364 A Comparison of Ketamine versus Etomidate for Procedural Sedation for the Reduction of Joint Dislocations

Abstract

Ketamine and etomidate are used for procedural sedation (PS) to facilitate reduction of dislocated joints. We hypothesized that ketamine produces adequate and comparable conditions for joint reduction compared to etomidate and may result in fewer adverse effects. This IRB-approved prospective trial randomized a convenience sample of subjects requiring PS for urgent reduction of joint dislocations to either ketamine or etomidate. After informed consent was obtained, subjects were randomly assigned via 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 till PS was achieved. The protocol’s primary endpoint was successful reduction. Secondary endpoints included: change in vital signs, respiratory depression, vomiting, emergence reactions, hypersalivation, laryngospasm and myoclonus, need for airway assistance with chin lift/ jaw thrust, bag-valve-mask (BVM) ventilation, or intubation, and utilization of additional doses of non-study sedative and/or anesthetic agents. Recovery time from sedation, as measured by the Aldrete Score, was assessed by nursing staff. Exclusion criteria included pregnancy, age <14 years, altered mental status, and patients with suspected cocaine abuse. Total enrollment was 78 subjects, 46 in the ketamine cohort and 32 in the etomidate cohort. There was no significant difference in the primary endpoint of joint reduction between the ketamine and etomidate cohorts (46/46, 100%; 32/34, 94.1%; P=.01). Among secondary outcome variables (Table), myoclonus (1/46, 2.2%, 14/33, 45.5%; P<.0001) and chin lift/jaw thrust airway manipulation (3/45, 6.7%; 9/33, 27.3%; P=.01) were the only variables resulting in a significant between-group difference. All airway assists consisted of chin lift/jaw thrust or BVM ventilation; no intubations were required. There was no significant difference in recovery time from procedural sedation between the ketamine and etomidate cohorts (11 minutes v. 10 minutes; P=.69) Ketamine produces PS conditions for successful joint dislocation reduction that are adequate and comparable compared to etomidate. The significant reduction in myoclonus associated with ketamine use as well as the increased requirement for airway assistance observed with etomidate suggest a potential advantage with the use of ketamine for PS.TableKetamine (n = 46)Etomidate (n = 34)P-valuePrimary OutcomeSuccessful joint dislocation reduction46/46 (100%)32/34 (94.1%).10Secondary OutcomesAdditional dose of sedative agent required22/46 (47.8%)14/34 (41.2%).56•# additional doses• median (raw range) = 1 (1 – 2)• median (raw range) = 2 (1– 8)• .02Additional analgesics administered24/46 (52.2%)23/33 (69.7%).12Non-Study sedation administered3/46 (6.5%)1/31 (3.2%).52Emergence reaction0/450/33N/AMyoclonus1/46 (2.2%)15/33 (45.5%)< .0001Hypersalivation1/46 (2.2%)1/33 (3%).81Laryngospasm0/450/31N/AVomiting0/451/33 (3%).24Required intubation secondary to procedural sedation0/460/33NARequired assisted ventilation with bag- valve mask (BVM)1/45 (2.2%)3/33 (9.1%).17Required assisted ventilation with jaw thrust or chin lift3/45 (6.7%)9/33 (27.3%).01Post-procedure systolic blood pressure (sBP) < 100 or > 2001/46 (2.2%)2/34 (5.9%).39> 20% change in post-procedure sBP11/46 (23.9%)4/34 (11.8%).17> 20% change in post-procedure diastolic blood pressure12/46 (26.1%)8/34 (23.5%).79Post-procedure pulse oximetry change > 20%0/460/34N/ARecovery from sedation [median (range)]11 minutes (2 – 60 minutes)10 minutes (2 – 65 minutes).69 Open table in a new tab