Hemodynamic Response After Rapid Sequence Induction With Ketamine in Out-of-Hospital Patients at Risk of Shock as Defined by the Shock Index

Miller, Matthew; Kruit, Natalie; Heldreich, Charlotte; Ware, Sandra; Habig, Karel; Reid, Cliff; Burns, Brian

doi:10.1016/j.annemergmed.2016.03.041

Cited by 90 publications

(63 citation statements)

References 32 publications

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“…19,45 It has been proposed that the negative inotropic effects of ketamine may outweigh the sympathomimetic effects in patients with depleted physiologic reserve, and potentially lead to increased mortality and longer duration of organ dysfunction in these patients. 18,46 This finding also requires independent confirmation in future studies.…”

Section: Discussionmentioning

confidence: 74%

Comparison of Etomidate and Ketamine for Induction During Rapid Sequence Intubation of Adult Trauma Patients

Upchurch

Grijalva

Russ

et al. 2017

Annals of Emergency Medicine

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Study objective Induction doses of etomidate during rapid sequence intubation (RSI) cause transient adrenal dysfunction, but its clinical significance on trauma patients is uncertain. Ketamine has emerged as an alternative for RSI induction. Among adult trauma patients emergently intubated, we compared clinical outcomes among those induced with etomidate and ketamine. Methods The study entailed a retrospective evaluation of a four-year (January 2011–December 2014) period spanning an institutional protocol switch from etomidate to ketamine as the standard induction agent for adult trauma patients undergoing RSI in the ED of an academic Level I trauma center. The primary outcome was hospital mortality evaluated with multivariable logistic regression adjusted for age, vital signs, and injury severity and mechanism. Secondary outcomes included intensive care unit (ICU)-free days and ventilator-free days (VFD) evaluated with multivariable ordered logistic regression using the same covariates. Results The analysis included 968 patients, including 526 with etomidate and 442 with ketamine. Hospital mortality was 20.4% among patients induced with ketamine compared to 17.3% among those induced with etomidate (aOR: 1.41; 95% CI: 0.92, 2.16). Patients induced with ketamine had similar ICU-free-days (aOR: 0.80; 95% CI: 0.63, 1.00) and VFDs (aOR: 0.96; 95% CI: 0.76, 1.20) as compared to patients induced with etomidate. Conclusion In this analysis spanning an institutional protocol switch from etomidate to ketamine as the standard RSI induction agent for adult trauma patients, patient-centered outcomes were similar for patients who received etomidate and ketamine.

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Section: Discussionmentioning

confidence: 74%

Comparison of Etomidate and Ketamine for Induction During Rapid Sequence Intubation of Adult Trauma Patients

Upchurch

Grijalva

Russ

et al. 2017

Annals of Emergency Medicine

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“…Two definitions of hypotension were analysed separately, consistent with two different approaches used in previous studies [5][6][7][8]. Our secondary outcome measures were the proportion of patients experiencing new hypotension or hypertension at each 3-min interval, as well as adherence to the RSI protocol.…”

Section: Methodsmentioning

confidence: 99%

“…Our secondary outcome measures were the proportion of patients experiencing new hypotension or hypertension at each 3-min interval, as well as adherence to the RSI protocol. Two definitions of hypotension were analysed separately, consistent with two different approaches used in previous studies [5][6][7][8]. Firstly, a SBP > 90 mmHg before induction, with any new episode of SBP < 90 mmHg post-intubation; and secondly, a reduction in SBP, of more than 20% from baseline.…”

Section: Methodsmentioning

confidence: 99%

Haemodynamic changes to a midazolam–fentanyl–rocuronium protocol for pre‐hospital anaesthesia following return of spontaneous circulation after cardiac arrest

Miller¹,

Groombridge

Lyon

2017

Anaesthesia

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Following the return of spontaneous circulation after out-of-hospital cardiac arrest, neurological dysfunction, airway or ventilatory compromise can impede transport to early percutaneous coronary intervention, necessitating pre-hospital or emergency department anaesthesia to facilitate this procedure. There are no published reports of the ideal induction agents in these patients. We sought to describe haemodynamic changes associated with induction of anaesthesia using a midazolam (0.1 mg.kg ), fentanyl (2 μg.kg ) and rocuronium (1 mg.kg ) regimen developed using expert opinion, and adherence to the protocol by our pre-hospital teams. We performed a retrospective review of haemodynamic data recorded during induction of anaesthesia in patients following return of spontaneous circulation, over a 30-month period. We analysed the changes in systolic blood pressure and heart rate using a repeated-measures design, as well as the rate of new hypotension or hypertension. Sixty-four patients had four consecutive measurements for analysis (one pre-induction and three post-induction). Systolic blood pressure at all three post-induction measurements was significantly lower than the pre-induction value. Heart rate did not differ between any time-points. New episodes of hypotension (systolic pressure < 90 mmHg) occurred in four (6%) patients at the first measurement post-induction (95%CI 2-15%) and 10 (16%) at the third measurement (95%CI 8-27%). Three patients (5%; 95%CI 1-13%) had a hypertensive response. The median (IQR[range]) dose of midazolam given at induction was 0.04 (0.03-0.05 [0.01 to 0.10]) mg.kg . Adherence to recommended fentanyl and rocuronium doses was high. Overall, systolic blood pressure was reduced following induction of anaesthesia, and systolic pressures < 90 mmHg occurred more often at measurements made later (up to 9 min) after induction. Changes in heart rate, and new hypertension were uncommon.

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“…This is a logical choice in an environment such as the ED or in prehospital care, where patients are undifferentiated, and may be overtly or cryptically shocked, due to the perceived haemodynamic stability of ketamine. However, the common understanding that ketamine is haemodynamically stable is flawed, given that it frequently causes tachycardia and hypertension, and in catecholamine‐depleted patients, may cause hypotension …”

Section: Introductionmentioning

confidence: 99%

Does the addition of fentanyl to ketamine improve haemodynamics, intubating conditions or mortality in emergency department intubation: A systematic review

Ferguson

Bliss

Åneman

2019

Acta Anaesthesiol Scand

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Background Ketamine is an induction agent frequently used for general anaesthesia in emergency medicine. Generally regarded as haemodynamically stable, it can cause hypertension and tachycardia and may cause or worsen shock. The effects of ketamine may be improved by the addition of fentanyl to the induction regime. We conducted a systematic review to identify evidence with regard to the effect of adding fentanyl to an induction regime of ketamine and a paralysing agent on post‐induction haemodynamics, intubating conditions and mortality. Methods We conducted a search of the Cochrane library, EMBASE, MEDLINE, PROQUEST, OpenGrey and clinical trial registries. Prominent authors were contacted in order to identify additional literature pertinent to the research question. Studies were included if they pertained to intubation of adult patients in the prehospital or emergency department environments and included an induction regime of ketamine and a paralysing agent, with at least one outcome measure of haemodynamics, intubating conditions or mortality. Search results were reviewed by two investigators independently, adjudicated by a third investigator where disagreement occurred. Results One observational study was identified that partially answered the research question. Discussion Only one observational study was identified that partially answered the research question. This paper demonstrated that the use of fentanyl as a pretreatment increases the incidence of post‐induction hypotension, a phenomenon that was seen with propofol, midazolam and ketamine. The difference in hypotension between these agents was not statistically significant. The impact of this on patient‐orientated outcomes is unclear.

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Hemodynamic Response After Rapid Sequence Induction With Ketamine in Out-of-Hospital Patients at Risk of Shock as Defined by the Shock Index

Cited by 90 publications

References 32 publications

Comparison of Etomidate and Ketamine for Induction During Rapid Sequence Intubation of Adult Trauma Patients

Comparison of Etomidate and Ketamine for Induction During Rapid Sequence Intubation of Adult Trauma Patients

Haemodynamic changes to a midazolam–fentanyl–rocuronium protocol for pre‐hospital anaesthesia following return of spontaneous circulation after cardiac arrest

Does the addition of fentanyl to ketamine improve haemodynamics, intubating conditions or mortality in emergency department intubation: A systematic review

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