Dr Nicholas George1, Ms Jodie Mills1, Dr Peter Clark1, Mr Tim Wallace1, Dr Mark Ross1
1CareFlight
Biography:
Nicholas George is a US-based emergency medicine and retrieval physician currently working in Australia. He received his medical degree from the University of Maryland School of Medicine and completed emergency medicine training and a prehospital fellowship at the University of Pittsburgh Medical Center. He subsequently spent a (very cold) year as a HEMS fellow at the University of Wisconsin followed by a (very hot and humid) year with CareFlight NT in Darwin. In his free time, he enjoys hiking with his dog, Tula, and trying to identify the model of helicopter flying overhead.
Abstract:
Background: The prevalence of psychiatric disease is increasing globally, and rural Australia is both disproportionately affected and uniquely lacking resources. Patients needing psychiatric assessment often require aeromedical retrieval, creating safety and operational challenges. The optimal medication regimen for sedating acutely agitated, non-intubated psychiatric patients is a topic of debate. Both ketamine and propofol are common choices, yet data on adverse events, efficacy, and provider satisfaction are lacking.
Methods: We performed a prospective, single-centre, open-label, phase IV randomized clinical trial of ketamine versus propofol for the sedation of acutely agitated psychiatric patients transported by a regional aeromedical retrieval program. Patients were randomized 1:1 to receive a pre-determined propofol or ketamine protocol. The primary outcome was the rate of medication-related adverse events. A multivariable logistic regression was performed, controlling for age, sex, weight, indigenous status, referring location, and diagnosis. We also evaluated medication efficacy and provider satisfaction as secondary outcomes.
Results: Of 1,078 referrals, 177 were enrolled after requiring sedation. 125 patients were included for analysis – 55 received ketamine and 70 propofol. Most patients were young (median age 32 years), indigenous (72.8%), male (64.8%), and suffering from psychosis (81.6%). Ketamine was associated with fewer adverse events (aOR 0.32 [95%CI 0.12-0.94]). Both medications exhibited similar efficacy at reaching the target Richmond Agitation Sedation Scale (RASS) score (OR 0.73 [95%CI 0.50-1.07]). Propofol was significantly preferred by clinicians (mean Likert 4.16 vs. 3.63, p = 0.005).
Conclusion: In our cohort of 125 patients, ketamine appears safer than propofol for sedation of the acutely agitated psychiatric patient with a native airway during aeromedical retrieval. In addition, while there was no significant difference in achieving the goal RASS between the two agents, clinicians reported higher satisfaction scores with propofol.