Alfentanil versus fentanyl for emergency department rapid sequence induction with ketamine: A-FAKT, a pilot randomized trial.

Alfentanil Fentanyl Hypertension Hypotension Ketamine Rapid sequence induction and intubation

Journal

The American journal of emergency medicine
ISSN: 1532-8171
Titre abrégé: Am J Emerg Med
Pays: United States
ID NLM: 8309942

Informations de publication

Date de publication:
18 Jul 2024
Historique:
received: 03 01 2024
revised: 12 06 2024
accepted: 14 07 2024
medline: 26 7 2024
pubmed: 26 7 2024
entrez: 26 7 2024
Statut: aheadofprint

Résumé

Fentanyl is often administered during rapid sequence induction of anesthesia (RSI) in the emergency department (ED) to ameliorate the hypertensive response that may occur. Due to its more rapid onset, the use of alfentanil may be more consistent with both the onset time of the sedative and the commencement of laryngoscopy. As such, we compared the effect of alfentanil and fentanyl on post-induction hemodynamic changes when administered as part of a standardized induction regimen including ketamine and rocuronium in ED RSI. This was a double-blind pilot randomized controlled trial of adult patients requiring RSI in the ED of three urban Australian hospitals. Patients were randomized to receive either alfentanil or fentanyl in addition to ketamine and rocuronium for RSI. Non-invasive blood pressure and heart rate were measured immediately before and at two, four, and six minutes after induction. The primary outcome was the occurrence of at least one post-induction systolic blood pressure outside the pre-specified range of 100-160mmHg (with adjustment for patients with baseline hypertension). Secondary outcomes included hypertension, hypotension, hypoxia, first-pass intubation success, 30-day mortality, and the pattern of hemodynamic changes. A total of 61 patients were included in the final analysis (31 in the alfentanil group and 30 in the fentanyl group). The primary outcome was met in 58% of the alfentanil group and 50% of the fentanyl group (difference 8%, 95% confidence interval: -17% to 33%). The 30-day mortality rate, first-pass success rate, and incidences of hypertension, hypotension, and hypoxia were similar between the groups. There were no significant differences in systolic blood pressure or heart rate between the groups at any of the measured time-points. Alfentanil and fentanyl produced comparable post-induction hemodynamic changes when used as adjuncts to ketamine in ED RSI. Future studies could consider comparing different dosages of these opioids.

Sections du résumé

BACKGROUND BACKGROUND
Fentanyl is often administered during rapid sequence induction of anesthesia (RSI) in the emergency department (ED) to ameliorate the hypertensive response that may occur. Due to its more rapid onset, the use of alfentanil may be more consistent with both the onset time of the sedative and the commencement of laryngoscopy. As such, we compared the effect of alfentanil and fentanyl on post-induction hemodynamic changes when administered as part of a standardized induction regimen including ketamine and rocuronium in ED RSI.
METHODS METHODS
This was a double-blind pilot randomized controlled trial of adult patients requiring RSI in the ED of three urban Australian hospitals. Patients were randomized to receive either alfentanil or fentanyl in addition to ketamine and rocuronium for RSI. Non-invasive blood pressure and heart rate were measured immediately before and at two, four, and six minutes after induction. The primary outcome was the occurrence of at least one post-induction systolic blood pressure outside the pre-specified range of 100-160mmHg (with adjustment for patients with baseline hypertension). Secondary outcomes included hypertension, hypotension, hypoxia, first-pass intubation success, 30-day mortality, and the pattern of hemodynamic changes.
RESULTS RESULTS
A total of 61 patients were included in the final analysis (31 in the alfentanil group and 30 in the fentanyl group). The primary outcome was met in 58% of the alfentanil group and 50% of the fentanyl group (difference 8%, 95% confidence interval: -17% to 33%). The 30-day mortality rate, first-pass success rate, and incidences of hypertension, hypotension, and hypoxia were similar between the groups. There were no significant differences in systolic blood pressure or heart rate between the groups at any of the measured time-points.
CONCLUSION CONCLUSIONS
Alfentanil and fentanyl produced comparable post-induction hemodynamic changes when used as adjuncts to ketamine in ED RSI. Future studies could consider comparing different dosages of these opioids.

Identifiants

DOI: 10.1016/j.ajem.2024.07.027 PMID: 39059038
pubmed: 39059038
pii: S0735-6757(24)00341-3
doi: 10.1016/j.ajem.2024.07.027
pii:
doi:

Types de publication

Journal Article

Langues

eng

Sous-ensembles de citation

IM

Pagination

25-32

Informations de copyright

Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.

Déclaration de conflit d'intérêts

Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Auteurs

Yichen Zhang (Y)

South Western Sydney Clinical School, University of New South Wales, Warwick Farm, New South Wales, Australia. Electronic address: z5256964@unsw.edu.au.

Matthew Miller (M)

Aeromedical Operations, New South Wales Ambulance, Bankstown Aerodrome, New South Wales, Australia; Department of Anaesthesia, St George Hospital, Kogarah, New South Wales, Australia; St George and Sutherland Clinical Schools, University of New South Wales, Kogarah, New South Wales, Australia.

Alexander Buttfield (A)

Emergency Department, Campbelltown Hospital, Campbelltown, New South Wales, Australia; School of Medicine, Western Sydney University, Campbelltown, New South Wales, Australia.

Brian Burns (B)

Aeromedical Operations, New South Wales Ambulance, Bankstown Aerodrome, New South Wales, Australia; Emergency Department, Northern Beaches Hospital, Frenchs Forest, New South Wales, Australia; Faculty of Medicine & Health, University of Sydney, Camperdown, New South Wales, Australia; Macquarie Medical School, Macquarie University, Macquarie Park, New South Wales, Australia.

Kimberley Lawrie (K)

Aeromedical Operations, New South Wales Ambulance, Bankstown Aerodrome, New South Wales, Australia; Emergency Department, Liverpool Hospital, Liverpool, New South Wales, Australia.

James Gaston (J)

Emergency Department, Campbelltown Hospital, Campbelltown, New South Wales, Australia; School of Medicine, Western Sydney University, Campbelltown, New South Wales, Australia.

Ian Ferguson (I)

South Western Sydney Clinical School, University of New South Wales, Warwick Farm, New South Wales, Australia; Aeromedical Operations, New South Wales Ambulance, Bankstown Aerodrome, New South Wales, Australia; Emergency Department, Liverpool Hospital, Liverpool, New South Wales, Australia.

Classifications MeSH