No 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.

We aim to discuss the efficacy and adverse effects of using ketamine in agitated patients in the emergency department (ED) compared with the combination therapy of haloperidol with benzodiazepine. This systematic review followed Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines. An electronic search from PubMed/Medline, Cochrane library, and Google Scholar was conducted from their inception to 30 th April 2022. We included agitated patients in ED who were given infusion with ketamine only. Our comparative group was patients infused with combined therapy of haloperidol and benzodiazepine. We did not include letters, case reports, abstracts, conference papers, appraisals, reviews, and studies where full text was unavailable. We did not put any language restrictions. Three studies were selected in our manuscript (one cohort and two randomized controlled trials). All three studies showed that ketamine was used to achieve sedation in less time than the other group. However, two studies reported significantly more adverse effects in ketamine-infused groups.We concluded that ketamine use is superior when its primary focus is to sedate the patient as quickly as possible, but it carries some side effects that should be considered. However, we still need more studies assessing the efficacy of ketamine in agitated patients presenting in the ED.

The CURB-65 (confusion, uremia, respiratory rate, blood pressure, age ≥ 65 years) score and the pneumonia severity index (PSI) are widely used and recommended in predicting 30-day mortality and the need for intensive care support in community-acquired pneumonia. This study aims to compare the performance of these two severity scores in both mortality prediction and the need for intensive care support. A systematic review and meta-analysis was carried out, following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) 2020 guidelines, and PubMed, Scopus, ScienceDirect, and Google Scholar were searched for articles published from 2012 to 2022. The reference lists of the included studies were also searched to retrieve possible additional studies. Twenty-five studies reporting prognostic information for CURB 65 and PSI were identified. ReviewManager (RevMan) 5.4.1 was used to produce risk ratios, and a random effects model was used to pool them. Both PSI and CURB-65 showed a high strength in identifying high-risk patients. However, CURB-65 was slightly better in early mortality prediction and had more sensitivity (96.7%) and specificity (89.3%) in predicting admission to intensive care support. Thus, CURB-65 seems to be the preferred tool in predicting mortality and the need for admission into intensive care support.

Paracetamol (acetaminophen) is an extensively used analgesic for acute and chronic pain management. Currently, paracetamol is manufactured for oral, rectal, and intravenous (IV) use. Research has shown varied results on the analgesic properties of IV paracetamol compared to oral and rectal paracetamol; however, research on the same doses of paracetamol is limited. Therefore, this review was constructed to explore the analgesic properties of IV paracetamol compared with oral and rectal paracetamol administered in equivalent doses. A broad and thorough literature search was performed on five electronic databases, including PubMed, ScienceDirect, Medline, Scopus, and Google Scholar. Statistical analysis of all outcomes in our review was then performed using the Review Manager software. Outcomes were categorized as primary (pain relief and time to request rescue analgesia) and secondary (adverse events after analgesia). An extensive quality appraisal was also done using the Review Manager software’s Cochrane risk of bias tool. The literature survey yielded 2,945 articles, of which 12 were used for review and analysis. The pooled analysis for patients undergoing surgical procedures showed that IV paracetamol had statistically similar postoperative pain scores at two (mean difference (MD) = -0.14; 95% confidence interval (CI) -0.58-0.29; p = 0.51), 24 (MD = 0.09; 95% CI = -0.02-0.21; p = 0.12), and 48 (MD = 0.04; 95% CI = -0.08-0.16; p = 0.52) hours as oral paracetamol. Similarly, the data on time to rescue analgesia showed no considerable difference between the IV and oral paracetamol groups (MD = -1.58; 95% CI = -5.51-2.35; p = 0.43). On the other hand, the pooled analysis for patients presenting non-surgical acute pain showed no significant difference in the mean pain scores between patients treated with IV and oral paracetamol (MD = -0.35; 95% CI = -2.19-1.48; p = 0.71). Furthermore, a subgroup analysis of analgesia-related adverse events showed that the incidences of vomiting/nausea and pruritus did not differ between patients receiving IV and oral paracetamol (odds ratio (OR) = 0.71; 95% CI = 0.45-1.11; p = 0.13 and OR = 0.48; 95% CI = 0.18-1.29; p = 0.05, respectively). A review of information from two trials comparing equal doses of IV and rectal paracetamol suggested that the postoperative pain scores were statistically similar between the groups. IV paracetamol is not superior to oral or rectal paracetamol administered in equal doses. Therefore, we cannot recommend or refute IV paracetamol as the first-line analgesia for acute and postoperative pain.