Hemodynamic Effects of Ketamine Versus Etomidate for Prehospital Rapid Sequence Intubation.

OBJECTIVE: Rapid sequence intubation (RSI) is often required in managing critically ill patients in the prehospital setting. Although etomidate is a commonly used induction agent for RSI, ketamine has gained new interest in prehospital management with reported neutral hemodynamic effects. Limited data exist to support ketamine as an alternative to etomidate, particularly in the prehospital setting. The purpose of this study was to evaluate hemodynamic changes after the administration of ketamine versus etomidate in prehospital RSI. METHODS: This retrospective study evaluated adult patients undergoing prehospital RSI over 13 months within a regional emergency transport medicine service. Hypotension was defined as a 20% decrease in systolic blood pressure (SBP) within 15 minutes of receiving ketamine or etomidate. Hemodynamic data were collected 15 minutes before and 15 minutes after administration or until additional sedative medications were given. Data were analyzed using SPSS software (Version 21; IBM Corp, Armonk, NY), with P < .05 considered significant. RESULTS: One hundred thirteen patients met the inclusion criteria (ketamine, n = 33; etomidate, n = 80), with the primary reasons for intubation being respiratory failure and trauma. There was no difference between the incidence of patients who experienced a 20% decrease in SBP (16% etomidate vs. 18% ketamine, P = .79). There were no significant differences in SBP pre- to postadministration between ketamine and etomidate. CONCLUSION: No hemodynamic differences occurred between patients who received ketamine versus etomidate for prehospital RSI. Neither drug was associated with an increased need for additional sedatives, and neither drug was associated with an increased first-pass intubation success rate. Larger, prospective, powered studies are required to identify patients who may benefit from either ketamine or etomidate.

Effects of feeding level on efficiency of high- and low-residual feed intake beef steers.

Comparing heat production after ad libitum (ADLIB) and restricted (RESTRICT) feeding periods may offer insight into how residual feed intake (RFI) groups change their energy requirements based on previous feeding levels. In this study, the authors sought to explain the efficiency changes of high- and low-RFI steers after feed restriction. To determine RFI classification, 56 Angus-cross steers with initial body weight (BW) of 350 ± 28.7 kg were individually housed, offered ad libitum access to a total mixed ration, and daily intakes were recorded for 56 d. RFI was defined as the residual of the regression of dry matter intake on mid-test BW0.75 and average daily gain. High- and low-RFI groups were defined as >0.5 SD above or below the mean of zero, respectively. Fourteen steers from each high and low groups (n = 28) were selected for the subsequent 56-d RESTRICT period. During the RESTRICT period, intake was restricted to 75% of previous ad libitum intake on a BW0.75 basis, and all other conditions remained constant. After the RESTRICT period, both RFI groups had decreased maintenance energy requirements. However, the low-RFI group decreased maintenance energy requirements by 32% on a BW0.75 basis, more (P < 0.05) than the high-RFI group decreased maintenance requirements (18%). Thus, the low-RFI steers remained more efficient after a period of feed restriction. We conclude that feed restriction decreases maintenance energy requirement in both high- and low-RFI groups that are restricted to the same degree.

Computed tomographic modeling before and after treatment for posttraumatic empyema: early decortication is superior to catheter drainage.

BACKGROUND: Posttraumatic empyema is relatively unusual. There are little data comparing the results of various interventions, and no data that have documented the restoration of lung volumes. METHODS: We compared patients with posttraumatic empyema who were treated with catheter drainage or decortication. Computed tomographic scans of the chest were obtained before and after treatment, and computed tomographic modeling was used to determine the change in lung volumes after each intervention. RESULTS: From 2006 to 2010 there were 478 patients admitted after sustaining chest trauma and 25 (5%) developed an empyema. The definitive treatment was decortication in 15 patients (60%) and chest tube or catheter drainage in 10 (40%). Four patients (16%) initially treated with chest tubes later required decortication. The overall complication rate was 33% for decortication and 100% for catheters. There was no significant difference in days of mechanical ventilation (catheter-median 0, SD±13 days; decortication-median 10, SD±12 days; p=0.6), total length of stay (catheter-median 15, SD±36 days; decortication-median 27, SD±17 days; p=0.9), and intensive care unit days (catheter-median 6, SD±19 days; decortication-median 15, SD±17 days; p=0.5). After chest tube drainage, the lung volume increased on average by 751 cubic centimeters (range, 99 to 1,982 cc). After decortication, the lung volume increased on average by 1,519 cc (range, 616 to 2,916, p=0.02). CONCLUSIONS: Decortication for posttraumatic empyema results in higher postoperative lung volumes than catheter drainage and has a lower complication rate. Decortication is more effective in restoring full pulmonary capacity in the treatment of posttraumatic empyema.