Psychiatric Outcomes of Patients With Severe Agitation Following Administration of Prehospital Ketamine
Background Ketamine is an emerging drug used in the management of undifferentiated, severe agitation in the prehospital setting. However, prior work has indicated that ketamine may exacerbate psychotic symptoms in patients with schizophrenia. The objective of this study was to describe psychiatric o...
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| Veröffentlicht in: | Academic emergency medicine 2019-08, Vol.26 (8), p.889-896 |
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| description | Background
Ketamine is an emerging drug used in the management of undifferentiated, severe agitation in the prehospital setting. However, prior work has indicated that ketamine may exacerbate psychotic symptoms in patients with schizophrenia. The objective of this study was to describe psychiatric outcomes in patients who receive prehospital ketamine for severe agitation.
Methods
This is a retrospective cohort study, conducted at two tertiary academic medical centers, utilizing chart review of patients requiring prehospital sedation for severe agitation from January 1, 2014, to June 30, 2016. Patients received either intramuscular (IM) versus intravenous (IV) ketamine or IM versus IV benzodiazepine. The primary outcome was psychiatric inpatient admission with secondary outcomes including ED psychiatric evaluation and nonpsychiatric inpatient admission. Generalized estimating equations and Fisher's exact tests were used to compare cohorts.
Results
During the study period, 141 patient encounters met inclusion with 59 (42%) receiving prehospital ketamine. There were no statistically significant differences between the ketamine and benzodiazepine cohorts for psychiatric inpatient admission (6.8% vs. 2.4%, difference = 4.3%, 95% CI = –2% to 12%, p = 0.23) or ED psychiatric evaluation (8.6% vs. 15%, difference = –6.8%, 95% CI = –18% to 5%, p = 0.23). Patients with schizophrenia who received ketamine did not require psychiatric inpatient admission (17% vs. 10%, difference = 6.7%, 95% CI = –46% to 79%, p = 0.63) or ED psychiatric evaluation (17% vs. 50%, difference = –33%, 95% CI = –100% to 33%, p = 0.55) significantly more than those who received benzodiazepines, although the subgroup was small (n = 16). While there was no significant difference in the nonpsychiatric admission rate between the ketamine and benzodiazepine cohorts (35% vs. 51%, p = 0.082), nonpsychiatric admissions in the benzodiazepine cohort were largely driven by intubation (63% vs. 3.8%, difference = 59%, 95% CI = 38% to 79%, p |
| doi_str_mv | 10.1111/acem.13725 |
| format | Article |
| fullrecord | <record><control><sourceid>proquest_cross</sourceid><recordid>TN_cdi_proquest_miscellaneous_2193171283</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><sourcerecordid>2271798290</sourcerecordid><originalsourceid>FETCH-LOGICAL-c3935-e1e47de915463026453cd3c5c936b3ef93cc13eb4ba421520c985da3bfaa09f93</originalsourceid><addsrcrecordid>eNp9kM1q3DAUhUVpaX7aTR4gCLIpAaeSrmWPlsOQn5KUBNrSpZDl6xkF25pIcsO8fTV1mkUX1UZC57uHy0fICWcXPJ_PxuJwwaEW8g055FJCIWou3uY3q1RRyQoOyFGMj4wxWav6PTkAtqihUuyQrB_izm6cScFZej8l6weM1Hf0wSSHY4r0p0sb-g1_YUC6XLuU__1Ir3zf-2c3rumyHdzoYgpzsB8NuPFxm9Ge3mIyOccP5F1n-ogfX-5j8uPq8vvqpri7v_6yWt4VFhTIAjmWdYuKy7ICJqpSgm3BSqugagA7BdZywKZsTCm4FMyqhWwNNJ0xTOX4mHyae7fBP00Ykx5ctNj3ZkQ_RS24Ap7tLCCjZ_-gj34KY95OiyywVguhWKbOZ8oGH2PATm-DG0zYac70Xr_e69d_9Gf49KVyagZsX9G_vjPAZ-DZ9bj7T5Veri6_zqW_AWQakBg</addsrcrecordid><sourcetype>Aggregation Database</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>2271798290</pqid></control><display><type>article</type><title>Psychiatric Outcomes of Patients With Severe Agitation Following Administration of Prehospital Ketamine</title><source>MEDLINE</source><source>Wiley Online Library Journals Frontfile Complete</source><source>Elektronische Zeitschriftenbibliothek - Frei zugängliche E-Journals</source><source>Wiley Free Content</source><creator>Lebin, Jacob A. ; Akhavan, Arvin R. ; Hippe, Daniel S. ; Gittinger, Melissa H. ; Pasic, Jagoda ; McCoy, Andrew M. ; Vrablik, Marie C. ; Miner, James D.</creator><contributor>Miner, James D.</contributor><creatorcontrib>Lebin, Jacob A. ; Akhavan, Arvin R. ; Hippe, Daniel S. ; Gittinger, Melissa H. ; Pasic, Jagoda ; McCoy, Andrew M. ; Vrablik, Marie C. ; Miner, James D. ; Miner, James D.</creatorcontrib><description>Background
Ketamine is an emerging drug used in the management of undifferentiated, severe agitation in the prehospital setting. However, prior work has indicated that ketamine may exacerbate psychotic symptoms in patients with schizophrenia. The objective of this study was to describe psychiatric outcomes in patients who receive prehospital ketamine for severe agitation.
Methods
This is a retrospective cohort study, conducted at two tertiary academic medical centers, utilizing chart review of patients requiring prehospital sedation for severe agitation from January 1, 2014, to June 30, 2016. Patients received either intramuscular (IM) versus intravenous (IV) ketamine or IM versus IV benzodiazepine. The primary outcome was psychiatric inpatient admission with secondary outcomes including ED psychiatric evaluation and nonpsychiatric inpatient admission. Generalized estimating equations and Fisher's exact tests were used to compare cohorts.
Results
During the study period, 141 patient encounters met inclusion with 59 (42%) receiving prehospital ketamine. There were no statistically significant differences between the ketamine and benzodiazepine cohorts for psychiatric inpatient admission (6.8% vs. 2.4%, difference = 4.3%, 95% CI = –2% to 12%, p = 0.23) or ED psychiatric evaluation (8.6% vs. 15%, difference = –6.8%, 95% CI = –18% to 5%, p = 0.23). Patients with schizophrenia who received ketamine did not require psychiatric inpatient admission (17% vs. 10%, difference = 6.7%, 95% CI = –46% to 79%, p = 0.63) or ED psychiatric evaluation (17% vs. 50%, difference = –33%, 95% CI = –100% to 33%, p = 0.55) significantly more than those who received benzodiazepines, although the subgroup was small (n = 16). While there was no significant difference in the nonpsychiatric admission rate between the ketamine and benzodiazepine cohorts (35% vs. 51%, p = 0.082), nonpsychiatric admissions in the benzodiazepine cohort were largely driven by intubation (63% vs. 3.8%, difference = 59%, 95% CI = 38% to 79%, p < 0.001).
Conclusions
Administration of prehospital ketamine for severe agitation was not associated with an increase in the rate of psychiatric evaluation in the emergency department or psychiatric inpatient admission when compared with benzodiazepine treatment, regardless of the patient's psychiatric history.</description><identifier>ISSN: 1069-6563</identifier><identifier>EISSN: 1553-2712</identifier><identifier>DOI: 10.1111/acem.13725</identifier><identifier>PMID: 30873690</identifier><language>eng</language><publisher>United States: Wiley Subscription Services, Inc</publisher><subject>Administration, Intravenous ; Adult ; Ambulance services ; Anesthesia ; Anesthetics, Dissociative - administration & dosage ; Benzodiazepines - administration & dosage ; Clinical outcomes ; Emergency medical care ; Emergency Medical Services - methods ; Emergency Medical Services - statistics & numerical data ; Female ; Hospitalization - statistics & numerical data ; Humans ; Ketamine ; Ketamine - administration & dosage ; Male ; Patients ; Psychomotor Agitation - drug therapy ; Retrospective Studies ; Schizophrenia ; Treatment Outcome</subject><ispartof>Academic emergency medicine, 2019-08, Vol.26 (8), p.889-896</ispartof><rights>2019 by the Society for Academic Emergency Medicine</rights><rights>2019 by the Society for Academic Emergency Medicine.</rights><rights>Copyright © 2019 Society for Academic Emergency Medicine</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c3935-e1e47de915463026453cd3c5c936b3ef93cc13eb4ba421520c985da3bfaa09f93</citedby><cites>FETCH-LOGICAL-c3935-e1e47de915463026453cd3c5c936b3ef93cc13eb4ba421520c985da3bfaa09f93</cites><orcidid>0000-0003-1553-3363</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://onlinelibrary.wiley.com/doi/pdf/10.1111%2Facem.13725$$EPDF$$P50$$Gwiley$$H</linktopdf><linktohtml>$$Uhttps://onlinelibrary.wiley.com/doi/full/10.1111%2Facem.13725$$EHTML$$P50$$Gwiley$$H</linktohtml><link.rule.ids>314,777,781,1412,1428,27905,27906,45555,45556,46390,46814</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/30873690$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><contributor>Miner, James D.</contributor><creatorcontrib>Lebin, Jacob A.</creatorcontrib><creatorcontrib>Akhavan, Arvin R.</creatorcontrib><creatorcontrib>Hippe, Daniel S.</creatorcontrib><creatorcontrib>Gittinger, Melissa H.</creatorcontrib><creatorcontrib>Pasic, Jagoda</creatorcontrib><creatorcontrib>McCoy, Andrew M.</creatorcontrib><creatorcontrib>Vrablik, Marie C.</creatorcontrib><creatorcontrib>Miner, James D.</creatorcontrib><title>Psychiatric Outcomes of Patients With Severe Agitation Following Administration of Prehospital Ketamine</title><title>Academic emergency medicine</title><addtitle>Acad Emerg Med</addtitle><description>Background
Ketamine is an emerging drug used in the management of undifferentiated, severe agitation in the prehospital setting. However, prior work has indicated that ketamine may exacerbate psychotic symptoms in patients with schizophrenia. The objective of this study was to describe psychiatric outcomes in patients who receive prehospital ketamine for severe agitation.
Methods
This is a retrospective cohort study, conducted at two tertiary academic medical centers, utilizing chart review of patients requiring prehospital sedation for severe agitation from January 1, 2014, to June 30, 2016. Patients received either intramuscular (IM) versus intravenous (IV) ketamine or IM versus IV benzodiazepine. The primary outcome was psychiatric inpatient admission with secondary outcomes including ED psychiatric evaluation and nonpsychiatric inpatient admission. Generalized estimating equations and Fisher's exact tests were used to compare cohorts.
Results
During the study period, 141 patient encounters met inclusion with 59 (42%) receiving prehospital ketamine. There were no statistically significant differences between the ketamine and benzodiazepine cohorts for psychiatric inpatient admission (6.8% vs. 2.4%, difference = 4.3%, 95% CI = –2% to 12%, p = 0.23) or ED psychiatric evaluation (8.6% vs. 15%, difference = –6.8%, 95% CI = –18% to 5%, p = 0.23). Patients with schizophrenia who received ketamine did not require psychiatric inpatient admission (17% vs. 10%, difference = 6.7%, 95% CI = –46% to 79%, p = 0.63) or ED psychiatric evaluation (17% vs. 50%, difference = –33%, 95% CI = –100% to 33%, p = 0.55) significantly more than those who received benzodiazepines, although the subgroup was small (n = 16). While there was no significant difference in the nonpsychiatric admission rate between the ketamine and benzodiazepine cohorts (35% vs. 51%, p = 0.082), nonpsychiatric admissions in the benzodiazepine cohort were largely driven by intubation (63% vs. 3.8%, difference = 59%, 95% CI = 38% to 79%, p < 0.001).
Conclusions
Administration of prehospital ketamine for severe agitation was not associated with an increase in the rate of psychiatric evaluation in the emergency department or psychiatric inpatient admission when compared with benzodiazepine treatment, regardless of the patient's psychiatric history.</description><subject>Administration, Intravenous</subject><subject>Adult</subject><subject>Ambulance services</subject><subject>Anesthesia</subject><subject>Anesthetics, Dissociative - administration & dosage</subject><subject>Benzodiazepines - administration & dosage</subject><subject>Clinical outcomes</subject><subject>Emergency medical care</subject><subject>Emergency Medical Services - methods</subject><subject>Emergency Medical Services - statistics & numerical data</subject><subject>Female</subject><subject>Hospitalization - statistics & numerical data</subject><subject>Humans</subject><subject>Ketamine</subject><subject>Ketamine - administration & dosage</subject><subject>Male</subject><subject>Patients</subject><subject>Psychomotor Agitation - drug therapy</subject><subject>Retrospective Studies</subject><subject>Schizophrenia</subject><subject>Treatment Outcome</subject><issn>1069-6563</issn><issn>1553-2712</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2019</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNp9kM1q3DAUhUVpaX7aTR4gCLIpAaeSrmWPlsOQn5KUBNrSpZDl6xkF25pIcsO8fTV1mkUX1UZC57uHy0fICWcXPJ_PxuJwwaEW8g055FJCIWou3uY3q1RRyQoOyFGMj4wxWav6PTkAtqihUuyQrB_izm6cScFZej8l6weM1Hf0wSSHY4r0p0sb-g1_YUC6XLuU__1Ir3zf-2c3rumyHdzoYgpzsB8NuPFxm9Ge3mIyOccP5F1n-ogfX-5j8uPq8vvqpri7v_6yWt4VFhTIAjmWdYuKy7ICJqpSgm3BSqugagA7BdZywKZsTCm4FMyqhWwNNJ0xTOX4mHyae7fBP00Ykx5ctNj3ZkQ_RS24Ap7tLCCjZ_-gj34KY95OiyywVguhWKbOZ8oGH2PATm-DG0zYac70Xr_e69d_9Gf49KVyagZsX9G_vjPAZ-DZ9bj7T5Veri6_zqW_AWQakBg</recordid><startdate>201908</startdate><enddate>201908</enddate><creator>Lebin, Jacob A.</creator><creator>Akhavan, Arvin R.</creator><creator>Hippe, Daniel S.</creator><creator>Gittinger, Melissa H.</creator><creator>Pasic, Jagoda</creator><creator>McCoy, Andrew M.</creator><creator>Vrablik, Marie C.</creator><creator>Miner, James D.</creator><general>Wiley Subscription Services, Inc</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>K9.</scope><scope>NAPCQ</scope><scope>U9A</scope><scope>7X8</scope><orcidid>https://orcid.org/0000-0003-1553-3363</orcidid></search><sort><creationdate>201908</creationdate><title>Psychiatric Outcomes of Patients With Severe Agitation Following Administration of Prehospital Ketamine</title><author>Lebin, Jacob A. ; Akhavan, Arvin R. ; Hippe, Daniel S. ; Gittinger, Melissa H. ; Pasic, Jagoda ; McCoy, Andrew M. ; Vrablik, Marie C. ; Miner, James D.</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c3935-e1e47de915463026453cd3c5c936b3ef93cc13eb4ba421520c985da3bfaa09f93</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2019</creationdate><topic>Administration, Intravenous</topic><topic>Adult</topic><topic>Ambulance services</topic><topic>Anesthesia</topic><topic>Anesthetics, Dissociative - administration & dosage</topic><topic>Benzodiazepines - administration & dosage</topic><topic>Clinical outcomes</topic><topic>Emergency medical care</topic><topic>Emergency Medical Services - methods</topic><topic>Emergency Medical Services - statistics & numerical data</topic><topic>Female</topic><topic>Hospitalization - statistics & numerical data</topic><topic>Humans</topic><topic>Ketamine</topic><topic>Ketamine - administration & dosage</topic><topic>Male</topic><topic>Patients</topic><topic>Psychomotor Agitation - drug therapy</topic><topic>Retrospective Studies</topic><topic>Schizophrenia</topic><topic>Treatment Outcome</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Lebin, Jacob A.</creatorcontrib><creatorcontrib>Akhavan, Arvin R.</creatorcontrib><creatorcontrib>Hippe, Daniel S.</creatorcontrib><creatorcontrib>Gittinger, Melissa H.</creatorcontrib><creatorcontrib>Pasic, Jagoda</creatorcontrib><creatorcontrib>McCoy, Andrew M.</creatorcontrib><creatorcontrib>Vrablik, Marie C.</creatorcontrib><creatorcontrib>Miner, James D.</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Nursing & Allied Health Premium</collection><collection>MEDLINE - Academic</collection><jtitle>Academic emergency medicine</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Lebin, Jacob A.</au><au>Akhavan, Arvin R.</au><au>Hippe, Daniel S.</au><au>Gittinger, Melissa H.</au><au>Pasic, Jagoda</au><au>McCoy, Andrew M.</au><au>Vrablik, Marie C.</au><au>Miner, James D.</au><au>Miner, James D.</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Psychiatric Outcomes of Patients With Severe Agitation Following Administration of Prehospital Ketamine</atitle><jtitle>Academic emergency medicine</jtitle><addtitle>Acad Emerg Med</addtitle><date>2019-08</date><risdate>2019</risdate><volume>26</volume><issue>8</issue><spage>889</spage><epage>896</epage><pages>889-896</pages><issn>1069-6563</issn><eissn>1553-2712</eissn><abstract>Background
Ketamine is an emerging drug used in the management of undifferentiated, severe agitation in the prehospital setting. However, prior work has indicated that ketamine may exacerbate psychotic symptoms in patients with schizophrenia. The objective of this study was to describe psychiatric outcomes in patients who receive prehospital ketamine for severe agitation.
Methods
This is a retrospective cohort study, conducted at two tertiary academic medical centers, utilizing chart review of patients requiring prehospital sedation for severe agitation from January 1, 2014, to June 30, 2016. Patients received either intramuscular (IM) versus intravenous (IV) ketamine or IM versus IV benzodiazepine. The primary outcome was psychiatric inpatient admission with secondary outcomes including ED psychiatric evaluation and nonpsychiatric inpatient admission. Generalized estimating equations and Fisher's exact tests were used to compare cohorts.
Results
During the study period, 141 patient encounters met inclusion with 59 (42%) receiving prehospital ketamine. There were no statistically significant differences between the ketamine and benzodiazepine cohorts for psychiatric inpatient admission (6.8% vs. 2.4%, difference = 4.3%, 95% CI = –2% to 12%, p = 0.23) or ED psychiatric evaluation (8.6% vs. 15%, difference = –6.8%, 95% CI = –18% to 5%, p = 0.23). Patients with schizophrenia who received ketamine did not require psychiatric inpatient admission (17% vs. 10%, difference = 6.7%, 95% CI = –46% to 79%, p = 0.63) or ED psychiatric evaluation (17% vs. 50%, difference = –33%, 95% CI = –100% to 33%, p = 0.55) significantly more than those who received benzodiazepines, although the subgroup was small (n = 16). While there was no significant difference in the nonpsychiatric admission rate between the ketamine and benzodiazepine cohorts (35% vs. 51%, p = 0.082), nonpsychiatric admissions in the benzodiazepine cohort were largely driven by intubation (63% vs. 3.8%, difference = 59%, 95% CI = 38% to 79%, p < 0.001).
Conclusions
Administration of prehospital ketamine for severe agitation was not associated with an increase in the rate of psychiatric evaluation in the emergency department or psychiatric inpatient admission when compared with benzodiazepine treatment, regardless of the patient's psychiatric history.</abstract><cop>United States</cop><pub>Wiley Subscription Services, Inc</pub><pmid>30873690</pmid><doi>10.1111/acem.13725</doi><tpages>8</tpages><orcidid>https://orcid.org/0000-0003-1553-3363</orcidid><oa>free_for_read</oa></addata></record> |
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| subjects | Administration, Intravenous Adult Ambulance services Anesthesia Anesthetics, Dissociative - administration & dosage Benzodiazepines - administration & dosage Clinical outcomes Emergency medical care Emergency Medical Services - methods Emergency Medical Services - statistics & numerical data Female Hospitalization - statistics & numerical data Humans Ketamine Ketamine - administration & dosage Male Patients Psychomotor Agitation - drug therapy Retrospective Studies Schizophrenia Treatment Outcome |
| title | Psychiatric Outcomes of Patients With Severe Agitation Following Administration of Prehospital Ketamine |
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