C Hendrikse , V Ngah , II Kallon , T D Leong , M McCaul
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Among the included reviews, only the most relevant, up to date, highest quality-assessed reviews and reviews that reported on critical outcomes were considered. Adjunctive ketamine showed a morphine sparing effect (MD −13.19 µmg kg<sup>–1</sup> h<sup>–1</sup>, 95 % CI −22.10 to −4.28, moderate certainty of evidence, 6 RCTs), but no to little effect on midazolam sparing effect (MD 0.75 µmg kg<sup>–1</sup> h<sup>–1</sup>, 95 % CI −1.11 to 2.61, low certainty of evidence, 6 RCTs) or duration of mechanical ventilation in days (MD −0.17 days, 95 % CI −3.03 to 2.69, moderate certainty of evidence, 3 RCTs).</p><p>Adjunctive ketamine therapy may reduce mortality (OR 0.88, 95 % CI 0.54 to 1.43, <em>P</em> = 0.60, very low certainty of evidence, 5 RCTs, <em>n</em> = 3076 patients) resulting in 30 fewer deaths per 1000, ranging from 132 fewer to 87 more, but the evidence is very uncertain. Ketamine results in little to no difference in length of ICU stay (MD 0.04 days, 95 % CI −0.12 to 0.20, high certainty of evidence, 5 RCTs <em>n</em> = 390 patients) or length of hospital stay (MD −0.53 days, 95 % CI −1.36 to 0.30, high certainty of evidence, 5 RCTs, <em>n</em> = 277 patients).</p><p>Monotherapy may have a positive effect on respiratory and haemodynamic outcomes, however the evidence is very uncertain.</p></div><div><h3>Conclusion</h3><p>Adjunctive ketamine for post-intubation analgosedation results in a moderate meaningful net benefit but there is uncertainty for benefit and harms as monotherapy.</p></div>","PeriodicalId":48515,"journal":{"name":"African Journal of Emergency Medicine","volume":"13 4","pages":"Pages 313-321"},"PeriodicalIF":1.4000,"publicationDate":"2023-11-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2211419X23000538/pdfft?md5=51d109993fca655fc6467b51f6994749&pid=1-s2.0-S2211419X23000538-main.pdf","citationCount":"0","resultStr":"{\"title\":\"Ketamine as adjunctive or monotherapy for post-intubation sedation in patients with trauma on mechanical ventilation: A rapid review\",\"authors\":\"C Hendrikse , V Ngah , II Kallon , T D Leong , M McCaul\",\"doi\":\"10.1016/j.afjem.2023.10.002\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<div><h3>Background</h3><p>The effectiveness of ketamine as adjunctive or monotherapy for post-intubation sedation in adults with trauma on mechanical ventilation is unclear.</p></div><div><h3>Methods</h3><p>A rapid review of systematic reviews of randomized controlled trials, then randomized controlled trials or observational studies was conducted searching three electronic databases (PubMed, Embase, Cochrane Library) and one clinical trial registry on June 1, 2022. We used a prespecified protocol following Cochrane rapid review methods.</p></div><div><h3>Results</h3><p>We identified eight systematic reviews of randomized controlled trials and observational studies. Among the included reviews, only the most relevant, up to date, highest quality-assessed reviews and reviews that reported on critical outcomes were considered. Adjunctive ketamine showed a morphine sparing effect (MD −13.19 µmg kg<sup>–1</sup> h<sup>–1</sup>, 95 % CI −22.10 to −4.28, moderate certainty of evidence, 6 RCTs), but no to little effect on midazolam sparing effect (MD 0.75 µmg kg<sup>–1</sup> h<sup>–1</sup>, 95 % CI −1.11 to 2.61, low certainty of evidence, 6 RCTs) or duration of mechanical ventilation in days (MD −0.17 days, 95 % CI −3.03 to 2.69, moderate certainty of evidence, 3 RCTs).</p><p>Adjunctive ketamine therapy may reduce mortality (OR 0.88, 95 % CI 0.54 to 1.43, <em>P</em> = 0.60, very low certainty of evidence, 5 RCTs, <em>n</em> = 3076 patients) resulting in 30 fewer deaths per 1000, ranging from 132 fewer to 87 more, but the evidence is very uncertain. 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引用次数: 0
摘要
背景氯胺酮作为辅助或单药治疗成人外伤机械通气插管后镇静的有效性尚不清楚。方法在2022年6月1日检索PubMed、Embase、Cochrane Library 3个电子数据库和1个临床试验注册库，对随机对照试验的系统综述进行快速回顾，然后对随机对照试验或观察性研究进行检索。我们采用预先指定的方案，遵循Cochrane快速回顾方法。结果我们确定了8项随机对照试验和观察性研究的系统综述。在纳入的审查中，只考虑最相关的、最新的、质量评价最高的审查和报告关键结果的审查。辅助氯胺酮显示吗啡节约效果(MD - 13.19µmg kg-1 h-1, 95% CI - 22.10 ~ - 4.28，证据确定性为中等，6个随机对照试验)，但对咪达唑仑节约效果(MD - 0.75µmg kg-1 h-1, 95% CI - 1.11 ~ 2.61，证据确定性为低，6个随机对照试验)或机械通气持续时间(MD - 0.17天，95% CI - 3.03 ~ 2.69，证据确定性为中等，3个随机对照试验)没有或几乎没有影响。辅助氯胺酮治疗可降低死亡率(OR 0.88, 95% CI 0.54 - 1.43, P = 0.60，证据确定性极低，5项rct, n = 3076例患者)，每1000例死亡减少30例，减少132例至增加87例，但证据非常不确定。氯胺酮对ICU住院时间(MD为0.04天，95% CI为- 0.12 ~ 0.20，证据高确定性，5个rct, n = 390例患者)或住院时间(MD为- 0.53天，95% CI为- 1.36 ~ 0.30，证据高确定性，5个rct, n = 277例患者)影响甚微或无差异。单药治疗可能对呼吸和血流动力学结果有积极影响，但证据非常不确定。结论氯胺酮辅助插管后分析镇静具有中等有意义的净获益，但与单一治疗相比利弊存在不确定性。
Ketamine as adjunctive or monotherapy for post-intubation sedation in patients with trauma on mechanical ventilation: A rapid review
Background
The effectiveness of ketamine as adjunctive or monotherapy for post-intubation sedation in adults with trauma on mechanical ventilation is unclear.
Methods
A rapid review of systematic reviews of randomized controlled trials, then randomized controlled trials or observational studies was conducted searching three electronic databases (PubMed, Embase, Cochrane Library) and one clinical trial registry on June 1, 2022. We used a prespecified protocol following Cochrane rapid review methods.
Results
We identified eight systematic reviews of randomized controlled trials and observational studies. Among the included reviews, only the most relevant, up to date, highest quality-assessed reviews and reviews that reported on critical outcomes were considered. Adjunctive ketamine showed a morphine sparing effect (MD −13.19 µmg kg–1 h–1, 95 % CI −22.10 to −4.28, moderate certainty of evidence, 6 RCTs), but no to little effect on midazolam sparing effect (MD 0.75 µmg kg–1 h–1, 95 % CI −1.11 to 2.61, low certainty of evidence, 6 RCTs) or duration of mechanical ventilation in days (MD −0.17 days, 95 % CI −3.03 to 2.69, moderate certainty of evidence, 3 RCTs).
Adjunctive ketamine therapy may reduce mortality (OR 0.88, 95 % CI 0.54 to 1.43, P = 0.60, very low certainty of evidence, 5 RCTs, n = 3076 patients) resulting in 30 fewer deaths per 1000, ranging from 132 fewer to 87 more, but the evidence is very uncertain. Ketamine results in little to no difference in length of ICU stay (MD 0.04 days, 95 % CI −0.12 to 0.20, high certainty of evidence, 5 RCTs n = 390 patients) or length of hospital stay (MD −0.53 days, 95 % CI −1.36 to 0.30, high certainty of evidence, 5 RCTs, n = 277 patients).
Monotherapy may have a positive effect on respiratory and haemodynamic outcomes, however the evidence is very uncertain.
Conclusion
Adjunctive ketamine for post-intubation analgosedation results in a moderate meaningful net benefit but there is uncertainty for benefit and harms as monotherapy.
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