Comparing the Safety and Effectiveness of Ketamine Versus Benzodiazepine/Opioid Combination for Procedural Sedation in Emergency Medicine: A Comprehensive Review and Meta-Analysis

Abstract

Procedural sedation is essential in the ED to conduct painful procedures effectively. Ketamine and benzodiazepines/opioids are commonly used, with ketamine providing adequate analgesia and preserving airway muscle tone. However, ketamine is associated with adverse effects while benzodiazepines/opioids can lead to respiratory depression. This study compares the safety and efficacy of ketamine and midazolam/fentanyl. Two search methods were used to identify studies related to our topic, including a database search and a manual search involving screening reference lists of articles retrieved by the database search. A methodological quality appraisal was conducted on the articles suitable for inclusion using Cochrane's risk of bias tool in the Review Manager software (Review Manager (RevMan) (Computer program). Version 5.4, The Cochrane Collaboration, 2020). Moreover, pooled analysis was performed using the Review manager software. The study analyzed 1366 articles, of which seven were included for analysis. Pooled data showed that ketamine and midazolam/fentanyl had similar effects on pain scores during procedures and sedation depth measured by the University of Michigan sedation scale. However, the Modified Ramsay Sedation Score showed significantly more profound sedation in the ketamine group. The only significant adverse events were vomiting and nausea, which had a higher incidence in the ketamine group. Our data suggest that ketamine is as effective as the midazolam/fentanyl combination for procedural sedation but is associated with higher incidences of adverse events. Therefore, midazolam/fentanyl can be recommended for procedural sedation in the ED. However, it should be provided in the presence of a physician comfortable with airway management due to high incidences of oxygen desaturation.

Keywords: benzodiazepines; emergency department; opioids; procedural sedation and analgesia; psa; systematic review and meta-analysis.

Figure 1. Risk of bias graph

Figure 2. Risk of bias summary

Jamal et al., 2011 [12], Roback et al., 2005 [13], McQueen et al., 2009 [14], Urbain et al., 2000 [15], Lightdale et al., 2011 [16], Krick et al., 2013 [17], Margaret et al., 2021 [18]

Figure 3. PRISMA flow diagram of the literature search results

PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Figure 4. A Forest plot comparing pain scores during procedures between ketamine and midazolam/fentanyl

Jamal et al., 2011 [12], Krick et al., 2013 [17], Margaret et al., 2021 [18]

Figure 5. A Forest plot comparing sedation depth between ketamine and midazolam/fentanyl

Krick et al., 2013 [17], Margaret et al., 2021 [18], Jamal et al., 2011 [12]

Figure 6. A Forest plot comparing adverse events between ketamine and midazolam/fentanyl

Jamal et al., 2011 [12], Roback et al., 2005 [13], McQueen et al., 2009 [14], Urbain et al., 2000 [15], Lightdale et al., 2011 [16], Krick et al., 2013 [17], Margaret et al., 2021 [18]