Is atropine needed with ketamine sedation? A prospective, randomised, double blind study

Heinz, Peter

doi:10.1136/emj.2005.028969

Cited by 95 publications

(58 citation statements)

References 19 publications

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“…Our finding of less vomiting with atropine relative to either glycopyrrolate or no anticholinergic supports the supposition of Heinz et al 3 that atropine has mild antiemetic properties. Based on our data the number needed to treat to prevent one child from vomiting would be 16.…”

Section: Discussionsupporting

confidence: 89%

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Anticholinergics and Ketamine Sedation in Children: A Secondary Analysis of Atropine Versus Glycopyrrolate

Green

Roback²,

Krauss

2010

Academic Emergency Medicine

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Objectives: Adjunctive anticholinergics are commonly administered during emergency department (ED) ketamine sedation in children under the presumption that drying oral secretions should decrease the likelihood of airway and respiratory adverse events. Pharmacologic considerations suggest that glycopyrrolate might exhibit a superior adverse effect profile to atropine. The authors contrasted the adverse events noted with use of each of these anticholinergics in a large multicenter observational database of ketamine sedations.Methods: This was a secondary analysis of an observational database of 8,282 ED ketamine sedations assembled from 32 prior series. The authors compared the relative incidence of six adverse events (airway and respiratory adverse events, laryngospasm, apnea, emesis, recovery agitation, and clinically important recovery agitation) between children who received coadministered atropine, glycopyrrolate, or no anticholinergic. Multivariable analysis using the specific anticholinergic as a covariate was performed, while controlling for other known predictors.Results: Atropine was associated with less vomiting (5.3%) than either glycopyrrolate (10.7%) or no anticholinergic (11.4%) in both unadjusted and multivariable analyses. Glycopyrrolate was associated with significantly more airway and respiratory adverse events (6.4%) than either atropine (3.3%) or no anticholinergic (3.0%) and similarly more clinically important recovery agitation (2.1% vs. 1.2 and 1.3%). There were, however, no differences noted in odds of laryngospasm and apnea.Conclusions: This secondary analysis unexpectedly found that the coadministered anticholinergic atropine exhibited a superior adverse event profile to glycopyrrolate during ketamine sedation. Any such advantage requires confirmation in a separate trial; however, our data cast doubt on the traditional premise that glycopyrrolate might be superior. Further, neither anticholinergic showed efficacy in decreasing airway and respiratory adverse events.ACADEMIC EMERGENCY MEDICINE 2010; 17:157-162 ª

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Section: Discussionsupporting

confidence: 89%

“…1,2 Their efficacy in this role is controversial, with study results both pro 3 and con. 2,4,5 It is possible that the conflicting evidence on this issue results from differences between the two anticholinergics typically used-atropine and glycopyrrolate.…”

mentioning

confidence: 99%

Anticholinergics and Ketamine Sedation in Children: A Secondary Analysis of Atropine Versus Glycopyrrolate

Green

Roback²,

Krauss

2010

Academic Emergency Medicine

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“…Numerous studies and randomized controlled trials (RCTs) on the use of ketamine show a favorable safety profile, with a low risk of airway complications and emergence phenomena. [1][2][3][4][5][6][7][8][9][10] One of the key disadvantages of ketamine, however, is the long recovery period. The optimal parenteral mode of ketamine administration-intravenous (IV) versus intramuscular (IM)-has been discussed in only a small number of studies and reviews in terms of time to discharge and its relationship to the incidence of adverse events.…”

mentioning

confidence: 99%

Pediatric Procedural Sedation with Ketamine: Time to Discharge after Intramuscular versus Intravenous Administration

Ramaswamy

Babl

Deasy

et al. 2009

Academic Emergency Medicine

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Objectives: Ketamine is an attractive agent for pediatric procedural sedation. There are limited data on time to discharge comparing intramuscular (IM) vs. intravenous (IV) ketamine. The authors set out to determine whether IM or IV ketamine leads to quicker discharge from the emergency department (ED) and how side effect profiles compare.Methods: All patients who had received ketamine IM or IV at a tertiary children's hospital ED during the 3-year study period (2004)(2005)(2006)(2007) were identified. Prospective sedation registry data, retrospective medical records, and administrative data were reviewed for drug dosages, use of additional agents, time of drug administration to discharge, total ED time (triage to discharge), and adverse events. A subgroup analysis for patients requiring five or fewer sutures (short suture group) was performed.Results: A total of 229 patients were enrolled (60% male) with median age of 2.8 years (IQR = 1.8-4.3 years) and median weight of 15.7 kg (range = 8.7-74 kg). Ketamine was most frequently employed for laceration repair (80%) and foreign body removal (9%). Overall, 48% received ketamine IM and 52% received it IV. In the short-suture subgroup, 52% received ketamine IM, while 48% received it IV. Multivariate linear regression analysis determined time from drug administration to patient discharge as 21 minutes shorter for IV compared with IM administration, adjusted for age and number of additional doses (R 2 = )0.35; 95% CI = )0.5 to )0.19; p < 0.001). Total time in the ED (triage to discharge) comparing IV versus IM administration, adjusting for age and gender and number of additional doses, was not significantly different (p = 0.16). In the short-suture subgroup, time to discharge from administration was also shorter in the IV ketamine group (R 2 = )0.454; 95%CI = )0.66 to )0.25; p < 0.001) but similar for total time in ED (p = 0.16). Overall, adverse events occurred in 35% (95% CI = 27% to 45%) of the IM group and 20% (95% CI = 13% to 28%) of the IV group (p = 0.01). Only one patient required brief bag-mask ventilation. Conclusions:In this institution, time from drug injection to discharge was shorter in the IV compared to IM ketamine group, both overall and for the short-suture group. However, time from triage to discharge was similar.

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“…Atropine has the potential to cause central toxicity which may complicate the management of cardiomyopathy (11). It has been reported that atropine may cause aspiration pneumonia through induction of the swallowing disorder and inhibition of the cough reflex (12), and it is associated with a higher incidence of a transient rash (13).…”

Section: Introductionmentioning

confidence: 99%

E-cadherin and 5-HT alterations in the heart of rats having undergone atropine-induced toxicity

Huang

Liu

2011

Mol Med Report

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Abstract. Atropine-induced heart damage is associated with changes in the expression of various enzymes and proteins. The purpose of this study was to investigate atropine-induced alterations in cardiac E-cadherin and 5-hydroxytryptamine (5-HT) after atropine administration. Male Wistar rats were randomly divided into two groups: a control group and an atropine group. The atropine group intraperitoneally received atropine at a single dose of 15 mg/kg for 7 days; the controls received the same amount of saline via the same route. On Day 8, the rats were anesthetized, and a thoracotomy was performed in all animals. Immunohistochemical analysis was performed to evaluate protein expression of E-cadherin and 5-HT. Sections were analyzed by digital image analysis. Cardiac protein expression of E-cadherin and 5-HT was altered after atropine-induced toxicity in the rat. The expression levels of E-cadherin and 5-HT were significantly decreased after atropine treatment, supported by IOD analysis, when compared with the control (P<0.05). The current findings indicate that such changes would be reflected in abnormal cardiac function, and these proteins may be useful for revealing the mechanisms underlying atropine-induced toxicity and may also provide various clues for further research.

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Is atropine needed with ketamine sedation? A prospective, randomised, double blind study

Cited by 95 publications

References 19 publications

Anticholinergics and Ketamine Sedation in Children: A Secondary Analysis of Atropine Versus Glycopyrrolate

Anticholinergics and Ketamine Sedation in Children: A Secondary Analysis of Atropine Versus Glycopyrrolate

Pediatric Procedural Sedation with Ketamine: Time to Discharge after Intramuscular versus Intravenous Administration

E-cadherin and 5-HT alterations in the heart of rats having undergone atropine-induced toxicity

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