ISR: Ket/Celo SANS autre chose

Does the addition of fentanyl to ketamine improve haemodynamics, intubating conditions or mortality in emergency department intubation: A systematic review

Ferguson I et Al. Acta Anaesthesiol Scand. 2019 May;63(5):587-593

 

Background

Ketamine is an induction agent frequently used for general anaesthesia in emergency medicine. Generally regarded as haemodynamically stable, it can cause hypertension and tachycardia and may cause or worsen shock. The effects of ketamine may be improved by the addition of fentanyl to the induction regime. We conducted a systematic review to identify evidence with regard to the effect of adding fentanyl to an induction regime of ketamine and a paralysing agent on post‐induction haemodynamics, intubating conditions and mortality.

Methods

We conducted a search of the Cochrane library, EMBASE, MEDLINE, PROQUEST, OpenGrey and clinical trial registries. Prominent authors were contacted in order to identify additional literature pertinent to the research question. Studies were included if they pertained to intubation of adult patients in the prehospital or emergency department environments and included an induction regime of ketamine and a paralysing agent, with at least one outcome measure of haemodynamics, intubating conditions or mortality. Search results were reviewed by two investigators independently, adjudicated by a third investigator where disagreement occurred.

Results

One observational study was identified that partially answered the research question.

 

".......There was a difference in the primary outcome of post‐intuba‐
tion hypotension of 17% in the fentanyl group vs 6% in the non‐
fentanyl group (a relative risk of 2.81, 95% confidence interval
2.00‐3.92)..........Intubation was achieved on first pass more frequently in the fen‐
tanyl rather than the non‐fentanyl group, with a relative risk of need‐
ing more than one attempt at intubation of 0.74 (95% CI 0.60‐0.93)
in the fentanyl group...."

 

Discussion

Only one observational study was identified that partially answered the research question. This paper demonstrated that the use of fentanyl as a pretreatment increases the incidence of post‐induction hypotension, a phenomenon that was seen with propofol, midazolam and ketamine. The difference in hypotension between these agents was not statistically significant. The impact of this on patient‐orientated outcomes is unclear.