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Procedural Sedation With Dexmedetomidine in Combination With Ketamine in the Emergency Department

      Abstract

      Background

      Dexmedetomidine is an alternative agent for procedural sedation in the emergency department thanks to its ability to maintain hemodynamic and respiratory stability. Dexmedetomidine must, however, be combined with a powerful analgesic.

      Objective

      Our aim was to evaluate the quality and safety of procedural sedation using the combination of dexmedetomidine and ketamine for patients undergoing painful procedures in the emergency department.

      Methods

      This prospective interventional single-center study was conducted in an academic emergency department of an urban hospital in Brussels, Belgium. Patients received a bolus injection of 1 µg/kg dexmedetomidine over 10 min and then a continuous infusion of 0.6 µg/kg/h followed by a bolus of 1 mg/kg ketamine. The painful procedure was carried out 1 min later. The level of pain was evaluated with a numerical rating scale from 0 (no pain) to 10 (maximal pain). The level of patient comfort for the procedure was measured using a comfort scale.

      Results

      Thirty patients were included. Overall, 90% of patients felt little or no pain (n = 29 of 30) or discomfort (n = 28 of 30) during the procedure. One patient experienced apnea with desaturation, which was resolved by a jaw-thrust maneuver. Although 23% of patients had significant arterial hypertension, none required drug treatment.

      Conclusions

      The combination of dexmedetomidine and ketamine provides conscious sedation, bringing comfort and pain relief to patients in optimal conditions for respiratory and hemodynamic safety. However, sedation and recovery times are longer than with conventional drug combinations. The dexmedetomidine–ketamine combination should therefore be recommended for nonurgent procedures and fragile patients.

      Keywords

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      References

        • Swanson ER
        • Seaberg DC
        • Mathias S.
        The use of propofol for sedation in the emergency department.
        Acad Emerg Med. 1996; 3: 234-238
        • Godwin SA
        • Burton JH
        • Gerardo
        • et al.
        Clinical policy: procedural sedation and analgesia in the emergency department.
        Ann Emerg Med. 2014; 63 (e18): 247-258
        • Krauss BS
        • Andolfatto G
        • Krauss BA
        • et al.
        Characteristics of and predictors for apnea and clinical interventions during procedural sedation.
        Ann Emerg Med. 2016; 68: 564-573
        • Miller KA
        • Andolfatto G
        • Miner JR
        • et al.
        Clinical Practice Guideline for Emergency Department Procedural Sedation With Propofol: 2018 update.
        Ann Emerg Med. 2019; 73: 470-480
        • Pichot C
        • Longrois D
        • Ghignone M
        • et al.
        Dexmédétomidine et clonidine: revue de leurs propriétés pharmacodynamiques en vue de définir la place des agonistes alpha-2 adrénergiques dans la sédation en réanimation.
        Ann Fr Anesth Reanim. 2012; 31: 876-896
        • Jewett J
        • Phillips WJ.
        Dexmedetomidine for procedural sedation in the emergency department.
        Eur J Emerg Med. 2010; 17: 60
        • Hsu YW
        • Cortinez LI
        • Robertson KM
        • et al.
        Dexmedetomidine pharmacodynamics: part I: crossover comparison of the respiratory effects of dexmedetomidine and remifentanil in healthy volunteers.
        Anesthesiol. 2004; 101: 1066-1076https://doi.org/10.1097/00000542-200411000-00005
        • Weerink MAS
        • Struys MMRF
        • Hannivoort LN
        • et al.
        Clinical pharmacokinetics and pharmacodynamics of dexmedetomidine.
        Clin Pharmacokinet. 2017; 56: 893-913
        • Lu Z
        • Li W
        • Chen H
        • et al.
        Efficacy of a dexmedetomidine-remifentanil combination compared with a midazolam-remifentanil combination for conscious sedation during therapeutic endoscopic retrograde cholangio-pancreatography: a prospective, randomized, single-blinded preliminary trial.
        Dig Dis Sci. 2018; 63: 1633-1640
        • Zanos P
        • Moaddel R
        • Morris PJ
        • et al.
        Ketamine and ketamine metabolite pharmacology: insights into therapeutic mechanisms.
        Pharmacol Rev. 2018; 70 ([published correction appears in Pharmacol Rev. 2018 Oct;70(4):879]): 621-660
        • Brown L
        • Christian-Kopp S
        • Sherwin TS
        • et al.
        Adjunctive atropine is unnecessary during ketamine sedation in children.
        Acad Emerg Med. 2008; 15: 314-318
        • Tobias JD.
        Dexmedetomidine and ketamine: an effective alternative for procedural sedation?.
        Pediatr Crit Care Med. 2012; 13: 423-427
        • Woods RM
        • Miller PT
        • Prater NI
        • et al.
        205 Ketadex for adult procedural sedation in the emergency department: a pilot study.
        Ann Emerg Med. 2016; 68: S80
        • Newton A
        • Fitton L
        Intravenous ketamine for adult procedural sedation in the emergency department: a prospective cohort study.
        Emerg Med J. 2008; 25: 498-501
      1. Precedex® (dexmedetomidine hydrochloride) injection: prescribing information. Hospira Inc. Accessed July 14, 2011. Available at: http://www.accessdata.fda.gov/drugsatfda_docs/label/2010/021038s017lbl.pdf

      2. KETALAR® (ketamine hydrochloride) injection: prescribing information. Hospira Inc. Accessed 2020. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/016812s040lbl.pdf

        • Ghojazadeh M
        • Sanaie S
        • Paknezhad SP
        • et al.
        Using ketamine and propofol for procedural sedation of adults in the emergency department: a systematic review and meta-analysis.
        Adv Pharm Bull. 2019; 9: 5-11
        • Yan JW
        • McLeod SL
        • Iansavitchene A.
        Ketamine-propofol versus propofol alone for procedural sedation in the emergency department: a systematic review and meta-analysis.
        Acad Emerg Med. 2015; 22: 1003-1013
        • Bellolio MF
        • Gilani WI
        • Barrionuevo P
        • et al.
        Incidence of adverse events in adults undergoing procedural sedation in the emergency department: a systematic review and meta-analysis.
        Acad Emerg Med. 2016; 23: 119-134
        • Lemoel F
        • Contenti J
        • Giolito D
        • et al.
        Adverse events with ketamine versus ketofol for procedural sedation on adults: a double-blind, randomized controlled trial.
        Acad Emerg Med. 2017; 24: 1441-1449
        • Sener S
        • Eken C
        • Schultz CH
        • et al.
        Ketamine with and without midazolam for emergency department sedation in adults: a randomized controlled trial.
        Ann Emerg Med. 2011; 57 (e2): 109-114
        • Akhlaghi N
        • Payandemehr P
        • Yaseri M
        Premedication with midazolam or haloperidol to prevent recovery agitation in adults undergoing procedural sedation with ketamine: a randomized double-blind clinical trial.
        Ann Emerg Med. 2019; 73: 462-469
        • Gan TJ.
        Pharmacokinetic and pharmacodynamic characteristics of medications used for moderate sedation.
        Clin Pharmacokinet. 2006; 45: 855-869
        • Andolfatto G
        • Abu-Laban RB
        • Zed PJ
        • et al.
        Ketamine-propofol combination (Ketofol) versus propofol alone for emergency department procedural sedation and analgesia: a randomized double-blind trial.
        Ann Emerg Med. 2012; 59 (e122): 504-512
        • Miner JR
        • Gray RO
        • Bahr J
        • et al.
        Randomized clinical trial of propofol versus ketamine for procedural sedation in the emergency department.
        Acad Emerg Med. 2010; 17: 604-611
        • Green SM
        • Roback MG
        • Kennedy RM
        • Krauss B.
        Clinical Practice Guideline for Emergency Department Ketamine Dissociative Sedation: 2011 update.
        Ann Emerg Med. 2011; 57: 449-461
        • Arora S.
        Combining ketamine and propofol ("ketofol") for emergency department procedural sedation and analgesia: a review.
        West J Emerg Med. 2008; 9: 20-23