Rapid tranquilization of the agitated patient in the emergency department: A systematic review and network meta-analysis.
Name:
Publisher version
View Source
Access full-text PDFOpen Access
View Source
Check access options
Check access options
Average rating
Cast your vote
You can rate an item by clicking the amount of stars they wish to award to this item.
When enough users have cast their vote on this item, the average rating will also be shown.
Star rating
Your vote was cast
Thank you for your feedback
Thank you for your feedback
Journal title
The American journal of emergency medicineDate Published
2021-11-14Publication Volume
51Publication Begin page
363Publication End page
373
Metadata
Show full item recordAbstract
Safe and effective tranquilization of the acutely agitated patient is challenging, and head-to-head comparisons of medications are limited. We aimed to identify the most optimal agent(s) for rapid tranquilization of the severely agitated patient in the emergency department (ED).The protocol for systematic review was registered (PROSPERO; CRD42020212534). We searched MEDLINE, Embase, PsycINFO, and Cochrane Database/CENTRAL from inception to June 2, 2021. We limited studies to randomized controlled trials that enrolled adult ED patients with severe agitation and compared drugs for rapid tranquilization. Predetermined outcomes were: 1) Adequate sedation within 30 min (effectiveness), 2) Immediate, serious adverse event - cardiac arrest, ventricular tachydysrhythmia, endotracheal intubation, laryngospasm, hypoxemia, hypotension (safety), and 3) Time to adequate sedation (effect onset). We extracted data according to PRISMA-NMA and appraised trials using Cochrane RoB 2 tool. We performed Bayesian network meta-analysis (NMA) using a Markov Chain Monte Carlo method with random-effects model and vague prior distribution to calculate odds ratios with 95% credible intervals for dichotomous outcomes and frequentist NMA to calculate mean differences with 95% confidence intervals for continuous outcomes. We assessed confidence in results using CINeMA. We used surface under the cumulative ranking (SUCRA) curves to rank agent(s) for each outcome.
Eleven studies provided data for effectiveness (1142 patients) and safety (1147 patients). Data was insufficient for effect onset. The NMA found that ketamine (SUCRA = 93.0%) is most likely to have superior effectiveness; droperidol-midazolam (SUCRA = 78.8%) is most likely to be safest. There are concerns with study quality and imprecision. Quality of the point estimates varied for effectiveness but mostly rated "very low" for safety.
Available evidence suggests that ketamine and droperidol have intermediate effectiveness for rapid tranquilization of the severely agitated patient in the ED. There is insufficient evidence to definitively determine which agent(s) may be safest or fastest-acting. Further, direct-comparison study of ketamine and droperidol is recommended.
Citation
deSouza IS, Thode HC Jr, Shrestha P, Allen R, Koos J, Singer AJ. Rapid tranquilization of the agitated patient in the emergency department: A systematic review and network meta-analysis. Am J Emerg Med. 2022 Jan;51:363-373. doi: 10.1016/j.ajem.2021.11.011. Epub 2021 Nov 14. Erratum in: Am J Emerg Med. 2021 Nov 29;: PMID: 34823192.DOI
10.1016/j.ajem.2021.11.011ae974a485f413a2113503eed53cd6c53
10.1016/j.ajem.2021.11.011
Scopus Count
Collections
The following license files are associated with this item:
- Creative Commons
Except where otherwise noted, this item's license is described as Copyright © 2021 Elsevier Inc. All rights reserved.
Related articles
- Safety and Effectiveness of Antidysrhythmic Drugs for Pharmacologic Cardioversion of Recent-Onset Atrial Fibrillation: a Systematic Review and Bayesian Network Meta-analysis.
- Authors: deSouza IS, Shrestha P, Allen R, Koos J, Thode H Jr
- Issue date: 2024 Feb 7
- Ketamine for Rapid Sedation of Agitated Patients in the Prehospital and Emergency Department Settings: A Systematic Review and Proportional Meta-Analysis.
- Authors: Mankowitz SL, Regenberg P, Kaldan J, Cole JB
- Issue date: 2018 Nov
- Safety and efficacy of pharmacologic agents used for rapid tranquilization of emergency department patients with acute agitation or excited delirium.
- Authors: Kim HK, Leonard JB, Corwell BN, Connors NJ
- Issue date: 2021 Feb
- Effectiveness of pharmacological treatments for severe agitation in real-world emergency settings: protocol of individual-participant-data network meta-analysis.
- Authors: Siafis S, Wu H, Nomura N, Schneider-Thoma J, Bighelli I, Lorenz C, Dib JE, Tharyan P, Calver LA, Isbister GK, Chan EWY, Knott JC, Yap CYL, Mantovani C, Martel ML, Barbic D, Honer WG, Hansen WP, Huf G, Alexander J, Raveendran NS, Coutinho ESF, Priller J, Adams CE, Salanti G, Leucht S
- Issue date: 2024 Aug 2
- Retrospective evaluation of ketamine versus droperidol on time to restraint removal in agitated emergency department patients.
- Authors: Krenz JR, Medeiros K, Lupez K
- Issue date: 2023 Jul