I was a little surprised by the low reported rates of sedation at 5 minutes reported in the paper (22% with ketamine vs 0% with haldol/loraz), because it seemed inconsistent with what I have heard other folks describe in the past re: ketamine's time to effect. On reviewing the paper, I wonder if I've figured out why. The primary outcome was a RAAS of ≤0, which seems like a perfectly reasonable way to measure the end of acute agitation, but doesn't fully capture what we're looking for in the scenario with a violent, combative patient. Basically all of these folks are starting at a RAAS of 4, but we don't necessarily need to get them all the way to 0 to count it as a substantial improvement in their safety and the safety of ED staff. I wonder if the time to clinical effect would be substantially lower if the study had looked at a RAAS of 1 or 2, at which patients might still be somewhat agitated but they would no longer be interfering with their workup and stabilization as much as when they were combative and deemed to need immediate sedation.
Just a thought on why the numbers in the paper may not match what people seem to expect in practice!
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Joe Colucci - September 8, 2020 6:06 PM
I was a little surprised by the low reported rates of sedation at 5 minutes reported in the paper (22% with ketamine vs 0% with haldol/loraz), because it seemed inconsistent with what I have heard other folks describe in the past re: ketamine's time to effect. On reviewing the paper, I wonder if I've figured out why. The primary outcome was a RAAS of ≤0, which seems like a perfectly reasonable way to measure the end of acute agitation, but doesn't fully capture what we're looking for in the scenario with a violent, combative patient. Basically all of these folks are starting at a RAAS of 4, but we don't necessarily need to get them all the way to 0 to count it as a substantial improvement in their safety and the safety of ED staff. I wonder if the time to clinical effect would be substantially lower if the study had looked at a RAAS of 1 or 2, at which patients might still be somewhat agitated but they would no longer be interfering with their workup and stabilization as much as when they were combative and deemed to need immediate sedation.
Just a thought on why the numbers in the paper may not match what people seem to expect in practice!