Lombardo T, Koralnik IJ, Skolarus LE, Schroedl CJ, Budinger GRS, Wunderink RG, Dematte JE, Ungvari Z, Liotta EM. Impact of healthcare system strain on the implementation of ICU sedation practices and encephalopathy burden during the early COVID-19 pandemic. GeroScience 2024:10.1007/s11357-024-01336-4. [PMID: 39243283 DOI: 10.1007/s11357-024-01336-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Accepted: 08/31/2024] [Indexed: 09/09/2024] Open
Abstract
The COVID-19 pandemic posed unprecedented challenges to healthcare systems worldwide, particularly in managing critically ill patients requiring mechanical ventilation early in the pandemic. Surging patient volumes strained hospital resources and complicated the implementation of standard-of-care intensive care unit (ICU) practices, including sedation management. The objective of this study was to evaluate the impact of an evidence-based ICU sedation bundle during the early COVID-19 pandemic. The bundle was designed by a multi-disciplinary collaborative to reinforce best clinical practices related to ICU sedation. The bundle was implemented prospectively with retrospective analysis of electronic medical record data. The setting was the ICUs of a single-center tertiary hospital. The patients were the ICU patients requiring mechanical ventilation for confirmed COVID-19 between March and June 2020. A learning health collaborative developed a sedation bundle encouraging goal-directed sedation and use of adjunctive strategies to avoid excessive sedative administration. Implementation strategies included structured in-service training, audit and feedback, and continuous improvement. Sedative utilization and clinical outcomes were compared between patients admitted before and after the sedation bundle implementation. Quasi-experimental interrupted time-series analyses of pre and post intervention sedative utilization, hospital length of stay, and number of days free of delirium, coma, or death in 21 days (as a quantitative measure of encephalopathy burden). The analysis used the time duration between start of the COVID-19 wave and ICU admission to identify a "breakpoint" indicating a change in observed trends. A total of 183 patients (age 59.0 ± 15.9 years) were included, with 83 (45%) admitted before the intervention began. Benzodiazepine utilization increased for patients admitted after the bundle implementation, while agents intended to reduce benzodiazepine use showed no greater utilization. No "breakpoint" was identified to suggest the bundle impacted any endpoint measure. However, increasing time between COVID-19 wave start and ICU admission was associated with fewer delirium, coma, and death-free days (β = - 0.044 [95% CI - 0.085, - 0.003] days/wave day); more days of benzodiazepine infusion (β = 0.056 [95% CI 0.025, 0.088] days/wave day); and a higher maximum benzodiazepine infusion rate (β = 0.079 [95% CI 0.037, 0.120] mg/h/wave day). The evidence-based practice bundle did not significantly alter sedation utilization patterns during the first COVID-19 wave. Sedation practices deteriorated and encephalopathy burden increased over time, highlighting that strategies to reinforce clinical practices may be hindered under conditions of extreme healthcare system strain.
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Affiliation(s)
- Jeffrey R Clark
- Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
- Columbia University Irving Medical Center, New York, NY, USA
| | - Ayush Batra
- Ken & Ruth Davee Department of Neurology, Northwestern University-Feinberg School of Medicine, 625 N. Michigan Ave, Suite 1150, Chicago, IL, 60611, USA
| | - Robert A Tessier
- Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Kasey Greathouse
- Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Dan Dickson
- Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Abeer Ammar
- Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Brandon Hamm
- Department of Psychiatry and Behavioral Sciences, Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Lisa J Rosenthal
- Department of Psychiatry and Behavioral Sciences, Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Theresa Lombardo
- Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Igor J Koralnik
- Ken & Ruth Davee Department of Neurology, Northwestern University-Feinberg School of Medicine, 625 N. Michigan Ave, Suite 1150, Chicago, IL, 60611, USA
| | - Lesli E Skolarus
- Ken & Ruth Davee Department of Neurology, Northwestern University-Feinberg School of Medicine, 625 N. Michigan Ave, Suite 1150, Chicago, IL, 60611, USA
| | - Clara J Schroedl
- Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - G R Scott Budinger
- Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Richard G Wunderink
- Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Jane E Dematte
- Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Zoltan Ungvari
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Department of Health Promotion Sciences, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral College/Department of Public Health, Semmelweis University, Budapest, Hungary
| | - Eric M Liotta
- Ken & Ruth Davee Department of Neurology, Northwestern University-Feinberg School of Medicine, 625 N. Michigan Ave, Suite 1150, Chicago, IL, 60611, USA.
- International Training Program in Geroscience, Doctoral College/Department of Public Health, Semmelweis University, Budapest, Hungary.
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Molina Gutiérrez MA, Fernández Camuñas M, Ruíz Domínguez JA, Bueno Barriocanal M, De Miguel Lavisier B, López López R, de Ceano-Vivas La Calle M. Sedoanalgesia With Ketamine in the Emergency Department: Factors Associated With Unsatisfactory Effectiveness. Pediatr Emerg Care 2024; 40:654-659. [PMID: 38718384 DOI: 10.1097/pec.0000000000003150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2024]
Abstract
OBJECTIVE Ketamine is a safe and widely used sedative and analgesic in children. The purpose of this study is to evaluate the response to sedoanalgesia for painful procedures in the pediatric emergency department. METHODS A retrospective study was conducted in children younger than 16 years who underwent painful procedures with intravenous/intranasal ketamine between January 2016 and December 2022. We collected demographic variables, effectiveness, route of administration, indication, dose, sedation strategy, duration of procedure, and associated adverse effects. RESULTS A total of 671 ketamine sedation procedures (411 males/260 females) were included, with a mean age of 7.2 years. Closed reduction was the most common painful procedure (53.8%), followed by burn healing (24.6%). Ketamine was administered intravenously in 93.4% of procedures and intranasally in 6.6%. The result of sedoanalgesia was satisfactory in 84.9% and unsatisfactory in 15.1%. The percentage of cases with unsatisfactory analgesia was higher with intranasal administration (36.4%; P < 0.001). In the intravenous group, the percentage of cases with unsatisfactory effectiveness (28.7%) was higher for patients younger than 2 years of age ( P < 0.001). Arthrocentesis procedures were associated with the highest percentage of unsatisfactory sedoanalgesia failures among patients receiving intravenous ketamine (39.3%; P < 0.001). Intranasal ketamine patients who received a dose between 3.6 and 4 mg/kg had a significantly higher percentage of unsatisfactory sedoanalgesia (66.7%; P = 0.048). Patients receiving intravenous ketamine had significantly higher rates of unsatisfactory sedoanalgesia when the initial dose interval was 1.6 to 2 mg/kg (11.8%; P = 0.002) and when the final total dose was also 1.6 to 2 mg/kg (17.6%; P = 0.002). CONCLUSIONS This study concludes that intravenous/intranasal ketamine can provide safe and successful analgesia in pediatric patients in the ED. At intravenous doses of 1-1.5 mg/kg, good effectiveness was achieved in almost 90% of cases. Arthrocentesis had the highest percentage of unsatisfactory results. Repeat dosing should be considered for procedures longer than 20 minutes.
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Mills LA, Kuntz HM. Adverse Events in Patients Aged 90 Days or Younger Receiving Ketamine in the Emergency Department. Pediatr Emerg Care 2024; 40:665-667. [PMID: 38776429 DOI: 10.1097/pec.0000000000003218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
OBJECTIVES The aim of this study was to identify the incidence of adverse events of ketamine administration in the pediatric emergency department in patients aged 90 days or younger in order to demonstrate the safety and efficacy of administration in this patient population. METHODS An 8-year retrospective chart review of patients aged 90 days or younger who received ketamine in the pediatric emergency department was conducted. All patients who met the age criteria were included in this study. Identified routes of ketamine administration included oral, intramuscular, and intravenous. RESULTS Fourteen patients were identified who met the inclusion criteria and were included in the final analysis. The median age was 45 days old. Indications for ketamine administration included 7 cases for procedural sedation, 5 cases for RSI, and 2 cases for postintubation sedation. The average dose amount (mg/kg) of ketamine administered was 10, 4.43, and 1.59 for oral, intramuscular, and intravenous routes, respectively. Of the 14 patients, 1 patient was identified to have an adverse event to ketamine administration. A transient desaturation and bradycardic event due to laryngospasm was observed during laryngoscopy performed for RSI that was resolved with administration of anticholinergics and paralytics as well as successful intubation and ventilation. CONCLUSIONS In this study, 1 patient suffered an adverse event due to laryngospasm during intubation. In the pediatric population, the incidence of adverse events of ketamine administration has been found to be variable in the current literature, ranging from 0.71% to 7.26%. In our study, an adverse event occurred in 1 out of 14 administrations (7.1%). The incidence of adverse events associated with ketamine administration in our patients aged 90 days or less appeared to be similar to that reported in the general pediatric population.
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Simon MW, Olsen HA, Hoyte CO, Black JC, Reynolds KM, Dart RC, Monte AA. Clinical Effects of Psychedelic Substances Reported to United States Poison Centers: 2012 to 2022. Ann Emerg Med 2024:S0196-0644(24)00384-6. [PMID: 39093248 DOI: 10.1016/j.annemergmed.2024.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 06/18/2024] [Accepted: 06/25/2024] [Indexed: 08/04/2024]
Abstract
STUDY OBJECTIVE Psychedelic substances use is increasing in the United States (US). The approval of new psychedelic drugs and legalization of natural psychedelic substances will likely further increase exposures and subsequent adverse events. The study objective is to describe the clinical effects, therapies, and medical outcomes of patients with psychedelic exposures reported to US poison centers. METHODS We performed a retrospective, cross-sectional study on psychedelic exposures reported to the National Poison Data System from January 1, 2012, to December 31, 2022. We categorized exposures into groups: hallucinogenic amphetamines, lysergic acid diethylamide, tryptamines (such as N, N-dimethyltryptamine), phencyclidine, hallucinogenic mushrooms, hallucinogenic plants, and ketamine and ketamine analogs. We summarized effects, treatments, and outcomes and evaluated associations with logistic regression and odds ratios. RESULTS Our sample included 54,605 cases. There were concomitant exposures in 41.1% (n=22,460) of cases. Hallucinogenic mushroom exposures increased most over the study period from 593 in 2012 to 1,440 in 2022. Overall, 27,444 (50.3%) psychedelic exposures had symptoms that required treatment, severe residual or prolonged symptoms, or death. Cardiovascular effects were common, especially with hallucinogenic amphetamine exposures (31.1%). Patients managed in or referred to a health care facility received medical therapies in 62.4% of cases, including sedation (32.9%) and respiratory interventions (10.3%). CONCLUSION Over half of psychedelic exposures reported to US poison centers had symptoms that required treatment, severe residual or prolonged symptoms, or death. Increases in psychedelic use may lead to increased frequency of adverse events and health care utilization.
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Affiliation(s)
- Mark W Simon
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO.
| | - Heather A Olsen
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO
| | - Christopher O Hoyte
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Joshua C Black
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO
| | - Kate M Reynolds
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO
| | - Richard C Dart
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO
| | - Andrew A Monte
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
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Finney JD, Schuler PD, Rudloff JR, Agostin N, Lobanov OV, Siegler J, Shah MI, Guterman EL, Chamberlain JM, Ahmad FA. Evaluation of the Use of Ketamine in Prehospital Seizure Management: A Retrospective Review of the ESO Database. PREHOSP EMERG CARE 2024:1-8. [PMID: 39058382 DOI: 10.1080/10903127.2024.2382367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 07/12/2024] [Accepted: 07/14/2024] [Indexed: 07/28/2024]
Abstract
OBJECTIVES Benzodiazepines are the primary antiseizure medication used by Emergency Medical Services (EMS) for seizures. Available literature in the United States and internationally shows 30% to 40% of seizures do not terminate with benzodiazepines called benzodiazepine refractory status epilepticus (BRSE). Ketamine is a potential treatment for BRSE due to its unique pharmacology. However, its application in the prehospital setting is mostly documented in case reports. Little is known about its use by EMS professionals for seizure management, whether as initial treatment or for BRSE, creating an opportunity to describe its current use and inform future research. METHODS We performed a retrospective review of 9-1-1 EMS encounters with a primary or secondary impression of seizure using the ESO Data Collaborative from 2018 to 2021. We isolated encounters during which ketamine was administered. We excluded medication administrations prior to EMS arrival and encounters without medication administration. Subgroup analysis was performed to control for airway procedure as an indication for ketamine administration. We also evaluated for co-administration with other antiseizure medications, dose and route of administration, and response to treatment. RESULTS We identified 99,576 encounters that met inclusion. There were 2,531/99,576 (2.54%) encounters with ketamine administration and 50.7% (1,283/2,531) received ketamine without an airway procedure. There were 616 cases (48%, 616/1,283) where ketamine was given without another antiseizure medication (ASM) and without any airway procedure. The remaining 667 (52%) cases received ketamine with at least one other ASM, most commonly midazolam (89%, 593/667). Adjusted for the growth in the ESO dataset, ketamine use by EMS professionals during encounters for seizures without an airway procedure increased from 0.90% (139/15,375) to 1.45% (416/28,651) an increase of 62% over the study period. CONCLUSIONS In this retrospective review of the ESO Data Collaborative, ketamine administration for seizure encounters without an airway procedure increased over the study period, both as a single agent and with another ASM. Most ketamine administrations were for adult patients in the south and in urban areas. The frequency of BRSE, the need for effective treatment, and the growth in ketamine use warrant prospective prehospital research to evaluate the value of ketamine in prehospital seizure management.
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Affiliation(s)
- Joseph Daniel Finney
- Department of Pediatrics, Washington University in Saint Louis, Saint Louis, Missouri
| | - Paul D Schuler
- Department of Emergency Medicine, School of Medicine, University of Missouri, Columbia, Missouri
| | - James R Rudloff
- Department of Pediatrics, Institute for Informatics Data Science and Biostatistics, Washington University in Saint Louis, St. Louis, Missouri
| | - Nicholas Agostin
- Department of Pediatrics, Washington University in Saint Louis, Saint Louis, Missouri
| | - Oleg V Lobanov
- Department of Neurology, Washington University in St. Louis, St. Louis, Missouri
| | - Jeffrey Siegler
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Manish I Shah
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Elan L Guterman
- Philip R. Lee Institute for Health Policy Studies and Department of Neurology, University of California, San Francisco, California
| | - James M Chamberlain
- Pediatrics and Emergency Medicine, George Washington University, Washington, District of Columbia
| | - Fahd A Ahmad
- Department of Pediatrics, Washington University in Saint Louis, Saint Louis, Missouri
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Yabrodi M, Abdel-Mageed S, Abulebda K, Murphy LD, Rodenbarger A, Bhai H, Lutfi R, Friedman ML. Deep Sedation in Pediatric Patients With Single Ventricle Physiology Outside of the Operating Room. World J Pediatr Congenit Heart Surg 2024; 15:488-493. [PMID: 38213105 DOI: 10.1177/21501351231211584] [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] [Indexed: 01/13/2024]
Abstract
Background: Advancements in palliative surgery of patients with single ventricle physiology have led to an increase in the need for deep sedation protocols for painful procedures. However, positive pressure ventilation during anesthesia can result in unfavorable cardiopulmonary interactions. This patient population may benefit from sedation from these painful procedures. Methods: This study aims to demonstrate the safety and efficacy of deep sedation by pediatric intensivists outside the operating room for children with single ventricle physiology. This is a single-center, retrospective chart review on consecutive pediatric patients with single ventricle physiology who received deep sedation performed by pediatric intensivists between 2013 and 2020. Results: Thirty-three sedations were performed on 27 unique patients. The median age was 3.7 years (25th%-75th%: 2.1-15.6). The majority of the sedations, 88% (29/33), were done on children with Fontan physiology and 12% (4/33) were status-post superior cavopulmonary anastomosis. The primary cardiac defect was hypoplastic left heart in 63% (17/27) of all sedation procedures. There were 24 chest tube placements and 9 cardioversions. Ketamine alone [median dose 1.5 mg/kg (range 0.8-3.7)], ketamine [median dose 1 mg/kg (range 0.1-2.1)] with propofol [median dose 2.3 mg/kg (range 0.7-3.8)], and ketamine [median dose 1.5 mg/kg (range 0.4-3.0)] with morphine [median dose 0.06 mg/kg (range 0.03-0.20)] were the most common sedation regimens used. Adverse events (AEs) occurred in 4 patients (15%), three of which were transient AEs. All sedation encounters were successfully completed. Conclusion: Procedural deep sedation can be safely and effectively administered to single ventricle patients by intensivist-led sedation teams in selective case.
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Affiliation(s)
- Mouhammad Yabrodi
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | | | - Kamal Abulebda
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Lee D Murphy
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Andrew Rodenbarger
- Division of Pediatric Cardiology, Department of Pediatrics, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Hamza Bhai
- Marian University School of Medicine, Indianapolis, IN, USA
| | - Riad Lutfi
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Matthew L Friedman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
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8
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Bailey AM, Weant KA. Dream of the Endless: Updates in Agents for Procedural Sedation. Adv Emerg Nurs J 2024; 46:195-206. [PMID: 39094079 DOI: 10.1097/tme.0000000000000528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
Procedural sedation and analgesia is an essential activity in the emergency department for managing pain and anxiety during a variety of medical procedures. Various pharmacotherapy options, including opioid analgesics, antiemetics, anticholinergics, sedatives, and ketamine have been utilized, all with their unique efficacy and safety profiles. This review highlights the challenges associated with using certain agents and discusses emerging trends such as the use of newer synthetic opioids and the expanding use of dexmedetomidine. Overall, the selection of the optimal agents for procedural sedation and analgesia should be guided based on the unique characteristics of each agent tailored to the needs of the specific procedure, along with consideration for individual patient characteristics.
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Affiliation(s)
- Abby M Bailey
- Departments of Emergency Medicine Clinical Pharmacy, Emergency Medicine, and Pharmacy, University of Kentucky HealthCare, Lexington, Kentucky (Dr. Bailey); and Department of Clinical Pharmacy and Outcomes Sciences, College of Pharmacy, University of South Carolina, Columbia, South Carolina (Dr. Weant)
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9
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Han SM, Kwon SY, In JH, Joo JD. Enhancing ketamine anesthesia with midazolam and fentanyl for children's ear surgery: a prospective randomized study. JOURNAL OF YEUNGNAM MEDICAL SCIENCE 2024; 41:207-212. [PMID: 38778719 PMCID: PMC11294792 DOI: 10.12701/jyms.2024.00276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 04/04/2024] [Accepted: 04/11/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Myringotomy with tympanostomy tube insertion (MTI) is a superficial surgical procedure used to prevent hearing loss in children with serous otitis media. Intravenous anesthesia, often ketamine, is preferred for this procedure because of its ability to induce sedation without compromising airway reflexes. However, ketamine alone may be insufficient and potentially lead to spontaneous movement during surgery. This study evaluated the effectiveness of midazolam and fentanyl as adjuvants to ketamine in reducing spontaneous movement during MTI and enhancing the quality of recovery. METHODS This study involved two groups of 30 patients each: one group received intravenous ketamine (1.5 mg/kg) with an equal volume of normal saline (K group), while the other received a combination of midazolam, fentanyl, and ketamine (0.05 mg/kg, 1 μg/kg, and 1.5 mg/kg, respectively; MFK group). We assessed side effects, intraoperative patient movement, surgeon satisfaction, and emergence agitation scores. RESULTS The MFK group exhibited significantly lower scores for patient movement (p<0.01) and emergence agitation (p<0.01) and markedly higher surgeon satisfaction scores (p<0.01) than the K group. CONCLUSION Administering a midazolam-fentanyl-ketamine combination effectively reduced spontaneous movement during surgery and emergence agitation during recovery without prolonging discharge times in children undergoing MTI.
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Affiliation(s)
| | - So Young Kwon
- Department of Anesthesiology and Pain Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jang Hyeok In
- Department of Anesthesiology and Pain Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin Deok Joo
- Department of Anesthesiology and Pain Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Green SM, Bhatt M, Roback MG. Supplemental Oxygen for Pediatric Procedural Sedation: Common Sense Precaution or False Reassurance? Ann Emerg Med 2024:S0196-0644(24)00293-2. [PMID: 38912997 DOI: 10.1016/j.annemergmed.2024.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 05/20/2024] [Accepted: 05/21/2024] [Indexed: 06/25/2024]
Affiliation(s)
- Steven M Green
- Department of Emergency Medicine, Loma Linda University, Loma Linda, CA.
| | - Maala Bhatt
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada
| | - Mark G Roback
- Department of Pediatrics, University of Colorado, Aurora, CO
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Beckman S, Lu H, Alsharif P, Qiu L, Ali M, Adrian RJ, Alerhand S. Echocardiographic diagnosis and clinical implications of wide-open tricuspid regurgitation for evaluating right ventricular dysfunction in the emergency department. Am J Emerg Med 2024; 80:227.e7-227.e11. [PMID: 38702221 DOI: 10.1016/j.ajem.2024.04.039] [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: 02/04/2024] [Accepted: 04/19/2024] [Indexed: 05/06/2024] Open
Abstract
The tricuspid regurgitation pressure gradient (TRPG) reflects the difference in pressure between the right ventricle and right atrium (ΔPRV-RA). Its estimation by echocardiography correlates well with that obtained using right-heart catheterization. An elevated TRPG is an important marker for identifying right ventricular dysfunction in both the acute and chronic settings. However, in the "wide-open" variant of TR, the TRPG counterintuitively falls. Failure to recognize this potential pitfall and underlying pathophysiology can cause underestimation of the severity of right ventricular dysfunction. This could lead to erroneous fluid tolerance assessments, and potentially harmful resuscitative and airway management strategies. In this manuscript, we illustrate the pathophysiology and potential pitfall of wide-open TR through a series of cases in which emergency physicians made the diagnosis using cardiac point-of-care ultrasound. To our knowledge, this clinical series is the first to demonstrate recognition of the paradoxically-low TRPG of wide-open TR, which guided appropriate management of critically ill patients in the emergency department.
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Affiliation(s)
- Sean Beckman
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Helen Lu
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Peter Alsharif
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Linda Qiu
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Marwa Ali
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Robert James Adrian
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - Stephen Alerhand
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA.
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12
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Noto K, Uchida S, Kinoshita H, Takekawa D, Kushikata T, Hirota K. Predictive model for post-induction hypotension in patients undergoing transcatheter aortic valve implantation: a retrospective observational study. JA Clin Rep 2024; 10:33. [PMID: 38787499 PMCID: PMC11126397 DOI: 10.1186/s40981-024-00717-0] [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: 02/27/2024] [Revised: 04/26/2024] [Accepted: 05/19/2024] [Indexed: 05/25/2024] Open
Abstract
PURPOSE Post-induction hypotension (PIH) is an independent risk factor for prolonged postoperative stay and hospital death. Patients undergoing transcatheter aortic valve implantation (TAVI) are prone to develop PIH. This study aimed to develop a predictive model for PIH in patients undergoing TAVI. METHODS This single-center retrospective observational study included 163 patients who underwent TAVI. PIH was defined as at least one measurement of systolic arterial pressure <90 mmHg or at least one incident of norepinephrine infusion at a rate >6 µg/min from anesthetic induction until 20 min post-induction. Multivariate logistic regression analysis was performed to develop a predictive model for PIH in patients undergoing TAVI. RESULTS In total, 161 patients were analyzed. The prevalence of PIH was 57.8%. Multivariable logistic regression analysis showed that baseline mean arterial pressure ≥90 mmHg [adjusted odds ratio (aOR): 0.413, 95% confidence interval (95% CI): 0.193-0.887; p=0.023] and higher doses of fentanyl (per 1-µg/kg increase, aOR: 0.619, 95% CI: 0.418-0.915; p=0.016) and ketamine (per 1-mg/kg increase, aOR: 0.163, 95% CI: 0.062-0.430; p=0.002) for induction were significantly associated with lower risk of PIH. A higher dose of propofol (per 1-mg/kg increase, aOR: 3.240, 95% CI: 1.320-7.920; p=0.010) for induction was significantly associated with higher risk of PIH. The area under the curve (AUC) for this model was 0.802. CONCLUSION The present study developed predictive models for PIH in patients who underwent TAVI. This model may be helpful for anesthesiologists in preventing PIH in patients undergoing TAVI.
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Affiliation(s)
- Kohei Noto
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, 036-8562, Japan
| | - Satoshi Uchida
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, 036-8562, Japan
| | - Hirotaka Kinoshita
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, 036-8562, Japan
| | - Daiki Takekawa
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, 036-8562, Japan.
| | - Tetsuya Kushikata
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, 036-8562, Japan
| | - Kazuyoshi Hirota
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, 036-8562, Japan
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13
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Isık G, Alpay N, Daglioglu G, Ciftci V. Effects of propofol, ketamine-propofol mixture in pediatric dental patients undergoing intravenous sedation: a clinical study. Sci Rep 2024; 14:11806. [PMID: 38782977 PMCID: PMC11116380 DOI: 10.1038/s41598-024-61823-8] [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: 12/14/2023] [Accepted: 05/09/2024] [Indexed: 05/25/2024] Open
Abstract
This study aimed to evaluate the clinical effects, complications (peri- and postoperative), depth of sedation, recovery times, and changes in anxiety levels in paediatric dental patients receiving intravenous sedation with propofol and ketamine-propofol mixtures. This prospective clinical study included 69 healthy children (ASA 1) aged 3-7 years. The patients were assigned randomly to propofol group (n = 23), which received propofol; 1:3 ketofol group (n = 23), which received 1:3 ketofol; or 1:4 ketofol group (n = 23), which received 1:4 ketofol. The bispectral index (BIS) and Ramsay Sedation Scale (RSS) score were recorded at intervals of 5 min to measure the depth of sedation, and vital signs were evaluated. Peri- and postoperative complications and recovery times were recorded. Anxiety levels were also evaluated using the Facial Image Scale (FIS) and changes in saliva cortisol levels (SCLs) before and after the intravenous sedation procedure. The Kruskal‒Wallis test and Wilcoxon signed-rank test were used to determine pre- and posttreatment parameters. Dunn's test for post hoc analysis was used to determine the differences among groups. Children's pre- and posttreatment anxiety levels did not differ significantly according to FIS scores, and increases in SCLs were detected in 1:3 ketofol and 1:4 ketofol groups after dental treatment was completed. Compared with those in the other groups, the BIS values of the patients in 1:4 ketofol indicated a slightly lower depth of sedation. The recovery time of the patients in 1:3 ketofol was longer than that of patients in propofol and 1:4 ketofol. The incidence of postoperative complications (agitation, hypersalivation, nausea/vomiting, and diplopia) did not differ among the groups. Ketamine-propofol combinations provided effective sedation similar to that of propofol infusion without any serious complications during dental treatment performed under intravenous sedation. The ketofol infusion increased the anxiety level of paediatric dental patients to a greater extent than the propofol infusion.
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Affiliation(s)
- Gizem Isık
- Department of Pediatric Dentistry, Faculty of Dentistry, Cukurova University, Sarıçam, 01330, Adana, Turkey
| | - Nilgun Alpay
- Department of Anesthesiology and Reanimation, Faculty of Dentistry, Cukurova University, Adana, Turkey
| | - Gülcin Daglioglu
- Department of Biochemistry, Balcalı Hospital Central Laboratory, Cukurova University, Adana, Turkey
| | - Volkan Ciftci
- Department of Pediatric Dentistry, Faculty of Dentistry, Cukurova University, Sarıçam, 01330, Adana, Turkey.
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Hudson JL, Wong J, Durkin M, Gangathimmaiah V, Furyk J. Review article: Efficacy of prophylactic ondansetron versus placebo or control in reducing vomiting in children undergoing ketamine procedural sedation in the emergency department: A systematic review and meta-analysis. Emerg Med Australas 2024; 36:178-186. [PMID: 38220580 DOI: 10.1111/1742-6723.14372] [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: 06/21/2023] [Revised: 12/13/2023] [Accepted: 12/24/2023] [Indexed: 01/16/2024]
Abstract
Ketamine is commonly used for procedural sedation anaesthesia in paediatric patients undergoing painful procedures in the ED. Ketamine's safety profile is excellent, but ketamine-associated vomiting (KAV) is common. Routine ondansetron prophylaxis could reduce KAV incidence. This literature review evaluated the efficacy of prophylactic ondansetron in reducing KAV incidence. A systematic literature review was performed on databases and trial registries on 14 January 2023 to identify randomised controlled trials. The primary outcome was reduction in KAV incidence, for any route of prophylactic ondansetron, in ED and up to 24 h post-discharge. ED length of stay, parental satisfaction and time to resumption of normal diet were secondary outcomes. Data analysis was performed using Revman 5.3. Meta-analysis was performed using random effects modelling. Risk of bias was assessed using the Cochrane Risk-of-Bias 2 tool. Evidence quality was assessed using Grading of Recommendation, Assessment Development and Evaluation methodology. Five trials with 920 participants met the eligibility criteria. Prophylactic ondansetron resulted in a reduction in KAV incidence overall odds ratio of 0.51 (95% confidence interval: 0.36-0.73). Intravenous and intramuscular prophylactic ondansetron showed benefit whereas the effect of oral administration was unclear. There was no difference between groups for secondary outcomes overall. The quality of evidence was deemed to be low overall because of high risk of bias and imprecision in outcome measures. This review found low to moderate certainty evidence that prophylactic ondansetron reduces KAV incidence. Methodologically rigorous research, with appropriately timed prophylactic ondansetron based on the route of administration, would further elucidate prophylactic oral ondansetron's efficacy.
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Affiliation(s)
- Jack L Hudson
- Emergency Department, Townsville University Hospital, Townsville, Queensland, Australia
| | - Julian Wong
- Emergency Department, Townsville University Hospital, Townsville, Queensland, Australia
- James Cook University, Townsville, Queensland, Australia
| | - Michael Durkin
- Emergency Department, Townsville University Hospital, Townsville, Queensland, Australia
| | - Vinay Gangathimmaiah
- Emergency Department, Townsville University Hospital, Townsville, Queensland, Australia
- James Cook University, Townsville, Queensland, Australia
| | - Jeremy Furyk
- Emergency Department, University Geelong Hospital, Geelong, Victoria, Australia
- Deakin University, Geelong, Victoria, Australia
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Salloum E, Lotte Seibold E, Azimaraghi O, Rudolph MI, Beier J, Schaefer MS, Sauer WJ, Tam C, Fassbender P, Kiyatkin M, Eikermann M, Wongtangman K. Association of ketamine use during procedural sedation with oxygen desaturation and healthcare utilisation: a multicentre retrospective hospital registry study. Br J Anaesth 2024; 132:779-788. [PMID: 38087741 DOI: 10.1016/j.bja.2023.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 11/13/2023] [Accepted: 11/13/2023] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND We investigated the effects of ketamine on desaturation and the risk of nursing home discharge in patients undergoing procedural sedation by anaesthetists. METHODS We included adult patients who underwent procedures under monitored anaesthetic care between 2005 and 2021 at two academic healthcare networks in the USA. The primary outcome was intraprocedural oxygen desaturation, defined as oxygen saturation <90% for ≥2 consecutive minutes. The co-primary outcome was a nursing home discharge. RESULTS Among 234,170 included patients undergoing procedural sedation, intraprocedural desaturation occurred in 5.6% of patients who received ketamine vs 5.2% of patients who did not receive ketamine (adjusted odds ratio [ORadj] 1.22, 95% confidence interval [CI] 1.15-1.29, P<0.001; adjusted absolute risk difference [ARDadj] 1%, 95% CI 0.7-1.3%, P<0.001). The effect was magnified by age >65 yr, smoking, or preprocedural ICU admission (P-for-interaction <0.001, ORadj 1.35, 95% CI 1.25-1.45, P<0.001; ARDadj 2%, 95% CI 1.56-2.49%, P<0.001), procedural risk factors (upper endoscopy of longer than 2 h; P-for-interaction <0.001, ORadj 2.91, 95% CI 1.85-4.58, P<0.001; ARDadj 16.2%, 95% CI 9.8-22.5%, P<0.001), and high ketamine dose (P-for-trend <0.001, ORadj 1.61, 95% CI, 1.43-1.81 for ketamine >0.5 mg kg-1). Concomitant opioid administration mitigated the risk (P-for-interaction <0.001). Ketamine was associated with higher odds of nursing home discharge (ORadj 1.11, 95% CI 1.02-1.21, P=0.012; ARDadj 0.25%, 95% CI 0.05-0.46%, P=0.014). CONCLUSIONS Ketamine use for procedural sedation was associated with an increased risk of oxygen desaturation and discharge to a nursing home. The effect was dose-dependent and magnified in subgroups of vulnerable patients.
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Affiliation(s)
- Elie Salloum
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Eva Lotte Seibold
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Omid Azimaraghi
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Maíra I Rudolph
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA; Department for Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Juliane Beier
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Maximilian S Schaefer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - William J Sauer
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Christopher Tam
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Philipp Fassbender
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA; Klinik für Anästhesiologie, Operative Intensivmedizin, Schmerz- und Palliativmedizin, Marien Hospital Herne, Universitätsklinikum der Ruhr-Universität Bochum, Herne, Germany
| | - Michael Kiyatkin
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Matthias Eikermann
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA; Klinik für Anä¨sthesiologie and Intensivmedizin, Universität Duisburg-Essen, Essen, Germany.
| | - Karuna Wongtangman
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA; Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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16
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Bell CM, Rech MA, Akuamoah-Boateng KA, Kasotakis G, McMurray JD, Moses BA, Mueller SW, Patel GP, Roberts RJ, Sakhuja A, Salvator A, Setliff EL, Droege CA. Ketamine in Critically Ill Patients: Use, Perceptions, and Potential Barriers. J Pharm Pract 2024; 37:351-363. [PMID: 36282867 DOI: 10.1177/08971900221134551] [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] [Indexed: 02/16/2024]
Abstract
Objective: To evaluate practitioner use of ketamine and identify potential barriers to use in acutely and critically ill patients. To compare characteristics, beliefs, and practices of ketamine frequent users and non-users. Methods: An online survey developed by members of the Society of Critical Care Medicine (SCCM) Clinical Pharmacy and Pharmacology Section was distributed to physician, pharmacist, nurse practitioner, physician assistant and nurse members of SCCM. The online survey queried SCCM members on self-reported practices regarding ketamine use and potential barriers in acute and critically ill patients. Results: Respondents, 341 analyzed, were mostly adult physicians, practicing in the United States at academic medical centers. Clinicians were comfortable or very comfortable using ketamine to facilitate intubation (80.0%), for analgesia (77.9%), procedural sedation (79.4%), continuous ICU sedation (65.8%), dressing changes (62.4%), or for asthma exacerbation and status epilepticus (58.8% and 40.4%). Clinicians were least comfortable with ketamine use for alcohol withdrawal and opioid detoxification (24.7% and 23.2%). Most respondents reported "never" or "infrequently" using ketamine preferentially for continuous IV analgesia (55.6%) or sedation (61%). Responses were mixed across dosing ranges and duration. The most common barriers to ketamine use were adverse effects (42.6%), other practitioners not routinely using the medication (41.5%), lack of evidence (33.5%), lack of familiarity (33.1%), and hospital/institutional policy guiding the indication for use (32.3%). Conclusion: Although most critical care practitioners report feeling comfortable using ketamine, there are many inconsistencies in practice regarding dose, duration, and reasons to avoid or limit ketamine use. Further educational tools may be targeted at practitioners to improve appropriate ketamine use.
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Affiliation(s)
- Carolyn M Bell
- Department of Pharmacy, Medical University of South Carolina, Charleston, SC, USA
| | - Megan A Rech
- Department of Pharmacy, Department of Emergency Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Kwame A Akuamoah-Boateng
- Department of Surgery: Division of Acute Care Surgical Services, Virginia Commonwealth University Medical Center, Richmond, VA, USA
| | - George Kasotakis
- Department of Surgery, Duke University School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey D McMurray
- Department of Anesthesia, Medical University of South Carolina, Charleston, SC, USA
| | - Benjamin A Moses
- Department of Anesthesia: Division of Critical Care, University of Virginia Health, Charlottesville, VA, USA
| | - Scott W Mueller
- Department of Pharmacy, University of Colorado Health, Aurora, CO, USA
| | - Gourang P Patel
- Department of Pharmacy, University of Chicago Medical Center, Chicago, IL, USA
| | - Russel J Roberts
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Ankit Sakhuja
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Ann Salvator
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Erika L Setliff
- Department of Clinical Education Services, Atrium Health Cabarrus, Concord, NC, USA
| | - Christopher A Droege
- Department of Pharmacy Services, UC Health-University of Cincinnati Medical Center, Cincinnati, OH, USA
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17
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McMurray M, Orthober R, Huecker M. Ketamine's love story with the heart: A Takotsubo twist. Am J Emerg Med 2024; 77:232.e5-232.e7. [PMID: 38184443 DOI: 10.1016/j.ajem.2023.12.041] [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: 11/29/2023] [Revised: 12/21/2023] [Accepted: 12/25/2023] [Indexed: 01/08/2024] Open
Abstract
INTRODUCTION Ketamine is a dissociative anesthetic with N-methyl-d-aspartate and glutamate receptor antagonist properties. It has been the most popular agent to facilitate emergency department procedures for three decades. Considered a safe and effective option for procedural sedation, ketamine has rapid onset, short effective sedation time, and a low risk profile. Ketamine's sympathomimetic effects could theoretically induce stress-related cardiac dysfunction, including cardiomyopathy. A review of the literature demonstrates one prior report of stress (Takotsubo) cardiomyopathy after ketamine sedation. CASE REPORT In this case report, we present a case of Takotsubo cardiomyopathy after ketamine sedation for distal radius fracture reduction. The patient presented hemodynamically normal with an unremarkable cardiac ultrasound and progressed to hypoxia from bilateral pulmonary edema, eventually requiring intubation. Inpatient evaluation revealed elevated high sensitivity troponin, non-obstructive coronary arteries on catheterization, and echocardiogram findings of Takotsubo cardiomyopathy. She received operative fixation of her radius fracture by orthopedics and was discharged home on hospital day 9. She had an unremarkable follow up with cardiology but had no echocardiogram to determine full resolution. CONCLUSION Although ketamine has robust evidence of safety and efficacy, physicians should be aware of the potential complications of its sympathomimetic effects, from hypertension and tachycardia to overt Takotsubo cardiomyopathy.
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Affiliation(s)
- Mitchell McMurray
- Department of Emergency Medicine, University of Louisville School of Medicine, 550 South Jackson Street, Louisville, KY 40202, United States of America.
| | - Raymond Orthober
- Department of Emergency Medicine, University of Louisville School of Medicine, 550 South Jackson Street, Louisville, KY 40202, United States of America.
| | - Martin Huecker
- Department of Emergency Medicine, University of Louisville School of Medicine, 550 South Jackson Street, Louisville, KY 40202, United States of America.
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Williams NC, Morgan LA, Friedman J, Siegler J. Ketamine Efficacy for Management of Status Epilepticus: Considerations for Prehospital Clinicians. Air Med J 2024; 43:84-89. [PMID: 38490790 DOI: 10.1016/j.amj.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 09/10/2023] [Accepted: 09/21/2023] [Indexed: 03/17/2024]
Abstract
Current first-line therapies for seizure management recommend benzodiazepines, which target gamma-aminobutyric acid type A channels to stop the seizure activity. However, seizures may be refractory to traditional first-line therapies, transitioning into status epilepticus and becoming resistant to gamma-aminobutyric acid type A augmenting drugs. Although there are other antiseizure medications available for clinicians to use in the intensive care unit, these options can be less readily available outside of the intensive care unit and entirely absent in the prehospital setting. Instead, patients frequently receive multiple doses of first-line agents with increased risk of hemodynamic or airway collapse. Ketamine is readily available in the prehospital setting and emergency department, has well-established antiseizure effects with a favorable safety profile, and is a drug often used for several other indications. This article aimed to explore the utilization of ketamine for seizure management in the prehospital setting, reviewing seizure pathophysiology, established treatment mechanisms of action and pharmacokinetics, and potential benefits of early ketamine use in status epilepticus.
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Affiliation(s)
| | - Lindsey A Morgan
- Department of Neurology, Division of Pediatric Neurology, University of Washington, Seattle, WA; Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, WA
| | | | - Jeffrey Siegler
- Department of Emergency Medicine, Washington University School of Medicine, St Louis, MO
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19
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Xing F, Zhang TT, Yang Z, Qu M, Shi X, Li Y, Li Y, Zhang W, Wang Z, Xing N. Comparison of dexmedetomidine and a dexmedetomidine-esketamine combination for reducing dental anxiety in preschool children undergoing dental treatment under general anesthesia: A randomized controlled trial. J Affect Disord 2024; 347:569-575. [PMID: 38065480 DOI: 10.1016/j.jad.2023.12.011] [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: 07/01/2023] [Revised: 11/06/2023] [Accepted: 12/02/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND Dental anxiety is a widespread complication occurring in pediatric patients during dental visits and may lead to undesirable complications. Esketamine may be effective in anxiety. OBJECTIVE The objective of this study was to investigate the effect of premedication with a dexmedetomidine-esketamine combination compared with dexmedetomidine alone on dental anxiety in preschool children undergoing dental treatment under general anesthesia. METHODS This is a prospective, double-blinded, randomized controlled trial. A total of 84 patients were scheduled for elective outpatient dental caries treatment under general anesthesia. Patients were randomly premedicated with intranasal dexmedetomidine (group D) or intranasal dexmedetomidine-esketamine (group DS). The primary outcome was the level of dental anxiety assessed by the Modified Child Dental Anxiety Scale (MCDAS) at 2 h after surgery. Secondary outcomes included level of dental anxiety at 1 day and 7 days after surgery, the incidence of dental anxiety at 2 h, 1 day, and 7 days after surgery, sedation onset time, overall success of sedation, acceptance of mask induction, postoperative pain intensity, incidence of emergence agitation in PACU, adverse reactions, HR, and SpO2 before premedication (baseline) and at 10, 20, and 30 min after the end of study drug delivery. RESULTS The dental anxiety in group DS was lower than that in group D at 2 h, 1 day, and 7 days postoperatively (P = 0.04, 0.004, and 0.006, respectively). The incidences of dental anxiety in group DS were lower than those in group D at 2 h (53 % vs 76 %, P = 0.03), 1 day (47 % vs 71 %, P = 0.04), and 7 days (44 % vs 71 %, P = 0.02) after surgery. Group DS had a higher success rate of sedation (P = 0.03) but showed a lower MAS score (P = 0.005) and smoother hemodynamics (P < 0.01) after drug administration than group D. Group DS showed a significantly lower incidence rate of emergence agitation (P = 0.03) and postoperative pain intensity (P = 0.006) than that in group D during the anesthesia recovery time. The occurrence of adverse reactions was similar in both groups (P > 0.05). LIMITATIONS We did not analyze and correct for the learning effect caused by repeated applications of the MCDAS and MCDAS scores on the 1 day after surgery were obtained by telephone follow-up. CONCLUSIONS Compared to premedication with dexmedetomidine alone, premedication with intranasal dexmedetomidine combined with esketamine could significantly improve dental anxiety in preschool children undergoing dental treatment under general anesthesia.
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Affiliation(s)
- Fei Xing
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China; Henan Province International Joint Laboratory of Pain, Cognition and Emotion, Zhengzhou, Henan 450052, China
| | - Tong-Tong Zhang
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Zhihu Yang
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Mingcui Qu
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Xiaoshan Shi
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Yanna Li
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Yan Li
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Wei Zhang
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China; Henan Province International Joint Laboratory of Pain, Cognition and Emotion, Zhengzhou, Henan 450052, China
| | - Zhongyu Wang
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China; Henan Province International Joint Laboratory of Pain, Cognition and Emotion, Zhengzhou, Henan 450052, China.
| | - Na Xing
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China; Henan Province International Joint Laboratory of Pain, Cognition and Emotion, Zhengzhou, Henan 450052, China.
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Yang R, Zhao R, Chaudry F, Wang T, Brunton P, Khurshid Z, Ratnayake J. Modern sedative agents and techniques used in dentistry for patients with special needs: A review. J Taibah Univ Med Sci 2024; 19:153-163. [PMID: 38047240 PMCID: PMC10692720 DOI: 10.1016/j.jtumed.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 09/24/2023] [Accepted: 10/18/2023] [Indexed: 12/05/2023] Open
Abstract
According to the World Health Organisation, approximately 1.3 billion people worldwide experience substantial disability due to physical, mental or sensory impairment. People with special needs require special consideration and more time or altered delivery methods when receiving dental treatments. Various factors, such as patients' lack of cooperation, cognitive impairment and complex medical status, may lead dental practitioners to recommend conscious sedation. Several pharmacological agents and administrative routes are available, which achieve varying levels of sedation ranging from minimal to deep. Pre-operative assessment and careful case selection are necessary to determine the appropriate sedative agent, route of administration and level of sedation for each patient. Thus, a thorough understanding of the pharmacokinetics, risks and benefits, and implications of various sedatives available for PSN is essential to achieve the desired clinical outcomes. This review critically presents the considerations associated with the use of various sedative agents for PSN in dentistry. Considerations include patients' pre-anaesthesia medical comorbidities, cardiorespiratory adverse effects and cooperativeness, and the viable alternative treatment modalities.
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Affiliation(s)
- Ruijia Yang
- Department of Oral Science, Faculty of Dentistry, University of Otago, Dunedin, New Zealand
| | - Rusin Zhao
- Department of Oral Science, Faculty of Dentistry, University of Otago, Dunedin, New Zealand
| | - Fatima Chaudry
- Department of Oral Science, Faculty of Dentistry, University of Otago, Dunedin, New Zealand
| | - Tao Wang
- Department of Oral Science, Faculty of Dentistry, University of Otago, Dunedin, New Zealand
| | - Paul Brunton
- Department of Prosthodontics and Dental Implantology, Curtin University, Bentley, Australia
| | - Zohaib Khurshid
- Department of Prosthodontics and Dental Implantology, College of Dentistry, King Faisal University, Al-Ahsa, KSA
| | - Jithendra Ratnayake
- Department of Oral Science, Faculty of Dentistry, University of Otago, Dunedin, New Zealand
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21
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Nelles-McGee T, Waddington A, Pudwell J, Zouros I, Gibson MES. Intravenous Ketamine for Pain Control in First-Trimester Surgical Abortion: Interim Analysis of a Randomized Controlled Trial. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2024; 46:102235. [PMID: 37820929 DOI: 10.1016/j.jogc.2023.102235] [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: 06/09/2023] [Revised: 09/14/2023] [Accepted: 09/15/2023] [Indexed: 10/13/2023]
Abstract
OBJECTIVES Surgical abortion is common, with most completed in the first trimester. Gold standard pain control is intravenous (IV) fentanyl and midazolam, requiring continuous cardio-respiratory monitoring, a potential challenge where this monitoring is unavailable. Ketamine is a sedative and analgesic without the cardio-respiratory depression risk associated with IV opioids, representing a potential alternative. Investigating non-opiate pain control methods is imperative given the context of the opioid crisis. This is an interim analysis of 45 participants from a randomized controlled trial comparing IV ketamine, oral morphine, and IV fentanyl for pain control in first-trimester surgical abortion. We hypothesize that ketamine will provide better pain control than morphine. METHODS This is a double-blind, single-centre superiority trial of 3 parallel groups. Participants were ≥18 years old with confirmed intrauterine pregnancy of gestational age <12 weeks. Pain was assessed using the Visual Analogue Scale and the Wong-Baker Faces Pain Rating Scale. RESULTS In total, 2 participants were excluded post-randomization for 43 treated. Findings indicate that ketamine (n = 14; M = 0.7; 95% CI 0.1-1.3) provides better intra-operative pain control than morphine (n = 15, M = 4.4, 95% CI 2.9-5.9) and fentanyl (n = 14; M = 4.3; 95% CI 3.0-5.6; P < 0.001). The ketamine group was more satisfied with the anaesthetic method than the morphine group (P = 0.017). No group experienced serious adverse events. CONCLUSIONS Findings support continuation of the randomized controlled trial and highlight ketamine as a compelling non-opiate pain control option in first-trimester surgical abortion. Ketamine use may represent more optimal pain control in settings where continuous cardio-respiratory monitoring is unavailable.
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Affiliation(s)
| | - Ashley Waddington
- Faculty of Health Sciences, Obstetrics and Gynaecology, Queen's University, Kingston General Hospital, Kingston, ON
| | - Jessica Pudwell
- Faculty of Health Sciences, Obstetrics and Gynaecology, Queen's University, Kingston General Hospital, Kingston, ON
| | - Irene Zouros
- Department of Family Medicine, Queen's University, Kingston, ON
| | - M E Sophie Gibson
- Faculty of Health Sciences, Obstetrics and Gynaecology, Queen's University, Kingston General Hospital, Kingston, ON.
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22
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Stojanović M, Marinković M, Miličić B, Stojičić M, Jović M, Jovanović M, Isaković Subotić J, Jurišić M, Karamarković M, Đekić A, Radenović K, Mihaljević J, Radosavljević I, Suđecki B, Savić M, Kostić M, Garabinović Ž, Jeremić J. The Role of Ketamine as a Component of Multimodal Analgesia in Burns: A Retrospective Observational Study. J Clin Med 2024; 13:764. [PMID: 38337458 PMCID: PMC10856234 DOI: 10.3390/jcm13030764] [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: 12/27/2023] [Revised: 01/19/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
Background: Burn wound dressing and debridement are excruciatingly painful procedures that call for appropriate analgesia-typically multimodal. Better post-procedural pain management, less opioid use, and consequently fewer side effects, which could prolong recovery and increase morbidity, are all benefits of this type of analgesia. Intravenously administered ketamine can be effective as monotherapy or in combination with opioids, especially with procedural sedation such as in burn wound dressing. Methods: This observational study investigated the effect of ketamine administered in subanesthetic doses combined with opioids during burn wound dressing. The study was conducted from October 2018 to October 2021. A total of 165 patients met the inclusion criteria. A total of 82 patients were in the ketamine group, while 83 patients were dressed without ketamine. The main outcome was the effect of ketamine on intraprocedural opioid consumption. The secondary outcome included the effect of ketamine on postprocedural pain control. Results: Patients dressed with ketamine were significantly older (p = 0.001), while the mean doses of intraoperatively administered propofol and fentanyl were significantly lower than in patients dressed without ketamine (150 vs. 220 mg, p < 0.001; and 0.075 vs. 0.150 mg, p < 0.001; respectively). Conclusions: Ketamine was an independent predictor of lower intraoperative fentanyl consumption, according to the multivariate regression analysis (p = 0.015). Contrarily, both groups of patients required postoperative tramadol treatment, while intraoperative ketamine administration had no beneficial effects on postoperative pain management.
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Affiliation(s)
- Marina Stojanović
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- Center for Anesthesiology and Resuscitation, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Milana Marinković
- Clinic for Burns, Plastic and Reconstructive Surgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Biljana Miličić
- Department of Medical Statistics and Informatics, School of Dental Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Milan Stojičić
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- Clinic for Burns, Plastic and Reconstructive Surgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Marko Jović
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- Clinic for Burns, Plastic and Reconstructive Surgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Milan Jovanović
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- Clinic for Burns, Plastic and Reconstructive Surgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Jelena Isaković Subotić
- Clinic for Burns, Plastic and Reconstructive Surgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Milana Jurišić
- Clinic for Burns, Plastic and Reconstructive Surgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Miodrag Karamarković
- Clinic for Burns, Plastic and Reconstructive Surgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Aleksandra Đekić
- Clinic for Burns, Plastic and Reconstructive Surgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Kristina Radenović
- Clinic for Burns, Plastic and Reconstructive Surgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Jovan Mihaljević
- Clinic for Burns, Plastic and Reconstructive Surgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Ivan Radosavljević
- Clinic for Burns, Plastic and Reconstructive Surgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Branko Suđecki
- Clinic for Burns, Plastic and Reconstructive Surgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Milan Savić
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- Clinic for Thoracic Surgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Marko Kostić
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- Clinic for Thoracic Surgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Željko Garabinović
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- Clinic for Thoracic Surgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Jelena Jeremić
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- Clinic for Burns, Plastic and Reconstructive Surgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia
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23
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Erumbala G, Anzar S, Deiratany S, Blackie B, Powell C, Al Ansari K. Procedural sedation programme minimising adverse events: a 3-year experience from a tertiary paediatric emergency department. Arch Dis Child 2024; 109:88-92. [PMID: 37775146 DOI: 10.1136/archdischild-2023-326021] [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: 06/29/2023] [Accepted: 09/12/2023] [Indexed: 10/01/2023]
Abstract
INTRODUCTION A well-developed procedural sedation programme in the paediatric emergency department can minimise adverse events. We examined how adherence to current best evidence ensures safe delivery of paediatric sedation in a newly established tertiary paediatric hospital. METHODS Our sedation service uses a robust provider training and privileging system, standardised policy and procedures and rigorous data collection all within an evidence-based clinical governance process. We examined sedation data from the first 3 years of operation. RESULTS From July 2018 to May 2022, ketamine was used in 3388 of the 3405 sedations. The mean age of sedated children was 5.5 years (range 6 months to 17.8 years) and common indications were closed reduction of fractures and laceration repairs. A total of 148 (4.37%, 95% CI 3.68% to 5.06%) adverse events were documented, including 88 (2.59%, 95% CI 2.06% to 3.13%) cases of vomiting, 50 (1.48%, 95% CI 1.07% to 1.88%) cases related to airway and breathing with 40 (1.18%, 95% CI 0.82% to 1.54%) cases of oxygen desaturation, 6 (0.18%, 95% CI 0.04% to 0.32%) cases of laryngospasm, 4 (0.12%, 95% CI 0% to 0.23%) cases of apnoea. CONCLUSION This study presents a large single-centre dataset on the use of intravenous ketamine in paediatric procedural sedation. Adhering to international standards and benchmarks for provider skills and training, drug administration and monitoring facilities, with a strict clinical governance process, optimizes patient safety.
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Affiliation(s)
- Gokul Erumbala
- Department of Emergency Medicine, Al Jalila Children's Specialty Hospital, Dubai, UAE
| | - Sabu Anzar
- Emergency Medicine Department, Sidra Medicine, Doha, Qatar
| | | | - Barbara Blackie
- Emergency Medicine Department, Sidra Medicine, Doha, Qatar
- Medical College, Weill Cornell Medcial College, Doha, Qatar
| | - Colin Powell
- Emergency Medicine Department, Sidra Medicine, Doha, Qatar
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Khalid Al Ansari
- Emergency Medicine Department, Sidra Medicine, Doha, Qatar
- Medical College, Weill Cornell Medcial College, Doha, Qatar
- Qatar University, Education City, Doha, Qatar
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24
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Halvorson CS, Sánchez-Lafuente CL, Johnston JN, Kalynchuk LE, Caruncho HJ. Molecular Mechanisms of Reelin in the Enteric Nervous System and the Microbiota-Gut-Brain Axis: Implications for Depression and Antidepressant Therapy. Int J Mol Sci 2024; 25:814. [PMID: 38255890 PMCID: PMC10815176 DOI: 10.3390/ijms25020814] [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: 11/29/2023] [Revised: 12/30/2023] [Accepted: 01/05/2024] [Indexed: 01/24/2024] Open
Abstract
Current pharmacological treatments for depression fail to produce adequate remission in a significant proportion of patients. Increasingly, other systems, such as the microbiome-gut-brain axis, are being looked at as putative novel avenues for depression treatment. Dysbiosis and dysregulation along this axis are highly comorbid with the severity of depression symptoms. The endogenous extracellular matrix protein reelin is present in all intestinal layers as well as in myenteric and submucosal ganglia, and its receptors are also present in the gut. Reelin secretion from subepithelial myofibroblasts regulates cellular migration along the crypt-villus axis in the small intestine and colon. Reelin brain expression is downregulated in mood and psychotic disorders, and reelin injections have fast antidepressant-like effects in animal models of depression. This review seeks to discuss the roles of reelin in the gastrointestinal system and propose a putative role for reelin actions in the microbiota-gut-brain axis in the pathogenesis and treatment of depression, primarily reflecting on alterations in gut epithelial cell renewal and in the clustering of serotonin transporters.
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Affiliation(s)
- Ciara S. Halvorson
- Division of Medical Sciences, University of Victoria, 3800 Finnerty Rd., Victoria, BC V8P 5C2, Canada; (C.S.H.); (C.L.S.-L.); (L.E.K.)
| | - Carla Liria Sánchez-Lafuente
- Division of Medical Sciences, University of Victoria, 3800 Finnerty Rd., Victoria, BC V8P 5C2, Canada; (C.S.H.); (C.L.S.-L.); (L.E.K.)
| | - Jenessa N. Johnston
- Section on the Neurobiology and Treatment of Mood Disorders, National Institute of Mental Health, National Institutes of Health, Bethesda, MD 20892, USA;
| | - Lisa E. Kalynchuk
- Division of Medical Sciences, University of Victoria, 3800 Finnerty Rd., Victoria, BC V8P 5C2, Canada; (C.S.H.); (C.L.S.-L.); (L.E.K.)
| | - Hector J. Caruncho
- Division of Medical Sciences, University of Victoria, 3800 Finnerty Rd., Victoria, BC V8P 5C2, Canada; (C.S.H.); (C.L.S.-L.); (L.E.K.)
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25
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Edem EE, Oguntala OA, Ikuelogbon DA, Nebo KE, Fafure AA, Akinluyi ET, Isaac GT, Kunlere OE. Prolonged ketamine therapy differentially rescues psychobehavioural deficits via modulation of nitro-oxidative stress and oxytocin receptors in the gut-brain-axis of chronically-stressed mice. Psychoneuroendocrinology 2023; 158:106370. [PMID: 37678086 DOI: 10.1016/j.psyneuen.2023.106370] [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: 01/18/2023] [Revised: 07/30/2023] [Accepted: 08/18/2023] [Indexed: 09/09/2023]
Abstract
Ketamine is an anaesthetic known to have short but rapid-acting anti-depressant effects; however, the neurobehavioural effects of its prolonged use and its role on the oxytocin system in the gut-brain axis are largely undetermined. Female BALB/c mice were either exposed to the chronic unpredictable mild stress (CUMS) paradigm for 21 days and then treated with ketamine in four doses for 14 days or exposed to CUMS and treated simultaneously in four doses of ketamine during the last two weeks of CUMS exposure. After each dose, the forced swim test was conducted to assess depressive-like behaviour. Before sacrifice, all the mice were subjected to behavioural tests to assess anxiety, memory, and social interaction. Prolonged treatment of depression with ketamine did not rescue depressive-like behaviour. It did, however, improve depression-associated anxiety-like behaviours, short-term memory and social interaction deficits when compared to the stressed untreated mice. Furthermore, ketamine treatment enhanced plasma oxytocin levels, expression of oxytocin receptors; as well as abrogated nitro-oxidative stress biomarkers in the intestinal and hippocampal tissues. Taken together, our findings indicate that while short-term use of ketamine has anti-depressant benefits, its prolonged therapeutic use does not seem to adequately resolve depressive-like behaviour in mice.
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Affiliation(s)
- Edem Ekpenyong Edem
- Neuroscience Unit, Department of Human Anatomy, College of Medicine and Health Sciences, Afe Babalola University, Ado-Ekiti, Ekiti State, Nigeria; Department of Anatomy, College of Medicine, University of Lagos, Idi-Araba, Lagos State, Nigeria.
| | - Oluwatomisn Adeyosola Oguntala
- Neuroscience Unit, Department of Human Anatomy, College of Medicine and Health Sciences, Afe Babalola University, Ado-Ekiti, Ekiti State, Nigeria
| | | | - Kate Eberechukwu Nebo
- Neuroscience Unit, Department of Human Anatomy, College of Medicine and Health Sciences, Afe Babalola University, Ado-Ekiti, Ekiti State, Nigeria
| | - Adedamola Adediran Fafure
- Neuroscience Unit, Department of Human Anatomy, College of Medicine and Health Sciences, Afe Babalola University, Ado-Ekiti, Ekiti State, Nigeria
| | - Elizabeth Toyin Akinluyi
- Neuropharmacology Unit, Department of Pharmacology and Therapeutics, College of Medicine and Health Sciences, Afe Babalola University, Ado-Ekiti, Ekiti State, Nigeria
| | - Godspower Tochukwu Isaac
- Department of Pharmaceutics, Faculty of Pharmaceutical Sciences, University of Nigeria, Nsukka, Enugu State, Nigeria
| | - Oladunni Eunice Kunlere
- Neuroscience Unit, Department of Human Anatomy, College of Medicine and Health Sciences, Afe Babalola University, Ado-Ekiti, Ekiti State, Nigeria
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26
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Hendrikse C, Ngah V, Kallon II, Leong TD, McCaul M. Ketamine as adjunctive or monotherapy for post-intubation sedation in patients with trauma on mechanical ventilation: A rapid review. Afr J Emerg Med 2023; 13:313-321. [PMID: 38033380 PMCID: PMC10682541 DOI: 10.1016/j.afjem.2023.10.002] [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: 04/03/2023] [Revised: 09/29/2023] [Accepted: 10/20/2023] [Indexed: 12/02/2023] Open
Abstract
Background The effectiveness of ketamine as adjunctive or monotherapy for post-intubation sedation in adults with trauma on mechanical ventilation is unclear. Methods A rapid review of systematic reviews of randomized controlled trials, then randomized controlled trials or observational studies was conducted searching three electronic databases (PubMed, Embase, Cochrane Library) and one clinical trial registry on June 1, 2022. We used a prespecified protocol following Cochrane rapid review methods. Results We identified eight systematic reviews of randomized controlled trials and observational studies. Among the included reviews, only the most relevant, up to date, highest quality-assessed reviews and reviews that reported on critical outcomes were considered. Adjunctive ketamine showed a morphine sparing effect (MD -13.19 µmg kg-1 h-1, 95 % CI -22.10 to -4.28, moderate certainty of evidence, 6 RCTs), but no to little effect on midazolam sparing effect (MD 0.75 µmg kg-1 h-1, 95 % CI -1.11 to 2.61, low certainty of evidence, 6 RCTs) or duration of mechanical ventilation in days (MD -0.17 days, 95 % CI -3.03 to 2.69, moderate certainty of evidence, 3 RCTs).Adjunctive ketamine therapy may reduce mortality (OR 0.88, 95 % CI 0.54 to 1.43, P = 0.60, very low certainty of evidence, 5 RCTs, n = 3076 patients) resulting in 30 fewer deaths per 1000, ranging from 132 fewer to 87 more, but the evidence is very uncertain. Ketamine results in little to no difference in length of ICU stay (MD 0.04 days, 95 % CI -0.12 to 0.20, high certainty of evidence, 5 RCTs n = 390 patients) or length of hospital stay (MD -0.53 days, 95 % CI -1.36 to 0.30, high certainty of evidence, 5 RCTs, n = 277 patients).Monotherapy may have a positive effect on respiratory and haemodynamic outcomes, however the evidence is very uncertain. Conclusion Adjunctive ketamine for post-intubation analgosedation results in a moderate meaningful net benefit but there is uncertainty for benefit and harms as monotherapy.
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Affiliation(s)
- C Hendrikse
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
- PHC/Adult Hospital Level Committee (2019-2023), South Africa
| | - V Ngah
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, South Africa
| | - II Kallon
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, South Africa
| | - T D Leong
- Secretariat to the PHC/Adult Hospital Level Committee (2019-2022), Secretariat to the National Essential Medicines List Committee (2012-2022), South Africa
- Health Systems Research Unit, South African Medical Research Council, South Africa
- South African GRADE Network, Stellenbosch University, South Africa
| | - M McCaul
- PHC/Adult Hospital Level Committee (2019-2023), South Africa
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, South Africa
- South African GRADE Network, Stellenbosch University, South Africa
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27
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Kirschen GW, Shorey ME, Han J, Leppla I, Masear CG, Robinson J. Dissociative identity precipitated by emergence from general anesthesia: A case report and analytical framework. PSYCHIATRY RESEARCH CASE REPORTS 2023; 2:100152. [PMID: 37614702 PMCID: PMC10443949 DOI: 10.1016/j.psycr.2023.100152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
Background Dissociative identity disorder (DID) is a complex and controversial psychiatric condition in which one person maintains at least two separate and distinct personalities. Patients with DID often report a history of childhood abuse and may have other comorbid psychiatric conditions. Psychosocial stressors may be triggers for DID inception or recurrence. While anesthetic agents, in particular ketamine, may induce a temporary dissociative state, it has not yet been reported that anesthesia can precipitate a dissociative identity. Case report We report a case of a woman with a history of childhood sexual abuse and past suicide attempt who experienced an episode of dissociative identity on emergence from anesthesia. The episode resolved within 90 minutes and the patient was discharged home safely on hospital day two. Conclusion This case adds to the literature of potentially precipitating factors of DID and we provide a unifying mechanistic hypothesis linking anesthesia to functional brain connectivity.
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Affiliation(s)
- Gregory W. Kirschen
- Department of Gynecology & Obstetrics, The Johns Hopkins Hospital, Baltimore, MD, 21287
| | - Mary E. Shorey
- Department of Gynecology & Obstetrics, The Johns Hopkins Hospital, Baltimore, MD, 21287
- Department of Complex Family Planning, Johns Hopkins Bayview Medical Center, Baltimore, MD 21224
| | - Joan Han
- Department of Psychiatry, The Johns Hopkins Hospital, Baltimore, MD, 21287
| | - Idris Leppla
- Department of Psychiatry, The Johns Hopkins Hospital, Baltimore, MD, 21287
| | - Courtney G. Masear
- Department of Anesthesiology, The Johns Hopkins Hospital, Baltimore, MD, 21287
| | - Jennifer Robinson
- Department of Gynecology & Obstetrics, The Johns Hopkins Hospital, Baltimore, MD, 21287
- Department of Complex Family Planning, Johns Hopkins Bayview Medical Center, Baltimore, MD 21224
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28
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Michelet F, Smyth M, Lall R, Noordali H, Starr K, Berridge L, Yeung J, Fuller G, Petrou S, Walker A, Mark J, Canaway A, Khan K, Perkins GD. Randomised controlled trial of analgesia for the management of acute severe pain from traumatic injury: study protocol for the paramedic analgesia comparing ketamine and morphine in trauma (PACKMaN). Scand J Trauma Resusc Emerg Med 2023; 31:84. [PMID: 38001541 PMCID: PMC10668487 DOI: 10.1186/s13049-023-01146-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 11/06/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Prehospital analgesia is often required after traumatic injury, currently morphine is the strongest parenteral analgesia routinely available for use by paramedics in the United Kingdom (UK) when treating patients with severe pain. This protocol describes a multi-centre, randomised, double blinded trial comparing the clinical and cost-effectiveness of ketamine and morphine for severe pain following acute traumatic injury. METHODS A two arm pragmatic, phase III trial working with two large NHS ambulance services, with an internal pilot. Participants will be randomised in equal numbers to either (1) morphine or (2) ketamine by IV/IO injection. We aim to recruit 446 participants over the age of 16 years old, with a self-reported pain score of 7 or above out of 10. Randomised participants will receive a maximum of 20 mg of morphine, or a maximum of 30 mg of ketamine, to manage their pain. The primary outcome will be the sum of pain intensity difference. Secondary outcomes measure the effectiveness of pain relief and overall patient experience from randomisation to arrival at hospital as well as monitoring the adverse events, resource use and cost-effectiveness outcomes. DISCUSSION The PACKMAN study is the first UK clinical trial addressing the clinical and cost-effectiveness of ketamine and morphine in treating acute severe pain from traumatic injury treated by NHS paramedics. The findings will inform future clinical practice and provide insights into the effectiveness of ketamine as a prehospital analgesia. TRIAL REGISTRATION ISRCTN, ISRCTN14124474. Registered 22 October 2020, https://www.isrctn.com/ISRCTN14124474.
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Affiliation(s)
- F Michelet
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK.
| | - M Smyth
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - R Lall
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - H Noordali
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - K Starr
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - L Berridge
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - J Yeung
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
- Critical Care Directorate, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - G Fuller
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - S Petrou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - A Walker
- West Midlands Ambulance Services NHS Trust, Brierley Hill, Dudley, UK
| | - J Mark
- Yorkshire Ambulance Services NHS Trust, Wakefield, UK
| | - A Canaway
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - K Khan
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - G D Perkins
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
- Critical Care Directorate, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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29
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Wehrmann T, Riphaus A, Eckardt AJ, Klare P, Kopp I, von Delius S, Rosien U, Tonner PH. Updated S3 Guideline "Sedation for Gastrointestinal Endoscopy" of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS) - June 2023 - AWMF-Register-No. 021/014. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:e654-e705. [PMID: 37813354 DOI: 10.1055/a-2165-6388] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Affiliation(s)
- Till Wehrmann
- Clinic for Gastroenterology, DKD Helios Clinic Wiesbaden, Wiesbaden, Germany
| | - Andrea Riphaus
- Internal Medicine, St. Elisabethen Hospital Frankfurt Artemed SE, Frankfurt, Germany
| | - Alexander J Eckardt
- Clinic for Gastroenterology, DKD Helios Clinic Wiesbaden, Wiesbaden, Germany
| | - Peter Klare
- Department Internal Medicine - Gastroenterology, Diabetology, and Hematology/Oncology, Hospital Agatharied, Hausham, Germany
| | - Ina Kopp
- Association of the Scientific Medical Societies in Germany e.V. (AWMF), Berlin, Germany
| | - Stefan von Delius
- Medical Clinic II - Internal Medicine - Gastroenterology, Hepatology, Endocrinology, Hematology, and Oncology, RoMed Clinic Rosenheim, Rosenheim, Germany
| | - Ulrich Rosien
- Medical Clinic, Israelite Hospital, Hamburg, Germany
| | - Peter H Tonner
- Anesthesia and Intensive Care, Clinic Leer, Leer, Germany
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Evanoff AB, Baig M, Taylor JB, Beach SR. Ketamine: A Practical Review for the Consultation-Liaison Psychiatrist. J Acad Consult Liaison Psychiatry 2023; 64:521-532. [PMID: 37301324 DOI: 10.1016/j.jaclp.2023.06.001] [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: 01/04/2023] [Revised: 04/15/2023] [Accepted: 06/01/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Ketamine is a noncompetitive N-methyl-D-aspartate-receptor antagonist often used for sedation and management of acute agitation in general hospital settings. Many hospitals now include ketamine as part of their standard agitation protocol, and consultation-liaison psychiatrists frequently find themselves treating patients who have received ketamine, despite lack of clear recommendations for management. OBJECTIVE Conduct a nonsystematic narrative review regarding the use of ketamine for agitation and continuous sedation, including benefits and adverse psychiatric effects. Compare ketamine to more traditional agents of agitation control. Provide consultation-liaison psychiatrists with a summary of available knowledge and recommendations for managing patients receiving ketamine. METHODS A literature review was performed using PubMed, querying published articles from inception to March 2023 for articles related to use of ketamine for agitation or continuous sedation and side effects including psychosis and catatonia. RESULTS A total of 37 articles were included. Ketamine was found to have multiple benefits, including shorter time to adequate sedation for agitated patients when compared to haloperidol ± benzodiazepines and unique advantages for continuous sedation. However, ketamine carries significant medical risks including high rates of intubation. Ketamine appears to induce a syndrome that mimics schizophrenia in healthy controls, and such effects are more pronounced and longer-lasting in patients with schizophrenia. Evidence regarding rates of delirium with ketamine for continuous sedation is mixed and requires further investigation before the agent is widely adopted for this purpose. Finally, the diagnosis of "excited delirium syndrome" and use of ketamine to treat this controversial syndrome warrants critical evaluation. CONCLUSIONS Ketamine carries many potential benefits and can be an appropriate medication for patients with profound undifferentiated agitation. However, intubation rates remain high, and ketamine may worsen underlying psychotic disorders. It is essential that consultation-liaison psychiatrists understand the advantages, disadvantages, biased administration, and areas of limited knowledge regarding ketamine.
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Affiliation(s)
- Anastasia B Evanoff
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Department of Psychiatry, McLean Hospital, Belmont, MA.
| | - Mirza Baig
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Department of Psychiatry, McLean Hospital, Belmont, MA
| | - John B Taylor
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | - Scott R Beach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
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Ayandeh A, Farrell N, Sheng AY. Requirement for Discharge in the Care of a Responsible Adult in Procedural Sedation in the Emergency Department: Necessity or Potential Barrier to Health Equity? J Emerg Med 2023; 65:e272-e279. [PMID: 37679283 DOI: 10.1016/j.jemermed.2023.05.010] [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: 11/15/2022] [Revised: 04/06/2023] [Accepted: 05/30/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Procedural sedation is commonly practiced by emergency physicians to facilitate patient care in the emergency department (ED). Although various guidelines have modernized our approach to procedural sedation, many procedural sedation guidelines and practices still often require that patients be discharged into the care of a responsible adult. DISCUSSION Such requirement for discharge often cannot be met by underserved and undomiciled patients. Benzodiazepines, opioids, propofol, ketamine, "ketofol," etomidate, and methohexital have all been utilized for procedural sedation in the ED. For patients who may require discharge without the presence of an accompanying responsible adult, ketamine, propofol, methohexital, "ketofol," and etomidate are ideal agents for procedural sedation given rapid onsets, short durations of action, and rapid recovery times in patients without renal or hepatic impairment. Proper pre- and postprocedure protocols should be utilized when performing procedural sedation to ensure patient safety. Through the use of appropriate medications and observation protocols, patients can safely be discharged 2 to 4 h postprocedure. CONCLUSION There is no pharmacodynamic or pharmacokinetic basis to require discharge in the care of a responsible adult after procedural sedation. Thoughtful medication selection and the use of evidence-based pre- and postprocedure protocols in the ED can help circumvent this requirement, which likely disproportionally impacts patients who are of low socioeconomic status or undomiciled.
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Affiliation(s)
- Armon Ayandeh
- Department of Emergency Medicine, Boston Medical Center, Boston, Massachusetts.
| | - Natalija Farrell
- Department of Emergency Medicine, Boston Medical Center, Boston, Massachusetts
| | - Alexander Y Sheng
- Department of Emergency Medicine, Boston Medical Center, Boston, Massachusetts; Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Zanza C, Saglietti F, Giamello JD, Savioli G, Biancone DM, Balzanelli MG, Giordano B, Trompeo AC, Longhitano Y. Effectiveness of Intranasal Analgesia in the Emergency Department. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1746. [PMID: 37893464 PMCID: PMC10608673 DOI: 10.3390/medicina59101746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 09/23/2023] [Accepted: 09/27/2023] [Indexed: 10/29/2023]
Abstract
In the Emergency Department (ED), pain is one of the symptoms that are most frequently reported, making it one of the most significant issues for the emergency physician, but it is frequently under-treated. Intravenous (IV), oral (PO), and intramuscular (IM) delivery are the standard methods for administering acute pain relief. Firstly, we compared the safety and efficacy of IN analgesia to other conventional routes of analgesia to assess if IN analgesia may be an alternative for the management of acute pain in ED. Secondly, we analyzed the incidence and severity of adverse events (AEs) and rescue analgesia required. We performed a narrative review-based keywords in Pubmed/Medline, Scopus, EMBASE, the Cochrane Library, and Controlled Trials Register, finding only twenty randomized Clinical trials eligible in the timeline 1992-2022. A total of 2098 patients were analyzed and compared to intravenous analgesia, showing no statistical difference in adverse effects. In addition, intranasal analgesia also has a rapid onset and quick absorption. Fentanyl and ketamine are two intranasal drugs that appear promising and may be taken simply and safely while providing effective pain relief. Intravenous is simple to administer, non-invasive, rapid onset, and quick absorption; it might be a viable choice in a variety of situations to reduce patient suffering or delays in pain management.
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Affiliation(s)
- Christian Zanza
- Italian Society of Prehospital Emergency Medicine-SIS 118-Taranto, 74121 Taranto, Italy
- Post Graduate School of Geriatric Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | - Francesco Saglietti
- Department of Anesthesia and Critical Care, Santa Croce and Carle Hospital, 12100 Cuneo, Italy
| | | | - Gabriele Savioli
- Emergency Medicine and Surgery, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy
| | | | | | - Benedetta Giordano
- Department of Human Neuroscience, Sapienza University of Rome, 00185 Roma, Italy
| | - Anna Chiara Trompeo
- Department of Anesthesia and Critical Care, AOU Città della Scienza e della Salute, 10126 Torino, Italy
| | - Yaroslava Longhitano
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15260, USA
- Department of Emergency Medicine, Humanitas University, 20089 Milan, Italy
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Wehrmann T, Riphaus A, Eckardt AJ, Klare P, Kopp I, von Delius S, Rosien U, Tonner PH. Aktualisierte S3-Leitlinie „Sedierung in der gastrointestinalen Endoskopie“ der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:1246-1301. [PMID: 37678315 DOI: 10.1055/a-2124-5333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Affiliation(s)
- Till Wehrmann
- Klinik für Gastroenterologie, DKD Helios Klinik Wiesbaden, Wiesbaden, Deutschland
| | - Andrea Riphaus
- Innere Medizin, St. Elisabethen Krankenhaus Frankfurt Artemed SE, Frankfurt, Deutschland
| | - Alexander J Eckardt
- Klinik für Gastroenterologie, DKD Helios Klinik Wiesbaden, Wiesbaden, Deutschland
| | - Peter Klare
- Abteilung Innere Medizin - Gastroenterologie, Diabetologie und Hämato-/Onkologie, Krankenhaus Agatharied, Hausham, Deutschland
| | - Ina Kopp
- Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF), Berlin, Deutschland
| | - Stefan von Delius
- Medizinische Klinik II - Innere Medizin - Gastroenterologie, Hepatologie, Endokrinologie, Hämatologie und Onkologie, RoMed Klinikum Rosenheim, Rosenheim, Deutschland
| | - Ulrich Rosien
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | - Peter H Tonner
- Anästhesie- und Intensivmedizin, Klinikum Leer, Leer, Deutschland
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Cunico D, Rossi A, Verdesca M, Principi N, Esposito S. Pain Management in Children Admitted to the Emergency Room: A Narrative Review. Pharmaceuticals (Basel) 2023; 16:1178. [PMID: 37631093 PMCID: PMC10459115 DOI: 10.3390/ph16081178] [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: 06/30/2023] [Revised: 08/11/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023] Open
Abstract
Pain is a biopsychosocial experience characterized by sensory, physiological, cognitive, affective, and behavioral components. Both acute and chronic pain can have short and long-term negative effects. Unfortunately, pain treatment is often inadequate. Guidelines and recommendations for a rational approach to pediatric pain frequently differ, and this may be one of the most important reasons for the poor attention frequently paid to pain treatment in children. This narrative review discusses the present knowledge in this regard. A literature review conducted on papers produced over the last 8 years showed that although in recent years, compared to the past, much progress has been made in the treatment of pain in the context of the pediatric emergency room, there is still a lot to do. There is a need to create guidelines that outline standardized and easy-to-follow pathways for pain recognition and management, which are also flexible enough to take into account differences in different contexts both in terms of drug availability and education of staff as well as of the different complexities of patients. It is essential to guarantee an approach to pain that is as uniform as possible among the pediatric population that limits, as much as possible, the inequalities related to ethnicity and language barriers.
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Affiliation(s)
- Daniela Cunico
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (D.C.); (A.R.); (M.V.)
| | - Arianna Rossi
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (D.C.); (A.R.); (M.V.)
| | - Matteo Verdesca
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (D.C.); (A.R.); (M.V.)
| | | | - Susanna Esposito
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (D.C.); (A.R.); (M.V.)
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De Vries LJ, Veeger NJGM, Van Roon EN, Lameijer H. Low-dose ketamine or opioids combined with propofol for procedural sedation in the emergency department: a systematic review. Eur J Emerg Med 2023; 30:244-251. [PMID: 37276055 DOI: 10.1097/mej.0000000000001046] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Procedural sedation is routinely performed for procedures in the emergency department (ED). Propofol is a commonly used sedative, frequently combined with an opioid or low-dose ketamine as an analgesic. However, there is still controversy on the optimal combination of agents in current guidelines. The objective of this systematic review is to identify and present studies comparing low-dose ketamine to opioids when combined with propofol for procedural sedation in the ED and to describe the dosing regimen, observed efficacy, and side effects. For this systematic review, following the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines, EMBASE and PubMed databases were searched. Studies comparing propofol with opioids versus propofol with low-dose (es)ketamine in patients undergoing procedural sedation for procedures in the ED were included. Analyses were descriptive because of the high heterogeneity among included studies. The outcomes were dosing regimen, efficacy of analgesia, efficacy of sedation depth, efficacy of recovery and (adverse) events. We included four out of 2309 studies found in the literature search. Overall, the studies had a low risk of bias, but the Grading of Recommendations Assessment, Development, and Evaluation evidence profile was downgraded due to the imprecision and inconsistency of the studies. All studies compared low-dose ketamine with fentanyl. Dosing ranged from 0.3 to 1.0 mg/kg (ketamine), 1.0-1.5 μg/kg (fentanyl) and 0.4-1.0 mg/kg (propofol). The efficacy of analgesia was measured by two studies, one favoring the fentanyl group, and one favoring the ketamine group. The efficacy of sedation depth was measured by one study, with the fentanyl group having a deeper sedation score. Two studies showed shorter recovery time with low-dose ketamine. One study showed a higher incidence of cardio-respiratory clinical events and interventions in the fentanyl group. Two studies showed significant differences of overall sedation events in the fentanyl group. One study did not find any significant differences of the incidence of sedation events. This systematic review did not provide sufficient evidence that the combination of low-dose ketamine and propofol is associated with a shorter recovery time and fewer sedation events compared to the combination of opioids and propofol.
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Affiliation(s)
| | - Nic J G M Veeger
- Department of Epidemiology, MCL Academy, Medical Center Leeuwarden, Leeuwarden
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen
| | - Eric N Van Roon
- Department of Clinical Pharmacy and Pharmacology, Medical Center Leeuwarden, Leeuwarden
- Department of Pharmacy, University of Groningen, Groningen, The Netherlands
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Ryan K, Hosanagar A. Ketamine Use in Child and Adolescent Psychiatry: Emerging Data in Treatment-Resistant Depression, Insights from Adults, and Future Directions. Curr Psychiatry Rep 2023; 25:337-344. [PMID: 37389787 DOI: 10.1007/s11920-023-01432-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/30/2023] [Indexed: 07/01/2023]
Abstract
PURPOSE OF REVIEW The following review will explore ketamine's antidepressant and antisuicidal properties in adults, review of what is known about ketamine's safety in children, and summarize the limited information we have on ketamine's role in treating depression and suicidal ideation in adolescents with depression. Future directions for ketamine's role in child psychiatry based on animal and adult studies will also be explored. RECENT FINDINGS Over the past 20 years, ketamine has emerged as a novel treatment for depression and suicidal ideation in adults. In recent years, these studies have been extended to adolescents. In 2021, the first placebo-controlled trial examining ketamine's antidepressant potential in adolescents was performed, demonstrating superior efficacy over midazolam. Initial studies suggest that ketamine functions as a rapidly acting antidepressant in adolescents. Case reports suggest that ketamine may also reduce suicidal ideation in this population. However, existing studies are small, and more research is needed to solidify these findings and inform clinical practice.
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Affiliation(s)
- Kaitlyn Ryan
- Department of Psychiatry, Adolescent Partial Hospitalization Program, Trinity Health Ann Arbor Hospital, Ann Arbor, MI, USA.
| | - Avinash Hosanagar
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
- Mental Health Service, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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Jain A, Kaushal A, Trivedi S, Thaware P, Chaudhary N, Jain S. Intramuscular ketamine provides better sedation and scan conditions in children undergoing magnetic resonance imaging: A single-blinded observational study. J Neurosci Rural Pract 2023; 14:477-481. [PMID: 37692818 PMCID: PMC10483216 DOI: 10.25259/jnrp_24_2023] [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: 01/11/2023] [Accepted: 05/29/2023] [Indexed: 09/12/2023] Open
Abstract
Objectives The objectives of this study were to compare the quality of sedation provided by intravenous (i.v.) and intramuscular (im) ketamine for pediatric magnetic resonance imaging (MRI). Materials and Methods This study was a non-randomized, single-blinded, and prospective observational study. After receiving approval from the Institutional Ethics Committee, a total of 108 children aged 2-7 years were divided into two groups, with 54 children in each group. In the i.v. group, children received ketamine at a dose of 1.5 mg/kg intravenously, while in the im group, children received ketamine at a dose of 4 mg/kg intramuscularly. If a Ramsay sedation score of 6 (RSS-6) was not achieved, half of the loading dose of ketamine was repeated. In both groups, rescue propofol boluses of 1 mg/kg intravenously were administered whenever the child moved. The primary outcome measure was the quality of sedation, which was assessed by a blinded radiologist. The time taken to reach RSS-6, the number of rescue propofol boluses, the total time wasted in taking repeat sequences, and the time required to achieve a modified Aldrete score of 9 (MAS-9) were recorded. Results The im group demonstrated significantly better sedation quality. In the i.v. group, the time to achieve RSS-6 was significantly shorter, but it required more rescue propofol boluses to maintain sedation. The i.v. group also experienced a notable increase in the total time wasted during repeat sequences. On the other hand, the i.v. group exhibited a shorter time to reach MAS-9 compared to the im group. Conclusion The im group showed superior sedation quality when compared to the i.v. group. However, it is important to consider that the im group experienced a longer recovery time.
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Affiliation(s)
- Anuj Jain
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Ashutosh Kaushal
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Saurabh Trivedi
- Department of Anaesthesiology and Critical Care, Chirayu Medical College and Hospital, Bhopal, Madhya Pradesh, India
| | - Pooja Thaware
- Department of Anaesthesiology and Critical Care, L N Medical College and J K Hospital, Bhopal, Madhya Pradesh, India
| | - Narendra Chaudhary
- Department of Pediatrics, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Suruchi Jain
- Department of Nuclear Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
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Liu J, Lin D, Yau A, Cottrell JE, Kass IS. Early-life propofol exposure does not affect later-life GABAergic inhibition, seizure induction, or social behavior. IBRO Neurosci Rep 2023; 14:483-493. [PMID: 37252630 PMCID: PMC10220478 DOI: 10.1016/j.ibneur.2023.05.007] [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: 03/09/2023] [Accepted: 05/13/2023] [Indexed: 05/31/2023] Open
Abstract
The early developing brain is especially vulnerable to anesthesia, which can result in long lasting functional changes. We examined the effects of early-life propofol on adult excitatory-inhibitory balance and behavior. Postnatal day 7 male mice were exposed to propofol (250 mg/kg i.p.) and anesthesia was maintained for 2 h; control mice were given the same volume of isotonic saline and treated identically. The behavior and electrophysiology experiments were conducted when the mice were adults. We found that a 2-h neonatal propofol exposure did not significantly reduce paired pulse inhibition, alter the effect of muscimol (3 µM) to inhibit field excitatory postsynaptic potentials or alter the effect of bicuculline (100 µM) to increase the population spike in the CA1 region of hippocampal slices from adult mice. Neonatal propofol did not alter the evoked seizure response to pentylenetetrazol in adult mice. Neonatal propofol did not affect anxiety, as measured in the open field apparatus, depression-like behavior, as measured by the forced swim test, or social interactions with novel mice, in either the three-chamber or reciprocal social tests. These results were different from those with neonatal sevoflurane which demonstrated reduced adult GABAergic inhibition, increased seizure susceptibility and reduced social interaction. Even though sevoflurane and propofol both prominently enhance GABA inhibition, they have unique properties that alter the long-term effects of early-life exposure. These results indicate that clinical studies grouping several general anesthetic agents in a single group should be interpreted with great caution when examining long-term effects.
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Affiliation(s)
- Jinyang Liu
- Department of Anesthesiology, State University of New York Downstate Health Sciences University, 450 Clarkson Avenue, Brooklyn, NY 11203-2098, USA
| | - Daisy Lin
- Department of Anesthesiology, State University of New York Downstate Health Sciences University, 450 Clarkson Avenue, Brooklyn, NY 11203-2098, USA
- Department of Physiology and Pharmacology, State University of New York Downstate Health Sciences University, 450 Clarkson Avenue, Brooklyn, NY 11203-2098, USA
| | - Alice Yau
- State University of New York Downstate Health Sciences University College of Medicine, 450 Clarkson Avenue, Brooklyn, NY 11203-2098, USA
| | - James E. Cottrell
- Department of Anesthesiology, State University of New York Downstate Health Sciences University, 450 Clarkson Avenue, Brooklyn, NY 11203-2098, USA
| | - Ira S. Kass
- Department of Anesthesiology, State University of New York Downstate Health Sciences University, 450 Clarkson Avenue, Brooklyn, NY 11203-2098, USA
- Department of Physiology and Pharmacology, State University of New York Downstate Health Sciences University, 450 Clarkson Avenue, Brooklyn, NY 11203-2098, USA
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V R P, A VS, Ramar K. Changing Trends in Conscious Sedation at Pediatric Dental Offices: A Bibliometric Analysis. Cureus 2023; 15:e40191. [PMID: 37431365 PMCID: PMC10329863 DOI: 10.7759/cureus.40191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2023] [Indexed: 07/12/2023] Open
Abstract
The uncooperative behavior of children in the dental office has increased the demand for pharmacological behavior management techniques. Moderate sedation is more effective by providing analgesia and anxiolysis, thereby aiding in carrying out the most comfortable, efficient, and high-quality dental services. There is a need to understand the various aspects such as the choice of drug, method of drug administration, safety, and efficacy. Bibliometrics can reveal significant shifts in research and publication trends. Therefore, this study aimed to perform a bibliometric analysis of the literature on evolving trends in conscious sedation at pediatric dental offices. The bibliometric research used RStudio 2021.09.0+351 for Windows (RStudio, Boston, MA), package "bibliometrix," and VOS viewer software (Centre for Science and Technology Studies, Leiden University, The Netherlands. https://www.vosviewer.com). Elsevier's Scopus database (www.scopus.com) provided the literary data for this study, which were exported in BibTex format. The articles were independently categorized according to the following aspects: (a) annual scholarly output; (b) leading countries or regions; (c) leading journals; (d) productive authors; (e) citations; (f) study design; and (g) distribution of topics. The findings considered 1996 through 2022 and used journals, books, articles, and other sources, totaling 1064 papers, with an average of 10.7 per year. According to the findings, the United States, the United Kingdom, and India were principally leading the field of conscious sedation research. In total, 2433 authors were found through the search. The study identified the nations that are currently researching the topics such as midazolam and nitrous-oxide; this paves the way for future partnerships to strengthen the evidence generated in other topic areas using novel sedatives and exploring the different routes of drug administration, thereby benefiting the scientific community by identifying knowledge gaps and experts in this area of research.
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Affiliation(s)
- Pooja V R
- Department of Pediatric and Preventive Dentistry, SRM Kattankulathur Dental College and Hospital, Kattankulathur, IND
| | - Victor Samuel A
- Department of Pediatric and Preventive Dentistry, SRM Kattankulathur Dental College and Hospital, Kattankulathur, IND
| | - Kavitha Ramar
- Department of Pediatric and Preventive Dentistry, SRM Kattankulathur Dental College and Hospital, Kattankulathur, IND
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Abramova V, Leal Alvarado V, Hill M, Smejkalova T, Maly M, Vales K, Dittert I, Bozikova P, Kysilov B, Hrcka Krausova B, Vyklicky V, Balik A, Fili K, Korinek M, Chodounska H, Kudova E, Ciz D, Martinovic J, Cerny J, Bartunek P, Vyklicky L. Effects of Pregnanolone Glutamate and Its Metabolites on GABA A and NMDA Receptors and Zebrafish Behavior. ACS Chem Neurosci 2023; 14:1870-1883. [PMID: 37126803 PMCID: PMC10198160 DOI: 10.1021/acschemneuro.3c00131] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 04/11/2023] [Indexed: 05/03/2023] Open
Abstract
Multiple molecular targets have been identified to mediate membrane-delimited and nongenomic effects of natural and synthetic steroids, but the influence of steroid metabolism on neuroactive steroid signaling is not well understood. To begin to address this question, we set out to identify major metabolites of a neuroprotective synthetic steroid 20-oxo-5β-pregnan-3α-yl l-glutamyl 1-ester (pregnanolone glutamate, PAG) and characterize their effects on GABAA and NMDA receptors (GABARs, NMDARs) and their influence on zebrafish behavior. Gas chromatography-mass spectrometry was used to assess concentrations of PAG and its metabolites in the hippocampal tissue of juvenile rats following intraperitoneal PAG injection. PAG is metabolized in the peripheral organs and nervous tissue to 20-oxo-17α-hydroxy-5β-pregnan-3α-yl l-glutamyl 1-ester (17-hydroxypregnanolone glutamate, 17-OH-PAG), 3α-hydroxy-5β-pregnan-20-one (pregnanolone, PA), and 3α,17α-dihydroxy-5β-pregnan-20-one (17-hydroxypregnanolone, 17-OH-PA). Patch-clamp electrophysiology experiments in cultured hippocampal neurons demonstrate that PA and 17-OH-PA are potent positive modulators of GABARs, while PAG and 17-OH-PA have a moderate inhibitory effect at NMDARs. PAG, 17-OH-PA, and PA diminished the locomotor activity of zebrafish larvae in a dose-dependent manner. Our results show that PAG and its metabolites are potent modulators of neurotransmitter receptors with behavioral consequences and indicate that neurosteroid-based ligands may have therapeutic potential.
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Affiliation(s)
- Vera Abramova
- Laboratory
of Cellular Neurophysiology, Institute of
Physiology CAS, Videnska 1083, 142 20 Prague 4, Czech Republic
- Charles
University, Third Faculty of Medicine, Ruska 87, 100 00 Prague 10,Czech Republic
| | - Vanessa Leal Alvarado
- Laboratory
of Cellular Neurophysiology, Institute of
Physiology CAS, Videnska 1083, 142 20 Prague 4, Czech Republic
| | - Martin Hill
- Institute
of Endocrinology, Narodni
8, 116 94 Prague
1, Czech Republic
| | - Tereza Smejkalova
- Laboratory
of Cellular Neurophysiology, Institute of
Physiology CAS, Videnska 1083, 142 20 Prague 4, Czech Republic
| | - Michal Maly
- Laboratory
of Cellular Neurophysiology, Institute of
Physiology CAS, Videnska 1083, 142 20 Prague 4, Czech Republic
| | - Karel Vales
- Institute
of Physiology CAS, Videnska 1083, 142 20 Prague 4, Czech Republic
- National
Institute of Mental Health, Topolova 748, 250 67 Klecany, Czech Republic
| | - Ivan Dittert
- Laboratory
of Cellular Neurophysiology, Institute of
Physiology CAS, Videnska 1083, 142 20 Prague 4, Czech Republic
| | - Paulina Bozikova
- Institute
of Biotechnology CAS, Prumyslova 595, 252 50 Vestec, Czech Republic
| | - Bohdan Kysilov
- Laboratory
of Cellular Neurophysiology, Institute of
Physiology CAS, Videnska 1083, 142 20 Prague 4, Czech Republic
| | - Barbora Hrcka Krausova
- Laboratory
of Cellular Neurophysiology, Institute of
Physiology CAS, Videnska 1083, 142 20 Prague 4, Czech Republic
| | - Vojtech Vyklicky
- Laboratory
of Cellular Neurophysiology, Institute of
Physiology CAS, Videnska 1083, 142 20 Prague 4, Czech Republic
| | - Ales Balik
- Laboratory
of Cellular Neurophysiology, Institute of
Physiology CAS, Videnska 1083, 142 20 Prague 4, Czech Republic
| | - Klevinda Fili
- Laboratory
of Cellular Neurophysiology, Institute of
Physiology CAS, Videnska 1083, 142 20 Prague 4, Czech Republic
- Charles
University, Third Faculty of Medicine, Ruska 87, 100 00 Prague 10,Czech Republic
| | - Miloslav Korinek
- Laboratory
of Cellular Neurophysiology, Institute of
Physiology CAS, Videnska 1083, 142 20 Prague 4, Czech Republic
| | - Hana Chodounska
- Institute
of Organic Chemistry and Biochemistry CAS, Flemingovo nam. 2, 166 10 Prague 2, Czech Republic
| | - Eva Kudova
- Institute
of Organic Chemistry and Biochemistry CAS, Flemingovo nam. 2, 166 10 Prague 2, Czech Republic
| | - David Ciz
- IT4Innovations
National Supercomputing Center, Studentska 6231/1B, 708 00 Ostrava-Poruba, Czech Republic
| | - Jan Martinovic
- IT4Innovations
National Supercomputing Center, Studentska 6231/1B, 708 00 Ostrava-Poruba, Czech Republic
| | - Jiri Cerny
- Laboratory
of Cellular Neurophysiology, Institute of
Physiology CAS, Videnska 1083, 142 20 Prague 4, Czech Republic
| | - Petr Bartunek
- Institute
of Molecular Genetics CAS, Videnska 1083, 142 20 Prague, Czech Republic
- CZ-OPENSCREEN, Institute of
Molecular Genetics CAS, Videnska 1083, 142
20 Prague 4, Czech Republic
| | - Ladislav Vyklicky
- Laboratory
of Cellular Neurophysiology, Institute of
Physiology CAS, Videnska 1083, 142 20 Prague 4, Czech Republic
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Riccardi A, Guarino M, Serra S, Spampinato MD, Vanni S, Shiffer D, Voza A, Fabbri A, De Iaco F. Narrative Review: Low-Dose Ketamine for Pain Management. J Clin Med 2023; 12:jcm12093256. [PMID: 37176696 PMCID: PMC10179418 DOI: 10.3390/jcm12093256] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/14/2023] [Accepted: 04/28/2023] [Indexed: 05/15/2023] Open
Abstract
Pain is the leading cause of medical consultations and occurs in 50-70% of emergency department visits. To date, several drugs have been used to manage pain. The clinical use of ketamine began in the 1960s and it immediately emerged as a manageable and safe drug for sedation and anesthesia. The analgesic properties of this drug were first reported shortly after its use; however, its psychomimetic effects have limited its use in emergency departments. Owing to the misuse and abuse of opioids in some countries worldwide, ketamine has become a versatile tool for sedation and analgesia. In this narrative review, ketamine's role as an analgesic is discussed, with both known and new applications in various contexts (acute, chronic, and neuropathic pain), along with its strengths and weaknesses, especially in terms of psychomimetic, cardiovascular, and hepatic effects. Moreover, new scientific evidence has been reviewed on the use of additional drugs with ketamine, such as magnesium infusion for improving analgesia and clonidine for treating psychomimetic symptoms. Finally, this narrative review was refined by the experience of the Pain Group of the Italian Society of Emergency Medicine (SIMEU) in treating acute and chronic pain with acute manifestations in Italian Emergency Departments.
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Affiliation(s)
| | - Mario Guarino
- Emergency Department, Centro Traumatologico Ortopedico, Azienda Ospedaliera di Rilievo Nazionale dei Colli, 80131 Napoli, Italy
| | - Sossio Serra
- Emergency Department, Maurizio Bufalini Hospital, 47522 Cesena, Italy
| | | | - Simone Vanni
- Dipartimento Emergenza e Area Critica, Azienda USL Toscana Centro Struttura Complessa di Medicina d'Urgenza, 50053 Empoli, Italy
| | - Dana Shiffer
- Emergency Department, Humanitas University, Via Rita Levi Montalcini 4, 20089 Milan, Italy
| | - Antonio Voza
- Emergency Department, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Andrea Fabbri
- Emergency Department, AUSL Romagna, Presidio Ospedaliero Morgagni-Pierantoni, 47121 Forlì, Italy
| | - Fabio De Iaco
- Emergency Department, Ospedale Maria Vittoria, 10144 Turin, Italy
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Gao F, Wu Y. Procedural sedation in pediatric dentistry: a narrative review. Front Med (Lausanne) 2023; 10:1186823. [PMID: 37181379 PMCID: PMC10169594 DOI: 10.3389/fmed.2023.1186823] [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: 03/15/2023] [Accepted: 04/05/2023] [Indexed: 05/16/2023] Open
Abstract
Procedural sedation and analgesia are now considered standard care for managing pain and anxiety in pediatric dental patients undergoing diagnostic and therapeutic procedures outside of the operating room. Anxiolysis, which combines both pharmacologic and non-pharmacologic approaches, plays a significant role in procedural sedation. Non-pharmacologic interventions such as Behavior Management Technology can help reduce preprocedural agitation, ease the transition to sedation, reduce the required amount of medication for effective sedation, and decrease the occurrence of adverse events. As the introduction of novel sedative regimen and methods in pediatric dentistry, the potential role of mainstay sedatives administered by new routes, for new indications, and with new delivery techniques, should be considered. The purpose of this paper is to examine and discuss the current state of sedation techniques in pediatric dentistry.
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Affiliation(s)
- Feng Gao
- Department of Anesthesiology, Stomatological Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Laboratory of Oral Diseases and Biomediacal Sciences, Chongqing, China
- Chongqing Municipal Key Laboratory of Oral Biomedical Engineering of Higher Education, Chongqing, China
| | - Yujia Wu
- Department of Anesthesiology, Stomatological Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Laboratory of Oral Diseases and Biomediacal Sciences, Chongqing, China
- Chongqing Municipal Key Laboratory of Oral Biomedical Engineering of Higher Education, Chongqing, China
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Riccardi A, Serra S, De Iaco F, Fabbri A, Shiffer D, Voza A. Uncovering the Benefits of the Ketamine-Dexmedetomidine Combination for Procedural Sedation during the Italian COVID-19 Pandemic. J Clin Med 2023; 12:jcm12093124. [PMID: 37176565 PMCID: PMC10179324 DOI: 10.3390/jcm12093124] [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: 02/21/2023] [Revised: 04/01/2023] [Accepted: 04/20/2023] [Indexed: 05/15/2023] Open
Abstract
This retrospective observational study evaluated the safety and efficacy of the ketamine and dexmedetomidine combination (keta-dex) compared to ketamine or dexmedetomidine alone for sedation of patients with acute respiratory distress due to COVID-19 pneumonia who require non-invasive ventilation. The following factors were assessed: tolerance to the ventilation, sedation level on the Richmond Agitation-Sedation Scale (RASS), hemodynamic and saturation profile, adverse effects, and discontinuation or mortality during ventilation. The study included 66 patients who underwent sedation for non-invasive ventilation using keta-dex (KETA-DEX group, n = 22), ketamine (KET group, n = 22), or dexmedetomidine (DEX group, n = 22). The DEX group showed a slower sedation rate and a significant reduction in blood pressure compared to the KETA-DEX group (p < 0.05). An increase in blood pressure was recorded more frequently in the KET group. No reduction in oxygen saturation and no deaths were observed in any of the groups. None of the patients discontinued ventilation due to intolerance. The mean duration of sedation was 28.12 h. No cases of delirium were observed in any of the groups. Overall, keta-dex was associated with faster sedation rates and better hemodynamic profiles compared to dexmedetomidine alone. Keta-dex is effective and safe for sedation of uncooperative patients undergoing non-invasive ventilation.
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Affiliation(s)
| | - Sossio Serra
- Emergency Department, Maurizio Bufalini Hospital, 47522 Cesena, Italy
| | - Fabio De Iaco
- Emergency Department, Ospedale Maria Vittoria, 10144 Turin, Italy
| | - Andrea Fabbri
- Emergency Department, AUSL Romagna, Presidio Ospedaliero Morgagni-Pierantoni, 47121 Forlì, Italy
| | - Dana Shiffer
- Emergency Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, Italy
| | - Antonio Voza
- Emergency Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, Italy
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Tsze DS. Intranasal Dexmedetomidine: Should It Have a Place in Your Emergency Department? Ann Emerg Med 2023:S0196-0644(23)00174-9. [PMID: 37055283 DOI: 10.1016/j.annemergmed.2023.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 04/15/2023]
Affiliation(s)
- Daniel S Tsze
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY.
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Xu LL, Wang C, Deng CM, Dai SB, Zhou Q, Peng YB, Shou HY, Han YQ, Yu J, Liu CH, Xia F, Zhang SQ, Wang DX, Chen XZ. Efficacy and Safety of Esketamine for Supplemental Analgesia During Elective Cesarean Delivery: A Randomized Clinical Trial. JAMA Netw Open 2023; 6:e239321. [PMID: 37083664 PMCID: PMC10122167 DOI: 10.1001/jamanetworkopen.2023.9321] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/22/2023] Open
Abstract
Importance Epidural anesthesia is a primary choice for cesarean delivery, but supplemental analgesics are often required to relieve pain during uterine traction. Objective To investigate the sedative and analgesic effects of intravenous esketamine administered before childbirth via cesarean delivery with the patient under epidural anesthesia. Design, Setting, and Participants This multicenter, double-blind randomized clinical trial assessed 903 women 18 years or older who had full-term single pregnancy and were scheduled for elective cesarean delivery with epidural anesthesia in 5 medical centers in China from September 18, 2021, to September 20, 2022. Intervention Patients were randomized to receive intravenous injection of 0.25 mg/kg of esketamine or placebo before incision. Main Outcomes and Measures The coprimary outcomes included scores on the numeric rating scale of pain (an 11-point scale, with 0 indicating no pain and 10 indicating the worst pain; a difference of ≥1.65 points was clinically meaningful) and Ramsay Sedation Scale (a 6-point scale, with 1 indicating restlessness and 6 indicating deep sleep without response; a difference of ≥2 points was clinically meaningful) immediately after fetal delivery. Secondary outcomes included neonatal Apgar score assessed at 1 and 5 minutes after birth. Results A total of 600 women (mean [SD] age, 30.7 [4.3] years) were enrolled and randomized; all were included in the intention-to-treat analysis. Immediately after fetal delivery, the score on the numeric rating scale of pain was lower with esketamine (median [IQR], 0 [0-1]) than with placebo (median [IQR], 0 [0-2]; median difference, 0; 95% CI, 0-0; P = .001), but the difference was not clinically important. The Ramsay Sedation Scale scores were higher (sedation deeper) with esketamine (median [IQR], 4 [3-4]) than with placebo (median [IQR], 2 [2-2]; median difference, 2; 95% CI, 2-2; P < .001). The neonatal Apgar scores did not differ between the 2 groups at 1 minute (median difference, 0; 95% CI, 0-0; P = .98) and at 5 minutes (median difference, 0; 95% CI, 0-0; P = .27). Transient neurologic or mental symptoms were more common in patients given esketamine (97.7% [293 of 300]) than in those given placebo (4.7% [14 of 300]; P < .001). Conclusions and Relevance For women undergoing cesarean delivery under epidural anesthesia, a subanesthetic dose of esketamine administered before incision produced transient analgesia and sedation but did not induce significant neonatal depression. Mental symptoms and nystagmus were common but transient. Indications and the optimal dose of esketamine in this patient population need further clarification, but study should be limited to those who require supplemental analgesia. Trial Registration ClinicalTrials.gov Identifier: NCT04548973.
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Affiliation(s)
- Li-Li Xu
- Department of Anesthesia, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Chun Wang
- Department of Anesthesia, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Chun-Mei Deng
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Shao-Bing Dai
- Department of Anesthesia, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Qun Zhou
- Department of Anesthesiology, Jiangxi Maternal and Child Health Hospital, Jiangxi Province, China
| | - Yong-Bao Peng
- Department of Anesthesiology, Jiangxi Maternal and Child Health Hospital, Jiangxi Province, China
| | - Hong-Yan Shou
- Department of Anesthesiology, Hangzhou Women's Hospital, Zhejiang, China
| | - Yin-Qiu Han
- Department of Anesthesiology, Hangzhou Women's Hospital, Zhejiang, China
| | - Jing Yu
- Department of Anesthesiology, Affiliated Xiaoshan Hospital, Hangzhou Normal University, Hangzhou, Zhejiang Province, China
| | - Chao-Hui Liu
- Department of Anesthesiology, Affiliated Xiaoshan Hospital, Hangzhou Normal University, Hangzhou, Zhejiang Province, China
| | - Feng Xia
- Department of Anesthesiology, Jiaxing Maternity and Child Health Care Hospital, Jiaxing, Zhejiang Province, China
| | - Su-Qin Zhang
- Department of Anesthesiology, Jiaxing Maternity and Child Health Care Hospital, Jiaxing, Zhejiang Province, China
| | - Dong-Xin Wang
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Xin-Zhong Chen
- Department of Anesthesia, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
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Coles L, Rosenthal ES, Bleck TP, Elm J, Zehtabchi S, Chamberlain J, Cloyd J, Shinnar S, Silbergleit R, Kapur J. Why ketamine. Epilepsy Behav 2023; 141:109066. [PMID: 36609129 PMCID: PMC10073319 DOI: 10.1016/j.yebeh.2022.109066] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 01/06/2023]
Abstract
We present the rationale for testing ketamine as an add-on therapy for treating benzodiazepine refractory (established) status epilepticus. In animal studies, ketamine terminates benzodiazepine refractory status epilepticus by interfering with the pathophysiological mechanisms and is a neuroprotectant. Ketamine does not suppress respiration when used for sedation and anesthesia. A Series of reports suggest that ketamine can help terminate refractory and super refractory status epilepticus. We propose to use 1 or 3 mg/Kg ketamine intravenously based on animal-to-human conversion and pharmacokinetic studies. This paper was presented at the 8th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures held in September 2022.
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Affiliation(s)
- Lisa Coles
- Center for Orphan Drug Research, Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, United States
| | - Eric S Rosenthal
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Thomas P Bleck
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Jordan Elm
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, United States
| | - Shahriar Zehtabchi
- Department of Emergency Medicine, Downstate Health Sciences University, Brooklyn, NY, United States
| | - James Chamberlain
- Division of Emergency Medicine, Children's National Hospital Washington, DC, United States
| | - James Cloyd
- Center for Orphan Drug Research, Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, United States
| | - Shlomo Shinnar
- Departments of Neurology, Pediatrics, Epidemiology and Public Health, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Robert Silbergleit
- Department of Emergency Medicine, University of Michigan, School of Medicine, Ann Arbor, MI, United States
| | - Jaideep Kapur
- Department of Neurology and Neuroscience, University of Virginia, School of Medicine, Charlottesville, VA, United States.
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47
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Zaki HA, Ibrahim T, Osman A, Elnabawy WA, Gebril A, Hamdi AH, Mohamed EH. Comparing the Safety and Effectiveness of Ketamine Versus Benzodiazepine/Opioid Combination for Procedural Sedation in Emergency Medicine: A Comprehensive Review and Meta-Analysis. Cureus 2023; 15:e36742. [PMID: 37123736 PMCID: PMC10132230 DOI: 10.7759/cureus.36742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2023] [Indexed: 03/29/2023] Open
Abstract
Procedural sedation is essential in the ED to conduct painful procedures effectively. Ketamine and benzodiazepines/opioids are commonly used, with ketamine providing adequate analgesia and preserving airway muscle tone. However, ketamine is associated with adverse effects while benzodiazepines/opioids can lead to respiratory depression. This study compares the safety and efficacy of ketamine and midazolam/fentanyl. Two search methods were used to identify studies related to our topic, including a database search and a manual search involving screening reference lists of articles retrieved by the database search. A methodological quality appraisal was conducted on the articles suitable for inclusion using Cochrane's risk of bias tool in the Review Manager software (Review Manager (RevMan) (Computer program). Version 5.4, The Cochrane Collaboration, 2020). Moreover, pooled analysis was performed using the Review manager software. The study analyzed 1366 articles, of which seven were included for analysis. Pooled data showed that ketamine and midazolam/fentanyl had similar effects on pain scores during procedures and sedation depth measured by the University of Michigan sedation scale. However, the Modified Ramsay Sedation Score showed significantly more profound sedation in the ketamine group. The only significant adverse events were vomiting and nausea, which had a higher incidence in the ketamine group. Our data suggest that ketamine is as effective as the midazolam/fentanyl combination for procedural sedation but is associated with higher incidences of adverse events. Therefore, midazolam/fentanyl can be recommended for procedural sedation in the ED. However, it should be provided in the presence of a physician comfortable with airway management due to high incidences of oxygen desaturation.
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48
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Dermatologic features of chronic intramuscular use of ketamine: a case report. Forensic Sci Med Pathol 2023; 19:129-132. [PMID: 36705883 DOI: 10.1007/s12024-023-00580-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2023] [Indexed: 01/28/2023]
Abstract
A 33-year-old female presented with lethargy due to multidrug toxicity. At physical examination, both gluteal regions showed brown patchy scars. The atrophic scars surrounding necrotic lesions were round and brown in appearance, and gluteal mass had gradually been lost. The patient disclosed using intramuscular ketamine injections for 3.5 years along with smoking hashish, alcohol use, intranasal use of methamphetamine (sniffing), and oral use of methadone. Since recreational drug use can affect multiple organs, dermatologists should be familiar with the dermatologic features of intravenous or intramuscular injecting drug use.
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Buratti S, Giacheri E, Palmieri A, Tibaldi J, Brisca G, Riva A, Striano P, Mancardi MM, Nobili L, Moscatelli A. Ketamine as advanced second-line treatment in benzodiazepine-refractory convulsive status epilepticus in children. Epilepsia 2023; 64:797-810. [PMID: 36792542 DOI: 10.1111/epi.17550] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 02/11/2023] [Accepted: 02/13/2023] [Indexed: 02/17/2023]
Abstract
Status epilepticus (SE) is one of the most common neurological emergencies in children. To date, there is no definitive evidence to guide treatment of SE refractory to benzodiazepines. The main objectives of treatment protocols are to expedite therapeutic decisions and to use fast- and short-acting medications without significant adverse effects. Protocols differ among institutions, and most frequently valproate, phenytoin, and levetiracetam are used as second-line treatment. After failure of first- and second-line medications, admission to the intensive care unit and continuous infusion of anesthetics are usually indicated. Ketamine is a noncompetitive N-methyl-D-aspartate receptor antagonist that has been safely used for the treatment of refractory SE in adults and children. In animal models of SE, ketamine demonstrated antiepileptic and neuroprotective properties and synergistic effects with other antiseizure medications. We reviewed the literature to demonstrate the potential role of ketamine as an advanced second-line agent in the treatment of SE. Pharmacological targets, pathophysiology of SE, and the receptor trafficking hypothesis are reviewed and presented. The pharmacology of ketamine is outlined with related properties, advantages, and side effects. We summarize the most recent and relevant publications on experimental and clinical studies on ketamine in SE. Key expert opinion is also reported. Considering the current knowledge on SE pathophysiology, early sequential polytherapy should include ketamine for its wide range of positive assets. Future research and clinical trials on SE pharmacotherapy should focus on the role of ketamine as second-line medication.
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Affiliation(s)
- Silvia Buratti
- Neonatal and Pediatric Intensive Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Emanuele Giacheri
- Intermediate Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Antonella Palmieri
- Emergency Medicine Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Jessica Tibaldi
- Emergency Medicine Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Giacomo Brisca
- Intermediate Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Antonella Riva
- Department of Neuroscience (DINOGMI), University of Genoa, Genoa, Italy
| | - Pasquale Striano
- Department of Neuroscience (DINOGMI), University of Genoa, Genoa, Italy.,Pediatric Neurology and Muscular Disease Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | | | - Lino Nobili
- Department of Neuroscience (DINOGMI), University of Genoa, Genoa, Italy.,Child Neuropsychiatry Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Andrea Moscatelli
- Neonatal and Pediatric Intensive Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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50
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Lee D, Yeo H, Lee Y, Park H, Park H. A Survey on Procedural Sedation and Analgesia for Pediatric Facial Laceration Repair in Korea. Arch Plast Surg 2023; 50:30-36. [PMID: 36755661 PMCID: PMC9902079 DOI: 10.1055/s-0042-1759792] [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: 06/15/2022] [Accepted: 10/19/2022] [Indexed: 02/08/2023] Open
Abstract
Background Most children with facial lacerations require sedation for primary sutures. However, sedation guidelines for invasive treatment are lacking. This study evaluated the current status of the sedation methods used for pediatric facial laceration repair in Korea. Methods We surveyed one resident in each included plastic surgery training hospital using face-to-face interviews or e-mail correspondence. The health care center types (secondary or tertiary hospitals), sedation drug types, usage, and dosage, procedure sequence, monitoring methods, drug effects, adverse events, and operator and guardian satisfaction were investigated. Results We included 45/67 hospitals (67%) that used a single drug, ketamine in 31 hospitals and chloral hydrate in 14 hospitals. All health care center used similar sedatives. The most used drug administered was 5 mg/kg intramuscular ketamine (10 hospitals; 32%). The most common chloral hydrate administration approach was oral 50 mg/kg (seven hospitals; 50%). Twenty-two hospitals (71%) using ketamine followed this sequence: administration of sedatives, local anesthesia, primary repair, and imaging work-up. The most common sequence used for chloral hydrate (eight hospitals; 57%) was local anesthesia, administration of sedatives, imaging work-up, and primary repair. All hospitals that used ketamine and seven (50%) of those using chloral hydrate monitored oxygen saturation. Median operator satisfaction differed significantly between ketamine and chloral hydrate (4.0 [interquartile range, 4.0-4.0] vs. 3.0 [interquartile range, 3.0-4.0]; p <0.001). Conclusion The hospitals used various procedural sedation methods for children with facial lacerations. Guidelines that consider the patient's condition and drug characteristics are needed for safe and effective sedation.
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Affiliation(s)
- Dongkyu Lee
- Department of Plastic and Reconstructive Surgery, Daegu Fatima Hospital, Daegu, Korea
| | - Hyeonjung Yeo
- Department of Plastic and Reconstructive Surgery, Daegu Fatima Hospital, Daegu, Korea,Address for correspondence Hyeonjung Yeo, MD Department of Plastic and Reconstructive SurgeryDaegu Fatima Hospital, 99 Ayang-ro, Dong-gu, Daegu 41199Korea
| | - Yunjae Lee
- Cheongdam Okay Plastic Surgery Clinic, Seoul, Korea
| | - Hyochun Park
- Department of Plastic and Reconstructive Surgery, Daegu Fatima Hospital, Daegu, Korea
| | - Hannara Park
- Department of Plastic and Reconstructive Surgery, Daegu Fatima Hospital, Daegu, Korea
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