To study the effectiveness and safety of ketamine and midazolam procedural sedation in the incision and drainage of abscesses in the adult emergency department

Abstract

The objective of the report was to study the efficacy and safety of ketamine and midazolam combination in the procedural sedation of incision and drainage of abscesses in the adult emergency department (ED) patients. This prospective observational study enrolled patients aged 16-60 years (American Society of Anesthesiologists class I) requiring abscess drainage in an adult ED. Patients received 2 mg/kg of ketamine infusion over 5 min and midazolam 2-5 mg titrated to deep sedation according to Ramsay sedation scale. Primary outcome was patient satisfaction using pain score after procedure. Secondary outcomes included adverse effects, hemodynamics alterations and recovery time. Descriptive statistics were calculated using SPSS software. Fifteen patients were recruited. One patient was excluded because of difficulty with pain score interpretation. Seventy-nine percent were male patients. The mean age was 29. The mean size of abscess was 3.4 cm. The mean dose of midazolam was 3.2 mg. Eighty-six percent did not experience any pain for the procedure. Only two patients (14%) reported mild pain during the procedure. There were no significant adverse events or complications. Three patients had giddiness, two had vomiting and only one reported an unpleasant dream. The median systolic blood pressure and heart rate elevation were 30+/-5.1 mmHg and 12.5+/-3.2/min, respectively. The median time for blood pressure and pulse rate to return to baseline was 20+/-2.7 min. The use of ketamine and midazolam sedation is both well tolerated and effective for adults in the ED undergoing incision and drainage of abscesses. This study is limited by the small sample size.

Incidence of Adverse Events in Adults Undergoing Procedural Sedation in the Emergency Department: A Systematic Review and Meta‐analysis

“…After screening the titles and abstracts and removing duplicates, we identified 465 potentially relevant studies. After full‐text review, 55 articles met inclusion criteria . Interobserver agreement (kappa) for phase II of the review was 0.99 (95% CI = 0.98 to 1.0).…”

“…Ketamine and ketamine/propofol had the highest rate of agitation. Among the studies that used ketamine, the incidence of agitation was 164.1 per 1,000 sedations (95% CI = 94.8 to 233.5), and among those receiving ketamine/propofol, 48.1 per 1,000 sedations (95% CI = 12.9 to 83.3; see Figure ) …”

“…She was admitted to the hospital and extubated 12 hours later with no long‐term sequelae. Figure provides the forest plot for the aspiration outcome …”

Discontinuance of Life Sustaining Treatment Utilizing Ketamine for Symptom Management

“…13 More recently adult studies have shown ketamine to produce effective sedation for procedures with benefits including less hemodynamic instability and improved pain control and the most commonly noted side effect being recovery agitation that can be mitigated with midazolam. [14][15][16][17] Ketamine also has been noted to have analgesic properties and to provide opioid-sparing effects. [18][19][20][21][22][23][24] Despite these properties, to our awareness it has never been reported in the literature for use in analgesia or sedation for terminal ventilator weaning.…”

“…We chose ketamine, as discussed below, as a rescue agent for agitation and as an analgesic adjunct based on its use for sedation in emergency medicine and in the anesthesia literature as well as its differing mechanism of action than the medications she was currently receiving. [7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24] Ketamine is an N-methyl-D aspartase (NMDA) receptor antagonist with known dissociative D. M. Noreika and P. Coyne 39 anesthetic properties. The analgesic and sedative effects that it produces are largely believed to be related to NMDA receptor blockade in the central nervous system and at the spinal cord level, although they additionally may be related to a complex interaction with opioid mu and kappa receptors.…”