Salen Philip, Grossman Michelle, Grossman Michael, Milazzo Anthony, Stoltzfus Jill
Department of Emergency Medicine, St. Luke's University Hospital, Bethlehem, PA 18015, USA.
Department of General Surgery and Emergency Medicine, Southside Hospital, North Shore-LIJ Hospital Network, NY 11706, USA.
Int J Crit Illn Inj Sci. 2016 Apr-Jun;6(2):79-84. doi: 10.4103/2229-5151.183022.
Ketamine and etomidate are used for procedural sedation (PS) to facilitate the performance of painful procedures. We hypothesized that ketamine produces adequate and comparable sedation conditions for dislocated large joint reduction when compared to etomidate and results in fewer adverse events.
This Institutional Review Board approved prospective trial compared a convenience sample of subjects, who were randomized to receive either ketamine or etomidate for PS to facilitate reduction of large joint dislocations. Following informed consent, subjects were assigned via a computer-generated algorithm to receive either etomidate (0.1 mg/kg) or ketamine (0.5 mg/kg) intravenously; if PS was not sufficient, subjects received repeat doses of etomidate or ketamine until adequate PS was achieved. The protocol's primary endpoint was a successful reduction of dislocated, large joints. Secondary endpoints included alteration in blood pressure, vomiting, recovery agitation, hypersalivation, laryngospasm, myoclonus, hypoxia, airway assistance with chin lift or jaw thrust, bag-valve-mask ventilation, endotracheal intubation, utilization of additional doses of ketamine or etomidate, and recovery time from sedation.
Total enrollment was eighty subjects, 46 in the ketamine cohort and 34 in the etomidate cohort. The two PS groups were comparable in terms of gender, age, and weight. There was no significant difference in the primary endpoint of large joint dislocation reduction between the ketamine and etomidate cohorts (46/46, 100%; 32/34, 94.1%; P - 0.1). Shoulder, hip, and ankle joints account for the majority of joint reductions in this trial. Titration of PS was necessary for almost half of each cohort as evidenced by the utilization of additional dosages of the sedative agents: ketamine (22/46, 47.8%) and etomidate (14/34, 41.2%; P - 0.56). Among secondary outcome variables, significant differences between ketamine and etomidate cohorts were myoclonus (1/46, 2.2%, 15/33, 45.5%; P - 0.0001), assisted ventilation with airway manipulation (3/45, 6.7%; 9/33, 27.3%; P - 0.01), and pulsoximetry desaturation < 90% (0/46; 7/34, 20.6%; P - 0.002). There was no significant difference in recovery time from PS between the ketamine and etomidate cohorts (11 min vs. 10 min; P - 0.69).
Ketamine produces PS conditions for successful large joint dislocation reduction that are adequate and comparable to etomidate. The increased likelihood of myoclonus, of the requirement for airway assistance, and of hypoxia observed with etomidate suggest potential benefits with the utilization of ketamine for PS for dislocated large joint reduction.
氯胺酮和依托咪酯用于程序镇静（PS）以辅助进行疼痛操作。我们假设，与依托咪酯相比，氯胺酮在大关节脱位复位时能产生足够且相当的镇静条件，并且不良事件更少。
本机构审查委员会批准的前瞻性试验比较了一个便利样本的受试者，这些受试者被随机分配接受氯胺酮或依托咪酯进行程序镇静以辅助大关节脱位复位。在获得知情同意后，通过计算机生成的算法将受试者分配接受静脉注射依托咪酯（0.1mg/kg）或氯胺酮（0.5mg/kg）；如果程序镇静不足，受试者接受依托咪酯或氯胺酮的重复剂量，直至达到足够的程序镇静。该方案的主要终点是大关节脱位成功复位。次要终点包括血压变化、呕吐、苏醒期躁动、流涎过多、喉痉挛、肌阵挛、缺氧、抬颏或托下颌辅助气道、球囊面罩通气、气管插管、额外剂量氯胺酮或依托咪酯的使用以及镇静苏醒时间。
共纳入80名受试者，氯胺酮组46名，依托咪酯组34名。两个程序镇静组在性别、年龄和体重方面具有可比性。氯胺酮组和依托咪酯组在大关节脱位复位的主要终点上无显著差异（46/46，100%；32/34，94.1%；P = 0.1）。本试验中大部分关节复位为肩关节、髋关节和踝关节。每个队列中近一半的受试者需要滴定程序镇静，这可通过镇静剂额外剂量的使用得到证明：氯胺酮（22/46，47.8%）和依托咪酯（14/34，41.2%；P = 0.56）。在次要结局变量中，氯胺酮组和依托咪酯组之间的显著差异为肌阵挛（1/46，2.2%，15/33，45.5%；P = 0.0001）、气道操作辅助通气（3/45，6.7%；9/33，27.3%；P = 0.01）以及脉搏血氧饱和度低于90%（0/46；7/34，20.6%；P = 0.002）。氯胺酮组和依托咪酯组在程序镇静后的苏醒时间上无显著差异（11分钟对10分钟；P = 0.69）。
氯胺酮在大关节脱位成功复位时产生的程序镇静条件足够且与依托咪酯相当。依托咪酯观察到的肌阵挛增加、气道辅助需求增加和缺氧提示氯胺酮用于大关节脱位复位的程序镇静可能具有潜在益处。
