Ketamine for excited delirium: airway management often follows


  • Jenny Blair, MD
  • Clinical Essentials
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Takeaway

  • In this meta-analysis, ketamine use resulted in invasive airway management in one-fifth of patients receiving it for excited delirium. 

Why this matters

  • Acutely agitated patients can make for a dangerous emergency department (ED) environment.
  • Attempts to physically restrain such patients can harm them.
  • Benzodiazepines and antipsychotics can cause important adverse effects.

Key results

  • Overall, quality of the studies was fair.
  • All studies reported on airway management.
    • Proportion of patients requiring airway management: 20% (95% CI, 0.0489 -1.6505).
  • 10 studies reported sedation (n=452):
    • Proportion of patients experiencing successful sedation: 85% (95% CI, 0.71-0.93).
  • Heterogeneity among studies was high in both groups of studies.
  • Of 4 deaths, ketamine possibly contributed to 2.

Study design

  • Systematic review and meta-analysis of 13 studies evaluating prehospital and ED use of ketamine for chemical restraint of agitated or delirious patients or those with behavioral disorders (n=674).
  • Outcomes: rate of effective sedation; requirement for airway management (placement of supraglottic airway or endotracheal tube).
  • Funding: None.

Limitations

  • Most studies retrospective; no randomized controlled trials.
  • Most conducted in prehospital setting.
  • Dosing, timing of ketamine varied, as did etiologies of agitation.
  • Some less experienced providers may have mistakenly thought a dissociative state indicated a need for airway management.