January 20, 2011 — Guidelines for use of the ketamine in emergency department (ED) procedural sedation have been updated for the first time since 2004; the use of ketamine has been expanded to include adults and babies between 3 and 12 months of age, according to a new report.
The updated guidelines were published online January 18 in the Annals of Emergency Medicine.
Accompanying the guidelines was a report conveying the results of the first randomized, controlled trial of ketamine plus propofol vs propofol alone in the ED setting. Study authors Henry David, MD, and Joseph Shipp, PAC, from the Department of Emergency Medicine at the University of Missouri-Columbia found that the use of ketamine plus propofol improved outcomes compared with ketamine alone.
The randomized trial included healthy children and adults undergoing procedural sedation who were pretreated with intravenous fentanyl and then randomly assigned to receive intravenous ketamine, 0.5 mg/kg (n = 97), or placebo (n = 96). Both groups then immediately received intravenous propofol, 1 mg/kg, with additional doses of 0.5 mg/kg given as needed to achieve and maintain sedation.
The trial found that the incidence of respiratory depression was similar in the ketamine/propofol group (22%) and the propofol-alone group (28%). In addition, compared with propofol alone, for the group receiving ketamine/propofol, clinicians were more satisfied, less propofol was administered, and there appeared to be a trend toward better sedation quality.
"Addition of a subdissociative dose of ketamine to propofol did not significantly reduce respiratory depression," the authors conclude. "However, it did result in greater provider satisfaction, a decreased propofol requirement, and a trend toward more effective sedation."
According the researchers, the "most striking" outcome was markedly greater provider satisfaction with ketamine/propofol. "This did not correlate with sedation scores and thus reflects features of sedation that transcend simple sedation depth," they suggest. "Possibilities include the more consistent sedation already described or the decreased need to titrate additional propofol."
Regarding the new guidelines, lead author of the guidelines, Steven M. Green, MD, from the Department of Emergency Medicine at Loma Linda University, California, noted, "It was time to update the clinical guidelines because substantial new research on the use of ketamine warranted it."
Since the guidelines were last updated, there has been "sufficient emergency department research in adults to support expansion of ketamine use beyond children," Dr. Green noted in a news release. He added that the body of research now supports the expansion of ketamine for use in children younger than previously recommended (ie, between 3 and 12 months of age). "We further recommend that emergency physicians administer ketamine intravenously instead of intra-muscularly whenever feasible, and that certain other medications not be routinely co-administered," he added.
The guidelines and report were not commercially funded. Dr. Green, Dr. David, and Joseph Shipp have disclosed no relevant financial relationships.
Ann Emerg Med. Guidelines and report published online January 18, 2011.
Emma Hitt, PhD
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