Ketamine for emergency sedation of agitated patients: A systematic review and meta-analysis

Sullivan, Natalie; Chen, Chen; Siegel, Rebecca; Ma, Yan; Pourmand, Ali; Montano, Nataly; Meltzer, Andrew C.

doi:10.1016/j.ajem.2019.11.007

Cited by 24 publications

(27 citation statements)

References 28 publications

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“…It is quite possible that IV ketamine may be especially effective in adults with agitated depression and recognize this remains a testable hypothesis. In accordance with this hypothesis, ketamine has demonstrated anti‐agitation effects without sedation in medically ill populations, especially in acute and emergency settings 49 …”

Section: Discussionmentioning

confidence: 65%

“…In accordance with this hypothesis, ketamine has demonstrated anti-agitation effects without sedation in medically ill populations, especially in acute and emergency settings. 49 A strength of our population is its representativeness, insofar as this large sample was enrolled at a community-based treatment centre for adults with TRD. A further strength of our study sample is that patients were permitted to have comorbidity as well as concomitantly administered medication, reflecting the reality of treating TRD patients.…”

Section: Discussionmentioning

confidence: 99%

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The effectiveness of ketamine on anxiety, irritability, and agitation: Implications for treating mixed features in adults with major depressive or bipolar disorder

et al. 2020

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Objective: To determine the effectiveness of intravenous (IV) ketamine on anxiety, irritability, agitation, and suicidality, in adults with treatment-resistant major depressive disorder (MDD) or bipolar disorder (BD). Method: Adults (N = 201) with treatment-resistant MDD or BD received repeatdose IV ketamine treatment at a community-based clinic. Mixed features were measured using symptoms of anxiety, irritability, and agitation (AIA), as measured by the Generalized Anxiety Disorder-7 (GAD-7) scale. The Quick Inventory for Depressive Symptomatology Self-Report-16 (QIDS-SR 16) was used to measure overall treatment response, and the QIDS-SR 16 suicidal ideation (SI) item was used to measure change in SI symptoms with ketamine treatment. The anxiety, irritability, and agitation items How to cite this article: McIntyre RS, Lipsitz O, Rodrigues NB, et al. The effectiveness of ketamine on anxiety, irritability, and agitation: Implications for treating mixed features in adults with major depressive or bipolar disorder. Bipolar Disord.

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Section: Discussionmentioning

confidence: 65%

Section: Discussionmentioning

confidence: 99%

The effectiveness of ketamine on anxiety, irritability, and agitation: Implications for treating mixed features in adults with major depressive or bipolar disorder

et al. 2020

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“…Ketamine was recently added to this list for severely agitated patients. [35][36][37] The most likely etiology for the patient's agitation influences medication choices ( Figure 2). 11 In general, antipsychotics are used for patients with psychosis and TA B L E 2 Diagnostic studies that may be indicated in the evaluation of the agitated patient…”

Section: Pharmacotherapymentioning

confidence: 99%

“…The medications most commonly used in the ED for acute agitation are antipsychotics and benzodiazepines. Ketamine was recently added to this list for severely agitated patients 35‐37 . The most likely etiology for the patient's agitation influences medication choices (Figure 2).…”

Section: Overview Of Beta Guidelinesmentioning

confidence: 99%

“…TA B L E 3 Pharmacology for the agitated patients 11,35,[38][39][40][41][42][43][44][45][46][47][48][49][50][51][52] 61 and document this in the electronic medical record where it is easily visible on the patient tracking board. A special wrist band is placed on the patient, and a sign is placed on their doorway to alert all healthcare workers of the violence risk.…”

Section: Implementation Of the Beta Guidelines: The Parkland Experiencementioning

confidence: 99%

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Improving the management of acutely agitated patients in the emergency department through implementation of Project BETA (Best Practices in the Evaluation and Treatment of Agitation)

et al. 2020

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Agitated patients presenting to the emergency department (ED) can escalate to aggressive and violent behaviors with the potential for injury to themselves, ED staff, and others. Agitation is a nonspecific symptom that may be caused by or result in a life‐threatening condition. Project BETA (Best Practices in the Evaluation and Treatment of Agitation) is a compilation of the best evidence and consensus recommendations developed by emergency medicine and psychiatry experts in behavioral emergencies to improve our approach to the acutely agitated patient. These recommendations focus on verbal de‐escalation as a first‐line treatment for agitation; pharmacotherapy that treats the most likely etiology of the agitation; appropriate psychiatric evaluation and treatment of associated medical conditions; and minimization of physical restraint/seclusion. Implementation of Project BETA in the ED can improve our ability to manage a patient's agitation and reduce the number of physical assaults on ED staff. This article summarizes the BETA guidelines and recent supporting literature for managing the acutely agitated patient in the ED followed by a discussion of how a large county hospital integrated these recommendations into daily practice.

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Efficacy and Safety of Esketamine for Supplemental Analgesia During Elective Cesarean Delivery

Wang

Deng

et al. 2023

JAMA Netw Open

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ImportanceEpidural anesthesia is a primary choice for cesarean delivery, but supplemental analgesics are often required to relieve pain during uterine traction.ObjectiveTo investigate the sedative and analgesic effects of intravenous esketamine administered before childbirth via cesarean delivery with the patient under epidural anesthesia.Design, Setting, and ParticipantsThis multicenter, double-blind randomized clinical trial assessed 903 women 18 years or older who had full-term single pregnancy and were scheduled for elective cesarean delivery with epidural anesthesia in 5 medical centers in China from September 18, 2021, to September 20, 2022.InterventionPatients were randomized to receive intravenous injection of 0.25 mg/kg of esketamine or placebo before incision.Main Outcomes and MeasuresThe coprimary outcomes included scores on the numeric rating scale of pain (an 11-point scale, with 0 indicating no pain and 10 indicating the worst pain; a difference of ≥1.65 points was clinically meaningful) and Ramsay Sedation Scale (a 6-point scale, with 1 indicating restlessness and 6 indicating deep sleep without response; a difference of ≥2 points was clinically meaningful) immediately after fetal delivery. Secondary outcomes included neonatal Apgar score assessed at 1 and 5 minutes after birth.ResultsA total of 600 women (mean [SD] age, 30.7 [4.3] years) were enrolled and randomized; all were included in the intention-to-treat analysis. Immediately after fetal delivery, the score on the numeric rating scale of pain was lower with esketamine (median [IQR], 0 [0-1]) than with placebo (median [IQR], 0 [0-2]; median difference, 0; 95% CI, 0-0; P = .001), but the difference was not clinically important. The Ramsay Sedation Scale scores were higher (sedation deeper) with esketamine (median [IQR], 4 [3-4]) than with placebo (median [IQR], 2 [2-2]; median difference, 2; 95% CI, 2-2; P &lt; .001). The neonatal Apgar scores did not differ between the 2 groups at 1 minute (median difference, 0; 95% CI, 0-0; P = .98) and at 5 minutes (median difference, 0; 95% CI, 0-0; P = .27). Transient neurologic or mental symptoms were more common in patients given esketamine (97.7% [293 of 300]) than in those given placebo (4.7% [14 of 300]; P &lt; .001).Conclusions and RelevanceFor women undergoing cesarean delivery under epidural anesthesia, a subanesthetic dose of esketamine administered before incision produced transient analgesia and sedation but did not induce significant neonatal depression. Mental symptoms and nystagmus were common but transient. Indications and the optimal dose of esketamine in this patient population need further clarification, but study should be limited to those who require supplemental analgesia.Trial RegistrationClinicalTrials.gov Identifier: NCT04548973

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Ketamine for emergency sedation of agitated patients: A systematic review and meta-analysis

Cited by 24 publications

References 28 publications

The effectiveness of ketamine on anxiety, irritability, and agitation: Implications for treating mixed features in adults with major depressive or bipolar disorder

The effectiveness of ketamine on anxiety, irritability, and agitation: Implications for treating mixed features in adults with major depressive or bipolar disorder

Improving the management of acutely agitated patients in the emergency department through implementation of Project BETA (Best Practices in the Evaluation and Treatment of Agitation)

Efficacy and Safety of Esketamine for Supplemental Analgesia During Elective Cesarean Delivery

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