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1.
Eur J Emerg Med ; 30(4): 244-251, 2023 Aug 01.
Article in English | MEDLINE | ID: mdl-37276055

ABSTRACT

Procedural sedation is routinely performed for procedures in the emergency department (ED). Propofol is a commonly used sedative, frequently combined with an opioid or low-dose ketamine as an analgesic. However, there is still controversy on the optimal combination of agents in current guidelines. The objective of this systematic review is to identify and present studies comparing low-dose ketamine to opioids when combined with propofol for procedural sedation in the ED and to describe the dosing regimen, observed efficacy, and side effects. For this systematic review, following the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines, EMBASE and PubMed databases were searched. Studies comparing propofol with opioids versus propofol with low-dose (es)ketamine in patients undergoing procedural sedation for procedures in the ED were included. Analyses were descriptive because of the high heterogeneity among included studies. The outcomes were dosing regimen, efficacy of analgesia, efficacy of sedation depth, efficacy of recovery and (adverse) events. We included four out of 2309 studies found in the literature search. Overall, the studies had a low risk of bias, but the Grading of Recommendations Assessment, Development, and Evaluation evidence profile was downgraded due to the imprecision and inconsistency of the studies. All studies compared low-dose ketamine with fentanyl. Dosing ranged from 0.3 to 1.0 mg/kg (ketamine), 1.0-1.5 µg/kg (fentanyl) and 0.4-1.0 mg/kg (propofol). The efficacy of analgesia was measured by two studies, one favoring the fentanyl group, and one favoring the ketamine group. The efficacy of sedation depth was measured by one study, with the fentanyl group having a deeper sedation score. Two studies showed shorter recovery time with low-dose ketamine. One study showed a higher incidence of cardio-respiratory clinical events and interventions in the fentanyl group. Two studies showed significant differences of overall sedation events in the fentanyl group. One study did not find any significant differences of the incidence of sedation events. This systematic review did not provide sufficient evidence that the combination of low-dose ketamine and propofol is associated with a shorter recovery time and fewer sedation events compared to the combination of opioids and propofol.


Subject(s)
Ketamine , Propofol , Humans , Propofol/adverse effects , Ketamine/adverse effects , Analgesics, Opioid/therapeutic use , Conscious Sedation/methods , Hypnotics and Sedatives , Pain/drug therapy , Fentanyl , Emergency Service, Hospital
2.
Ned Tijdschr Geneeskd ; 1662023 02 14.
Article in Dutch | MEDLINE | ID: mdl-36861649

ABSTRACT

BACKGROUND: Cognitive disorders lead to an increased risk of misuse of medication, resulting in possible auto-intoxication. CASE DESCRIPTION: We describe the case of a 68-year-old patient, with hypothermia and a coma, with accidental tricyclic antidepressant (TCA) intoxication. What is remarkable about this case is that there were no cardiac or hemodynamic abnormalities, which is to be expected with both hypothermia and TCA-intoxication. CONCLUSION: Intoxication should be considered in patients with hypothermia and a decreased level of consciousness, in addition to primarily neurological or metabolic causes. A good (hetero)anamnesis with attention to pre-existent cognitive functioning is important. Early screening for intoxication in patients with cognitive disorders with a coma and hypothermia is advisable, even in the absence of a typical toxidrome.


Subject(s)
Cognition Disorders , Cognitive Dysfunction , Hypothermia , Humans , Aged , Hypothermia/chemically induced , Hypothermia/diagnosis , Coma/chemically induced , Antidepressive Agents
3.
Ned Tijdschr Geneeskd ; 1662022 02 22.
Article in Dutch | MEDLINE | ID: mdl-35499563

ABSTRACT

BACKGROUND: Cognitive disorders lead to an increased risk of misuse of medication, resulting in possible auto-intoxication. CASE DESCRIPTION: We describe the case of a 68-year-old patient, with hypothermia and a coma, with accidental tricyclic antidepressant (TCA) intoxication. What is remarkable about this case is that there were no cardiac or hemodynamic abnormalities, which is to be expected with both hypothermia and TCA-intoxication. CONCLUSION: Intoxication should be considered in patients with hypothermia and a decreased level of consciousness, in addition to primarily neurological or metabolic causes. A good (hetero)anamnesis with attention to pre-existent cognitive functioning is important. Early screening for intoxication in patients with cognitive disorders with a coma and hypothermia is advisable, even in the absence of a typical toxidrome.


Subject(s)
Coma , Hypothermia , Aged , Antidepressive Agents, Tricyclic , Coma/chemically induced , Humans , Hypothermia/chemically induced , Hypothermia/diagnosis
4.
Ned Tijdschr Geneeskd ; 1632019 10 03.
Article in Dutch | MEDLINE | ID: mdl-31580035

ABSTRACT

A 16-year-old male patient with no known medical history presented at the Emergency Department (ED) with a 2-day history of pain and swelling in his right hemiscrotum. He was diagnosed with non-bacterial epididymitis and discharged home with medical advice. Six days after being diagnosed, the pain and swelling worsened and he was seen by a general practitioner who concluded that the symptoms were attributable to the previously diagnosed epididymitis. No further investigations were performed. Two days later he again presented at the ED, at which time colour Doppler echography revealed a testicular torsion of probably two days old. As after operative detorsion the testis was found to be non-vital, an orchidectomy was performed. This case illustrates that the diagnosis of epididymitis should always be reviewed in patients in whom the scrotum once again becomes painful. Early recognition and treatment of torsio testis gives a better chance of keeping the testis and therefore fertility.


Subject(s)
Epididymitis/diagnosis , Pelvic Pain/diagnosis , Spermatic Cord Torsion/diagnosis , Adolescent , Diagnosis, Differential , Epididymitis/complications , Epididymitis/surgery , Humans , Male , Orchiectomy , Pelvic Pain/etiology , Pelvic Pain/surgery , Scrotum/surgery , Spermatic Cord Torsion/complications , Spermatic Cord Torsion/surgery
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