Ketamine versus Ketamine / magnesium Sulfate for Procedural Sedation and Analgesia in the Emergency Department: A Randomized Clinical Trial

Document Type : Original Article

Authors

1 Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran

2 Department of Anesthesiology, Isfahan University of Medical Sciences, Isfahan, Iran

Abstract

Background: The present study was designed to evaluate the effectiveness of magnesium sulfate (MgSO4) in procedural sedation and analgesia (PSA) when combined with ketamine in patients with fractures in emergency departments and required short and painful emergency procedures. Materials and Methods: In this study, 100 patients with fractures and dislocations who were presented to the emergency departments and required PSA for short and painful emergency procedures were randomly allocated to groups of ketamine plus MgSO4or ketamine alone. Train of four (TOF) stimulation pattern was assessed using nerve stimulator machine and compared between groups. Results: The mean age of studied patients was 46.9 ± 9.3 years old. 48% were male and 52% were female. No significant differences were noted between groups in demographic variables. The status of TOF, 2 min after the injection of ketamine (1.5 mg/kg), in both groups was similar. After the injection of the second dose of ketamine (1 mg/kg) the status of TOF in four patients in ketamine plus MgSO(0.45 mg/kg) group changed, it was three quarters but in ketamine group, the status of TOF in all patients was four quarters. The difference between groups was not statistically significant (P = 0.12). Conclusion: The findings revealed that for muscle relaxation during medical procedures in the emergency department, ketamine in combination with MgSO4with this dose was not effective for muscle relaxation during procedures.

Keywords

1.
Yatim FM. Intravenous ketamine is as effective as midazolam/fentanyl for procedural sedation and analgesia in the emergency department. Med J Malaysia 2011;66:231.  Back to cited text no. 1
[PUBMED]    
2.
Majidinejad S, Esmailian M, Emadi M. Comparison of intravenous ketamine with morphine in pain relief of long bones fractures: A Double Blind Randomized Clinical Trial. Emerg (Tehran) 2014;2:77-80.  Back to cited text no. 2
[PUBMED]    
3.
Hosseini M, Karami Z, Janzadenh A, Jameie SB, Haji Mashhadi Z, Yousefifard M, et al. The effect of intrathecal administration of muscimol on modulation of neuropathic pain symptoms resulting from spinal cord injury; an experimental study. Emerg (Tehran) 2014;2:151-7.  Back to cited text no. 3
[PUBMED]    
4.
Azizkhani R, Kanani S, Sharifi A, Golshani K, Masoumi B, Ahmadi O. Oral chloral hydrate compare with rectal thiopental in pediatric procedural sedation and analgesia; a randomized clinical trial. Emerg (Tehran) 2014;2:85-9.  Back to cited text no. 4
[PUBMED]    
5.
Messenger DW, Sivilotti ML. Procedural sedation and analgesia. Evidence-Based Emergency Medicine. Oxford, UK: Wiley-Blackwell; 2009. p. 551-60.  Back to cited text no. 5
    
6.
Krauss B, Green SM. Procedural sedation and analgesia in children. Lancet 2006;367:766-80.  Back to cited text no. 6
[PUBMED]    
7.
Sahyoun C, Krauss B. Clinical implications of pharmacokinetics and pharmacodynamics of procedural sedation agents in children. Curr Opin Pediatr 2012;24:225-32.  Back to cited text no. 7
[PUBMED]    
8.
McGlone RG, Howes MC, Joshi M. The Lancaster experience of 2.0 to 2.5 mg/kg intramuscular ketamine for paediatric sedation: 501 cases and analysis. Emerg Med J 2004;21:290-5.  Back to cited text no. 8
    
9.
Brown L, Green SM, Sherwin TS, Besh B, Denmark TK, Moynihan JA, Khan A. Ketamine with and without atropine: What's the risk of excessive salivation?. Acad Emerg Med 2003;10:482-3.  Back to cited text no. 9
    
10.
Kashani P, Yousefian S, Amini A, Heidari K, Younesian S, Hatamabadi HR. The effect of intravenous ketamine in suicidal ideation of emergency department patients. Emerg (Tehran) 2014;2:36-9.  Back to cited text no. 10
[PUBMED]    
11.
Herroeder S, Schönherr ME, De Hert SG, Hollmann MW. Magnesium – Essentials for anesthesiologists. Anesthesiology 2011;114:971-93.  Back to cited text no. 11
    
12.
Rondón LJ, Privat AM, Daulhac L, Davin N, Mazur A, Fialip J, et al. Magnesium attenuates chronic hypersensitivity and spinal cord NMDA receptor phosphorylation in a rat model of diabetic neuropathic pain. J Physiol 2010;588:4205-15.  Back to cited text no. 12
    
13.
Srebro DP, Vuckovic S, Vujovic KS, Prostran M. Anti-hyperalgesic effect of systemic magnesium sulfate in carrageenan-induced inflammatory pain in rats: Influence of the nitric oxide pathway. Magnes Res 2014;27:77-85.  Back to cited text no. 13
    
14.
Borazan H, Kececioglu A, Okesli S, Otelcioglu S. Oral magnesium lozenge reduces postoperative sore throat: A randomized, prospective, placebo-controlled study. Anesthesiology 2012;117:512-8.  Back to cited text no. 14
[PUBMED]    
15.
Yousef AA, Al-deeb AE. A double-blinded randomised controlled study of the value of sequential intravenous and oral magnesium therapy in patients with chronic low back pain with a neuropathic component. Anaesthesia 2013;68:260-6.  Back to cited text no. 15
[PUBMED]    
16.
Soave PM, Conti G, Costa R, Arcangeli A. Magnesium and anaesthesia. Curr Drug Targets 2009;10:734-43.  Back to cited text no. 16
[PUBMED]    
17.
Nechifor M. Magnesium involvement in pain. Magnes Res 2011;24:220-2.  Back to cited text no. 17
[PUBMED]    
18.
Morrison AP, Hunter JM, Halpern SH, Banerjee A. Effect of intrathecal magnesium in the presence or absence of local anaesthetic with and without lipophilic opioids: A systematic review and meta-analysis. Br J Anaesth 2013;110:702-12.  Back to cited text no. 18
[PUBMED]    
19.
Irifune M, Shimizu T, Nomoto M, Fukuda T. Ketamine-induced anesthesia involves the N-methyl-D-aspartate receptor-channel complex in mice. Brain Res 1992;596:1-9.  Back to cited text no. 19
[PUBMED]    
20.
DeRossi R, Pompermeyer CT, Silva-Neto AB, Barros AL, Jardim PH, Frazílio FO. Lumbosacral epidural magnesium prolongs ketamine analgesia in conscious sheep. Acta Cir Bras 2012;27:137-43.  Back to cited text no. 20
    
21.
Jahangiri L, Kesmati M, Najafzadeh H. Evaluation of analgesic and anti-inflammatory effect of nanoparticles of magnesium oxide in mice with and without ketamine. Eur Rev Med Pharmacol Sci 2013;17:2706-10.  Back to cited text no. 21
[PUBMED]    
22.
Liu HT, Hollmann MW, Liu WH, Hoenemann CW, Durieux ME. Modulation of NMDA receptor function by ketamine and magnesium: Part I. Anesth Analg 2001;92:1173-81.  Back to cited text no. 22
[PUBMED]    
23.
Savic Vujovic KR, Vuckovic S, Srebro D, Medic B, Stojanovic R, Vucetic C, et al. Asynergistic interaction between magnesium sulphate and ketamine on the inhibition of acute nociception in rats. Eur Rev Med Pharmacol Sci 2015;19:2503-9.  Back to cited text no. 23
[PUBMED]    
24.
Clinical policy for procedural sedation and analgesia in the emergency department. American College of Emergency Physicians. Ann Emerg Med 1998;31:663-77.  Back to cited text no. 24
[PUBMED]    
25.
McQueen A, Wright RO, Kido MM, Kaye E, Krauss B. Procedural sedation and analgesia outcomes in children after discharge from the emergency department: Ketamine versus fentanyl/midazolam. Ann Emerg Med 2009;54:191-97.e1-4.  Back to cited text no. 25
    
26.
Melendez E, Bachur R. Serious adverse events during procedural sedation with ketamine. Pediatr Emerg Care 2009;25:325-8.  Back to cited text no. 26
[PUBMED]    
27.
Green SM, Roback MG, Krauss B, Brown L, McGlone RG, Agrawal D, et al. Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: An individual-patient data meta-analysis of 8,282 children. Ann Emerg Med 2009;54:158-68.e1-4.  Back to cited text no. 27
    
28.
Green SM, Roback MG, Krauss B, Brown L, McGlone RG, Agrawal D,et al. Predictors of emesis and recovery agitation with emergency department ketamine sedation: An individual-patient data meta-analysis of 8,282 children. Ann Emerg Med 2009;54:171-80.  Back to cited text no. 28
[PUBMED]    
29.
Miner JR, Gray R, Delavari P, Patel S, Patel R, Plummer D. Alfentanil for procedural sedation in the emergency department. Ann Emerg Med 2011;57:117-21.  Back to cited text no. 29
[PUBMED]    
30.
Dunn MJ, Mitchell R, Souza CD, Drummond G. Evaluation of propofol and remifentanil for intravenous sedation for reducing shoulder dislocations in the emergency department. Emerg Med J 2006;23:57-8.  Back to cited text no. 30
[PUBMED]    
31.
Newton A, Fitton L. Intravenous ketamine for adult procedural sedation in the emergency department: A prospective cohort study. Emerg Med J 2008;25:498-501.  Back to cited text no. 31
[PUBMED]    
32.
Jagoda AS, Campbell M, Karas S, Mariani PJ, Shepherd SM, Cantrill SV, et al. Clinical policy for procedural sedation and analgesia in the emergency department. Ann Emerg Med 1998;31:663-77.  Back to cited text no. 32
    
33.
O'Flaherty JE, Lin CX. Does ketamine or magnesium affect posttonsillectomy pain in children? Paediatr Anaesth 2003;13:413-21.  Back to cited text no. 33
    
34.
Oye I, Paulsen O, Maurset A. Effects of ketamine on sensory perception: Evidence for a role of N-methyl-D-aspartate receptors. J Pharmacol Exp Ther 1992;260:1209-13.  Back to cited text no. 34
[PUBMED]    
35.
Orser BA, Pennefather PS, MacDonald JF. Multiple mechanisms of ketamine blockade of N-methyl-D-aspartate receptors. Anesthesiology 1997;86:903-17.  Back to cited text no. 35
[PUBMED]    
36.
Hirota K, Lambert DG. Ketamine: New uses for an old drug? Br J Anaesth 2011;107:123-6.  Back to cited text no. 36