Michael C. Thomas

Combination of ketamine and propofol versus either agent alone for procedural sedation in the emergency department.

PURPOSE The safety of using ketamine-propofol combinations as an alternative to using either agent alone for procedural sedation is discussed. SUMMARY A total of 10 trials comparing the combination of ketamine and propofol with either agent alone for procedural sedation in the emergency department were examined. The evidence reviewed suggests that combining these agents may help to minimize adverse effects such as hypotension and respiratory depression. Ketamine is not commonly used as a single agent in adults because of the risk for emergence reactions; however, when combined with propofol, no significant increase in this adverse effect was found compared with propofol monotherapy. Administering ketamine and propofol can be accomplished by using a two-syringe technique or combining both medications into a single syringe. When two syringes are used, a ketamine 0.3-0.5-mg/kg i.v. bolus dose is administered, followed by a propofol 0.4-1-mg/kg i.v. bolus dose. Sedation is maintained with intermittent i.v. boluses of propofol 0.1-0.5 mg/kg. A 1:1 ratio of ketamine and propofol can also be combined into a single syringe by using the same concentration (10 mg/mL) and equal volumes of each drug, yielding a final concentration of 5 mg/mL for each component. CONCLUSION The combined use of ketamine and propofol is a reasonable alternative to propofol alone for procedural sedation in patients at higher risk for respiratory depression or hypotension. Use of the combination requires the development of standardized protocols for drug preparation and dosage to minimize the potential for errors.

Barbiturates for the treatment of alcohol withdrawal syndrome: A systematic review of clinical trials

PURPOSE To perform a systematic review of the clinical trials concerning the use of barbiturates for the treatment of acute alcohol withdrawal syndrome (AWS). MATERIALS AND METHODS A literature search of MEDLINE, EMBASE, and the Cochrane Library, together with a manual citation review was conducted. We selected English-language clinical trials (controlled and observational studies) evaluating the efficacy and safety of barbiturates compared with benzodiazepine (BZD) therapy for the treatment of AWS in the acute care setting. Data extracted from the included trials were duration of delirium, number of seizures, length of intensive care unit and hospital stay, cumulated doses of barbiturates and BZDs, and respiratory or cardiac complications. RESULTS Seven studies consisting of 4 prospective controlled and 3 retrospective trials were identified. Results from all the included studies suggest that barbiturates alone or in combination with BZDs are at least as effective as BZDs in the treatment of AWS. Furthermore, barbiturates appear to have acceptable tolerability and safety profiles, which were similar to those of BZDs in patients with AWS. CONCLUSIONS Although the evidence is limited, based on our findings, adding phenobarbital to a BZD-based regimen is a reasonable option, particularly in patients with BZD-refractory AWS.

Droperidol for the Treatment of Acute Migraine Headaches

Objective: To evaluate the safety and efficacy of droperidol for the relief of acute migraine headaches. Data Sources: A MEDLINE search (1946 to August 2014) was performed using the following keywords and associated medical subject headings: droperidol, inapsine, headache, migraine, and migraine disorder. Study Selection and Data Extraction: The search was conducted to identify randomized controlled trials comparing droperidol with placebo or an active control in adult patients with acute migraine headaches that were published in English. Primary end points included acute headache improvement after the intervention. Safety end points included the frequency of extrapyramidal symptoms, somnolence, and cardiac adverse effects. Data Synthesis: In all, 5 manuscripts are included in this review. Patients presenting to the emergency department with acute headache desire rapid pain relief, which was the primary objective in each of the evaluated studies. Droperidol was better than placebo and at least as effective as comparator drugs such as prochlorperazine, meperidine, or olanzapine using droperidol doses of 2.5 to 5 mg, given either intramuscularly (IM) or intravenously (IV). The most commonly reported adverse effects were extrapyramidal symptoms and sedation. Cardiac adverse effects were not reported in any of the studies; however, only 2 articles described using cardiac monitoring. Conclusions: Parenteral droperidol is an effective option for the treatment of acute migraine. The minimum effective dose is 2.5 mg given IM or IV. Clinicians must be aware of the risk for adverse events, select appropriate patients, perform EKG monitoring for patients at risk of QTc prolongation, and institute treatment if necessary.

Practice Patterns and Opinions on Current Clinical Practice Guidelines Regarding the Management of Delirium in the Intensive Care Unit.

Objective: The aim of this study was to determine current delirium practices in the intensive care unit (ICU) setting and evaluate awareness and adoption of the 2013 Pain, Agitation, and Delirium (PAD) guidelines with emphasis on delirium management. Design, Setting, and Participants: A large-scale, multidisciplinary, online survey was administered to physician, pharmacist, nurse, and mid-level practitioner members of the Society of Critical Care Medicine (SCCM) between September 2014 and October 2014. A total of 635 respondents completed the survey. Measurements and Main Results: Nonpharmacologic interventions such as early mobilization were used in most ICUs (83%) for prevention of delirium. A majority of respondents (97%) reported using pharmacologic agents to treat hyperactive delirium. Ninety percent of the respondents answered that they were aware of the 2013 PAD guidelines, and 75% of respondents felt that their delirium practices have been changed as a result of the new guidelines. In addition, logistic regression analysis of this study showed that respondents who use delirium screening tools were twice more likely to be fully aware of key components of the updated guidelines (odds ratio [OR] = 2.07, 95% confidence interval [CI] = 1.20-3.60). Conclusions: Most critical care practitioners are fully aware and knowledgeable of key recommendations in the new guidelines and have changed their delirium practices accordingly.

Key Articles and Guidelines Relative to Intensive Care Unit Pharmacology—2004

Compilations of key articles and guidelines in a particular clinical practice area are useful not only to clinicians who practice in that area, but to all clinicians. We compiled pertinent articles and guidelines pertaining to drug therapy in the intensive care setting from the perspective of actively practicing critical care pharmacists. This document differs from the original 2002 version in that a broader assembly of intensive care practitioners was involved in the compilation.

Pharmacists' role in procedural sedation and analgesia in the emergency department

Although emergency department (ED) pharmacy services have existed for decades in a few hospitals in the United States, only recently has there been a great increase in the number of pharmacists practicing in this setting.[1][1],[2][2] This trend has led to an opportunity for pharmacists to get

New treatment options for acute edema attacks caused by hereditary angioedema

PURPOSE New treatment options for acute edema attacks caused by hereditary angioedema (HAE) are reviewed. SUMMARY HAE is characterized by mutations in the C1 inhibitor gene leading to either a reduced expression of C1 inhibitor in the plasma or expression of a functionally impaired C1 inhibitor. HAE is classified into two major types based on the cause of the C1 inhibitor deficiency. Type I HAE is defined by a reduced expression of C1 inhibitor in the plasma, whereas type II HAE is characterized by the expression of a dysfunctional C1 inhibitor protein. Clinical data were reviewed for C1 inhibitor, ecallantide, and icatibant in the treatment of acute edema attacks caused by HAE. C1 inhibitor leads to a faster onset of edema relief and is effective in decreasing the duration of edema. Dosing strategies include fixed dosing and weight-based dosing. Optimal dosing strategies have not been established, but fixed dosing (500-1000 units) or 20 units/kg has been effective in clinical trials and reports. No comparative trials suggest that one strategy is superior to another; however, the approved labeling for acute treatment is based on weight. Ecallantide is also efficacious for treating acute episodes; however, the available evidence is limited to a single published trial. Icatibant has shown variable effects in two trials with placebo and active controls. CONCLUSION In patients with HAE, most edema episodes only involve the skin and gastrointestinal tract, though airway obstruction caused by laryngeal angioedema is the most common cause of death. I.V. C1 inhibitor should be considered first-line treatment for acute edema attacks because of its fast onset of action and effectiveness, though it is not clear whether fixed or weight-based dosing is preferred. Ecallantide can be considered as a second-line treatment option.

Key Articles and Guidelines for the Emergency Medicine Pharmacist

Compilations of articles important to the pharmacist practicing in the emergency department have not been published. Consistent with other specialty areas of practice, a collection of important literature is valuable for both the new and experienced clinician. A diverse breadth of medical problems are represented that were felt to be the most pertinent issues facing the emergency medicine pharmacist; however, it is not intended to be a complete representation of available literature.

Essential Training, Resources, and Skills of First-Year and Junior Pharmacy Practice Faculty Needed in the Development of an Individual Research Program

Objective: To describe types of current training/support received and elicit opinions on the level of importance of specific skills and resources needed to build confidence in conducting research for early-career pharmacy practice faculty. Methods: A survey instrument regarding available resources, levels of importance of resources, and skills needed to improve research confidence was sent to all new early-career practice faculty members with 3 or less years of experience in academia at 129 US colleges and schools of pharmacy. Results: Few respondents indicated a formal research training existed at their institution. Overall, a majority of respondents identified at least 14 specific developmental areas as moderately to very important in building confidence. Over 75% of respondents rated 15 basic skills as moderately to very important in successfully starting an individual research program. Conclusion: Although different types of research training programs are available, confidence in conducting research in both informal and formal ones is low. Both groups of respondents identified similar important developmental research areas that would increase their confidence and skills in achieving their early research goals.

Considerations for vaccine administration in the emergency department

Routine vaccination has helped prevent many diseases, decreased the number of severe outbreaks, and lowered death rates from vaccine-preventable diseases.[1][1] Despite these successes, vaccination rates are still below the targets set forth in the Healthy People 2020 Initiative.[2][2] Reasons