JACOBI EMERGENCY MEDICINE
Jacobi Emergency Medicine - May 10, 2016 - By Mark Estrellado
"Is a viable alternative sedative/hypnotic agent for procedural sedation in the ED?
Given the regularity of noninvasive and minimally invasive procedures that emergency physicians must perform on a daily basis, proficiency in the art of procedural sedation remains an indispensable component of their already broad repertoire of skills. And while every discussion on the topic of procedural sedation most often begins with the description of the “ideal sedative” as an inexpensive agent that is easily administered, has a rapid and predictable onset and dissipation of effect without prolonged accumulation despite repeated dosing, and is free of adverse side effects and drug interactions, no such agent exists. Instead, the ED physician’s current armamentarium consists of a handful of agents–namely benzodiazepines, opioids, propofol, ketamine, and etomidate–each of which have proven useful when taking into account each individual patient’s comorbidities and when utilized in the appropriate setting. Nevertheless, the issue of respiratory depression remains a constant concern, and this is where dexmedetomidine has garnered increasing attention over the last two decades as a potential addition to the current set of sedation agents...
Overall, while the existing data is still insufficient to make any definitive conclusions at this time, the potential for the dexmedetomidine-ketamine combination to be a viable sedative/hypnotic alternative for procedural sedation is undeniable. From a theoretical standpoint, the two agents have the capacity to complement each other’s limitations. When used in tandem, dexmedetomidine may limit the tachycardia, hypertension, and “emergence phenomenon” commonly associated with ketamine. Conversely, ketamine may counteract the bradycardia and hypotension seen with dexmedetomidine and may help achieve a more rapid time of onset of sedation compared to dexmedetomidine alone. Ultimately, more large randomized-control trials must be conducted with direct comparisons to other commonly used regimens in order to gain a better sense of the impact, if any, that dexmedetomidine-ketamine will have in the practice of procedural sedation in the ED."