O'Connor Laurel, Rebesco Matthew, Robinson Conor, Gross Karen, Castellana Andrew, O'Connor Mark J, Restuccia Marc
Prehosp Emerg Care. 2019 Mar-Apr;23(2):201-209. doi: 10.1080/10903127.2018.1501445. Epub 2018 Aug 27.
The goal of this study is to describe complications and outcomes of prehospital ketamine use for agitation as compared to other methods of physical or chemical restraint such as haloperidol plus benzodiazepine or physical restraint only.
We conducted a single-center retrospective review of patient encounters in which restraint was administered in the prehospital setting. At the beginning of our study window, only physical restraint was available to paramedics managing agitated patients but subsequently, haloperidol and benzodiazepines were introduced, followed by ketamine 2 years later. By comparing patients before and after each transition, we divided subjects into 3 cohorts based on restraint type: physical restraint, haloperidol plus benzodiazepine, and ketamine. Demographic data were collected, and outcome measures included intubation rate, need for additional physical or chemical restraint, emergency department (ED) length of stay, need for hospital admission, and employee injury.
Of 214 subjects included in the study, 95 patients were administered ketamine, 68 received haloperidol and benzodiazepine, and 51 were physically restrained. Eleven of the patients (11.6%) who received ketamine were intubated. Compared to patients who received haloperidol plus benzodiazepine, patients who received ketamine were more likely to be intubated (odds ratio [OR] = 8.77, 95% confidence interval [CI], 1.10-69.68) and were more likely to require additional chemical restraint when compared to haloperidol/benzodiazepine or physical restraint only (OR =2.94, 95% CI, 1.49-5.80, and OR =2.15, 95% CI, 1.07-4.31, respectively). There were no differences between the 2 chemical sedation groups in terms of ED length of stay or hospital admission rate.
This study demonstrates a lower intubation rate in patients administered ketamine than prior literature in association with a lower weight-based dosing regimen. Ketamine use was correlated with a higher frequency of intubation and a greater need for additional chemical restraint when compared with other restraint modalities, though exogenous factors such as provider preference may have impacted this result. There was no difference in ED length of stay or admission rate between the ketamine and haloperidol plus benzodiazepine groups. Further prospective study is needed to determine whether there is a subset of patients for whom ketamine would be beneficial compared to other therapies.
本研究的目的是描述院前使用氯胺酮治疗躁动的并发症和结果，并与其他物理或化学约束方法（如氟哌啶醇加苯二氮䓬类药物或仅采用物理约束）进行比较。
我们对院前环境中实施约束措施的患者进行了单中心回顾性研究。在我们研究时间段开始时，护理人员在处理躁动患者时仅可采用物理约束，随后引入了氟哌啶醇和苯二氮䓬类药物，两年后引入了氯胺酮。通过比较每次转变前后的患者，我们根据约束类型将受试者分为3组：物理约束组、氟哌啶醇加苯二氮䓬类药物组和氯胺酮组。收集了人口统计学数据，结果指标包括插管率、是否需要额外的物理或化学约束、急诊科（ED）住院时间、是否需要住院以及员工受伤情况。
在纳入研究的214名受试者中，95名患者使用了氯胺酮，68名接受了氟哌啶醇和苯二氮䓬类药物治疗，51名接受了物理约束。接受氯胺酮治疗的患者中有11名（11.6%）进行了插管。与接受氟哌啶醇加苯二氮䓬类药物治疗的患者相比，接受氯胺酮治疗的患者更有可能进行插管（优势比[OR]=8.77，95%置信区间[CI]，1.‘10 - 69.68），并且与仅接受氟哌啶醇/苯二氮䓬类药物或物理约束相比，更有可能需要额外的化学约束（OR分别为2.94，95%CI，1.49 - 5.80和OR =2.15，95%CI，1.07 - 4.31）。在急诊科住院时间或住院率方面，两个化学镇静组之间没有差异。
本研究表明，与先前文献相比，采用较低基于体重的给药方案时，接受氯胺酮治疗的患者插管率较低。与其他约束方式相比，使用氯胺酮与更高的插管频率和更大的额外化学约束需求相关，尽管提供者偏好等外部因素可能影响了这一结果。氯胺酮组与氟哌啶醇加苯二氮䓬类药物组在急诊科住院时间或住院率方面没有差异。需要进一步的前瞻性研究来确定与其他疗法相比，氯胺酮对哪些患者亚组有益。
