Objective Etomidate and ketamine are hemodynamically stable induction agents for rapid sequence intubation (RSI) of critically ill patients. Despite their relative stability in terms of hemodynamics, how the choice of agent affects mortality and the success of the procedure is debatable and has not yet been explored via systematic review and meta-analysis. The objective of this systematic review is to compare the efficacy of ketamine and etomidate for RSI in terms of mortality, hemodynamic parameters, and success rate.
Methods A comprehensive search of PubMed, Embase, and the Web of Science was conducted from the starting date of each database until April 2024. Randomized controlled trials comparing the safety and efficacy of ketamine and etomidate as induction drugs for critically ill patients undergoing RSI were included. The primary outcome was the risk of 28-day mortality, and the secondary outcomes included the success rate and postinduction hypotension. Pooled relative risks (RRs) with 95% confidence intervals (CIs) were calculated using a random-effects meta-analysis.
Results Four studies with 1,663 patients were meta-analyzed, and no statistically significant difference between the two drugs was found for 28-day mortality (RR, 0.95; 95% CI, 0.72–1.25; heterogeneity I2=39%; level of certainty of evidence per GRADE, moderate), first-pass success rate (RR, 1.00; 95% CI, 0.97–1.03), or postinduction cardiac arrest (RR, 1.10; 95% CI, 0.62–1.96). Postinduction hypotension was higher in the ketamine group (RR, 1.30; 95% CI, 1.03–1.64), but the result was not statistically significant.
Conclusion Mortality outcomes did not differ when ketamine or etomidate was used for RSI in critically ill patients. Ketamine, however, was associated with a non-significantly higher risk of postinduction hypotension.
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Objective Ketamine is a promising drug for analgesia in emergency medicine, but the high rate of side effects is a barrier to widespread usage. We hypothesized that ketamine bolus followed by ketamine infusion would provide a more even and longer duration of analgesia and lower rates of side effects in comparison to bolus-only administration.
Methods This was a double-blinded clinical trial. Eligible trauma patients were randomly allocated with the numeric rating scale ≥6 in two study groups. The first group received a dose of 0.3 mg/kg of ketamine over 1 minute, followed by an infusion of saline 0.9% over the next 30 minutes (bolus-only group). The second group was given 0.15 mg/kg of ketamine over 1 minute, followed by an infusion of 0.15 mg/kg over the next 30 minutes (bolus-and-infusion group). The primary outcome was to measure the average reduction in pain scores.
Results In total, 80 patients were recruited. Of these, 77 patients were analyzed. Both groups achieved a statistically significant decrease in pain scores (all P<0.001). After 30 minutes, patients in the bolus-and-infusion group reported lower pain scores in all intervals with lower rates of need for rescue analgesia, but this difference was not statistically significant. Vital signs remained stable during the study in both groups. No statistically significant difference was observed between study groups for any side effect (P<0.05).
Conclusion Both administration protocols resulted in significant pain control. No statistically significant difference was observed between study groups in terms of analgesic efficacy and side effects.
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Objective Urolithiasis is one of the most common urological diseases worldwide, usually presenting as renal colic that leads to severe pain that requires analgesic treatment. This study aimed to compare the efficacy of ketamine and desmopressin in the pain management of renal colic patients. Methods This double-blind, randomized clinical trial was conducted on renal colic patients referred to the emergency department from June 2021 to July 2022. Patients were randomly assigned to three groups. In the desmopressin group, patients were treated with intranasal desmopressin and intravenous ketorolac. The ketamine group was treated with intranasal ketamine and ketorolac. The control group received ketorolac and an intranasal placebo. Vital signs were evaluated at baseline and 60 minutes; and pain scores were assessed at baseline, 10, 30, and 60 minutes after treatment. Results Enrollment included 135 patients, the mean (standard deviation) age was 44.1±11.4 years, and 82 (60.7%) were men. The mean visual analog scale scores were significantly lower at 10, 30, and 60 minutes in the ketamine group (5.6±1.2, 3.0±1.1, and 0.9±0.9, respectively) compared to the control (8.2±1.1, 5.1±2.0, and 2.3±2.6, respectively) and desmopressin (6.7±1.8, 4.2±2.2, and 1.3±1.4, respectively) groups (P<0.05). Although patients in the desmopressin group had lower mean pain scores than the control group at 10, 30, and 60 minutes, this difference was only significant at 10 minutes after the intervention (P<0.05). No significant differences in vital signs were found at 60 minutes after treatment. Conclusion Ketamine showed more favorable analgesic effects in renal colic patients than desmopressin, although desmopressin showed efficacy in the first minutes posttreatment.
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Vaso-occlusive crisis (VOC) in sickle cell disease can cause severe pain and requires a thoughtful approach to analgesia. Considering the heightened awareness of the harm associated with opioids, an exploration of safer and more effective alternatives is overdue. Ketamine may play a role in supplementing or replacing opioid analgesia for patients in VOC. Studies on the use of ketamine for VOC are sparse, though increasing. In this review, we summarize the literature on subdissociative ketamine use for VOC to offer providers insight into the most effective and safe dosing regimens for sickle cell disease patients. Overall, the studies discussed in this review show decreased opioid use when subdissociative ketamine is provided as an adjunct and resolution of pain for most patients when subdissociative ketamine is used as the sole form of analgesia in VOC. Most studies examined intravenous delivery, and successful outcomes were established for both adult and pediatric patients in multiple clinical settings, including in the emergency department. Although more research is needed, it is clear from the published data that subdissociative ketamine may provide an efficacious addition to the clinician’s toolbox for managing VOC.
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Objective Children are sedated before undergoing diagnostic imaging tests in emergency medicine or pediatric sedation anesthesia units. The aim of this study was to identify variables potentially affecting the dose of ketamine required for induction of sedation in pediatric patients undergoing diagnostic imaging.
Methods This retrospective study included children aged 0 to 18 years who underwent sedation with ketamine for computed tomography or magnetic resonance imaging in the pediatric sedation anesthesia unit of a tertiary medical center between January 2011 and August 2016. The children’s hemodynamic status and depth of sedation were monitored during the examination. We recorded data on demographics, categories of imaging tests, ketamine doses administered, adverse events, respiratory interventions, and duration of sedation. Data for patients who experienced adverse events were excluded.
Results Sixty-six patients were included in the final analysis. Univariate linear regression analysis revealed that patient age, height, and body surface area (BSA) affected the sedative dose of ketamine administered. These three variables showed multicollinearity in multivariate linear regression analysis and were analyzed in three separate models. The model with the highest adjusted R-squared value suggested the following equation for determination of the dose of ketamine required to induce sedation: ketamine dose (mg)=-1.62+0.7×age (months)+36.36×BSA (m2).
Conclusion Variables such as age and BSA should be considered when estimating the dose of ketamine required for induction of sedation in pediatric patients.
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Objective Ketamine use in emergency departments (EDs) for procedural sedation and analgesia is becoming increasingly common. However, few studies have examined patient factors related to adverse events associated with ketamine. This study investigated factors for consideration when using ketamine to sedate pediatric ED patients.
Methods The study included pediatric patients receiving ketamine for laceration repair in the ED. Before sedation, information was collected about upper respiratory tract infection symptoms, allergy history, and fasting time. Patients received 2 mg/kg ketamine intravenously or 4 mg/kg ketamine intramuscularly. The primary outcomes were adverse events due to ketamine.
Results We studied 116 patients aged 8 months to 7 years (2.8±1.5 years). The group with adverse events was significantly younger on average than the group without adverse events (2.5±1.5 vs. 3.1±1.5, P=0.028). Upper respiratory tract infection symptoms were not significant variables affecting ketamine sedation (48.9% vs. 43.7%, P=0.719). There was no significant association between duration of fasting and adverse events (P=0.073 and P=0.897, respectively), or between food type and adverse events (P=0.734). However, the number of attempts to sedate and ketamine dose correlated with adverse events (P<0.001 and P=0.022, respectively). In multiple logistic regression analysis, intravenous injection and ketamine dose were significant factors (odds ratio, 16.77; 95% confidence interval, 1.78 to 498.54; odds ratio, 4.37; 95% confidence interval, 1.59 to 22.9, respectively).
Conclusion Emergency medicine physicians should consider injection type and ketamine dose when using ketamine sedation while suturing lacerations.
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