Key result
Ketamine is as effective as midazolam/fentanyl for procedural sedation but is associated with a significantly higher incidence of vomiting and nausea (OR 5.40).
Why the study?
Ketamine preserves airway tone but has adverse effects, whereas benzodiazepines and opioids can cause respiratory depression during procedural sedation.
Does ketamine improve sedation efficacy and safety compared to midazolam/fentanyl in patients undergoing procedural sedation in the emergency department?
Meta-Analysis (n=3,414)
Does ketamine improve sedation efficacy and safety compared to midazolam/fentanyl in patients undergoing procedural sedation in the emergency department?
Odds Ratio: 5.4 (95% CI 1.22–22.83)
p-value: p=0.03
Ketamine is as effective as midazolam/fentanyl for procedural sedation in the emergency department but is associated with a higher incidence of vomiting and nausea.
Clinicians may prefer midazolam/fentanyl to reduce nausea risk in ED procedural sedation; confirms comparable analgesia but poorer tolerability with ketamine.
Procedural sedation is essential in the ED to conduct painful procedures effectively. Ketamine and benzodiazepines/opioids are commonly used, with ketamine providing adequate analgesia and preserving airway muscle tone. However, ketamine is associated with adverse effects while benzodiazepines/opioids can lead to respiratory depression. This study compares the safety and efficacy of ketamine and midazolam/fentanyl. Two search methods were used to identify studies related to our topic, including a database search and a manual search involving screening reference lists of articles retrieved by the database search. A methodological quality appraisal was conducted on the articles suitable for inclusion using Cochrane's risk of bias tool in the Review Manager software (Review Manager (RevMan) (Computer program). Version 5.4, The Cochrane Collaboration, 2020). Moreover, pooled analysis was performed using the Review manager software. The study analyzed 1366 articles, of which seven were included for analysis. Pooled data showed that ketamine and midazolam/fentanyl had similar effects on pain scores during procedures and sedation depth measured by the University of Michigan sedation scale. However, the Modified Ramsay Sedation Score showed significantly more profound sedation in the ketamine group. The only significant adverse events were vomiting and nausea, which had a higher incidence in the ketamine group. Our data suggest that ketamine is as effective as the midazolam/fentanyl combination for procedural sedation but is associated with higher incidences of adverse events. Therefore, midazolam/fentanyl can be recommended for procedural sedation in the ED. However, it should be provided in the presence of a physician comfortable with airway management due to high incidences of oxygen desaturation.
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Zaki et al. (2023) conducted a meta-analysis in Procedural sedation in the emergency department (n=3,414). Ketamine vs. Midazolam/fentanyl combination was evaluated on Vomiting and nausea (OR 5.40, 95% CI 1.22-22.83, p=0.03). Ketamine is as effective as midazolam/fentanyl for procedural sedation but is associated with a significantly higher incidence of vomiting and nausea (OR 5.40).
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