UPDATED GUIDELINES EXPAND USE OF SEDATION AGENT IN ED SETTING

El passat 20 de gener, la verisó online d'Annals of Emergency Medicine, s'ha publicat un update sobre els agents sedants d'ús en el serveis d'urgències, remarcant l'ampliació de l'ús de la ketamina en pacients adults i en nens entre 3 i 12 mesos d'edat, a dosi de 0.5 mg/kg. Es basa en un estudi randomitzat de l'ús de ketamina + propofol vs. propofol sol, amb pretractament de fetanilo.  

Un petit resum i el link:

• Changes since the 2004 guidelines include the following:
  • The updated guidelines now support expansion of ketamine use to children aged 3 to 12 months, which is younger than previously recommended, as well as to adults.
  • Minor oropharyngeal procedures and head trauma are no longer contraindications to ketamine use.
  • Emergency medicine physicians should administer ketamine intravenously instead of intramuscularly whenever feasible because recovery is faster and there is less emesis.
  • Routine use of prophylactic anticholinergic medications is no longer recommended.
  • Routine use of prophylactic benzodiazepines is not recommended for children but may be helpful in adults (eg, midazolam 0.03 mg/kg intravenously; number needed to benefit = 6).
  • Prophylactic use of ondansetron may slightly reduce vomiting (number needed to benefit ≥ 9).
• Other recommendations in the 2011 guidelines include the following:
  • Indications for ketamine use include short, painful procedures, especially those in which immobilization is needed, such as facial laceration, burn debridement, fracture reduction, abscess incision and drainage, central line placement, or tube thoracostomy.
  • Other indications for ketamine use are examinations that could be emotionally disturbing (eg, examination for pediatric sexual assault).
  • Absolute contraindications are age younger than 3 months and known or suspected schizophrenia.
  • Relative contraindications are major procedures stimulating the posterior aspect of the pharynx (eg, endoscopy); history of airway instability, tracheal surgery, or stenosis; active pulmonary infection or disease; known or suspected cardiovascular disease or hypertension; and central nervous system masses, abnormalities, or hydrocephalus.
  • Other relative contraindications are glaucoma or acute globe injury, porphyria, thyroid disorder, or use of thyroid medication.
  • 2 staff members, both knowledgeable about the unique characteristics of ketamine, are needed to administer dissociative sedation: one (eg, nurse) to monitor the patient and one (eg, physician) to perform the procedure.
  • Ketamine should not be given until the physician is ready to start the procedure because onset of dissociation is typically rapid.
  • Ketamine is initially given as a single intravenous loading dose or intramuscular injection, with no apparent benefit from attempts to titrate to effect.
  • Although the intravenous route is preferred, intramuscular administration is useful when intravenous access cannot be reliably established with minimal upset, and when the patient is uncooperative or combative.
  • Intravenous access is unnecessary for children receiving intramuscular administration of ketamine but is desirable in adults to treat unpleasant recovery reactions if they occur.
  • Loading dose is 1.5 to 2.0 mg/kg intravenously in children or 1.0 mg/kg intravenously in adults, given for 30 to 60 seconds. Additional incremental doses of 0.5 to 1.0 mg/kg may be given if needed.
  • For intramuscular use in children, loading dose is 4 to 5 mg/kg. Full- or half-dose intramuscular access may be repeated after 5 to 10 minutes if sedation is inadequate or if additional doses are needed.
  • Suction equipment, oxygen, bag-valve-mask, and age-appropriate equipment for advanced airway management should be immediately available during ketamine administration and recovery.
  • Close observation of the airway and respirations by an experienced healthcare professional is mandatory until recovery is well established.
  • Common adverse effects are muscular hypertonicity and random, purposeless movements.
  • During recovery, emesis may occur (8.4% of children), as may agitation (mild in 6.3%, clinically important in 1.4%).
  • Other adverse effects, with percentage estimates in children, may include airway misalignment requiring head repositioning, transient laryngospasm (0.3%), transient apnea or respiratory depression (0.8%), hypersalivation (rare), clonus, hiccupping, or short-lived nonallergic rash of the face and neck.

Clinical Implications

• Changes in the updated guidelines for ED dissociative sedation using ketamine now support expansion of ketamine use to additional age groups and recommend intravenous instead of intramuscular use for adults whenever feasible because recovery is faster and there is less emesis.
• The updated guidelines also describe detailed recommendations for patient selection, administration, monitoring, and recovery for ED dissociative sedation using ketamine.

http://www.medscape.org/viewarticle/736223?src=cmemp