Bangladesh J Pharmacol. 2018; 2018. |
| Readers' | Comment | |
Dear Editor-in-Chief,
I read an interesting article published in the Bangladesh J Pharmacol (Abdolrazaghnejad and Banaie, 2017). The authors had compared the efficacy of ketamine vs fentanyl, with midazolam being the common drug for both groups of patients undergoing emergency orthopedic procedures. I have some points to raise regarding that study.
The authors did not mention about the route of administration as well as the dose of the drugs [midazolam, ketamine, and fentanyl] used in their study. However, they have written a sentence in the discussion section, which is as follows: “Although it is advised to determine the exact dose of opiates and sedatives, the weight-adjusted dose was used in this study, and individual differences were neglected for standardization.” I think that this sentence does not convey the meaning what the authors would have probably intended. Instead of using the word “titrated”, they had used “weight-adjusted” erroneously.
The main point of contention for me is that they have assessed the pain with visual analogue scale [VAS] during the procedure, which I feel would be technically not feasible in patients who were administered ketamine. This is because, even a very low dose of ketamine would make the patient “incoherent”, thereby rendering him unsuitable for judging the VAS clearly, particularly during the procedure.
Another study by Jamal et al (2011), which is similar to this study, had assessed the pain score in the adult population, only before and after the procedure i. e. when the patient is conscious and alert. However, the authors (Abdolrazaghnejad and Banaie, 2017) had incorrectly mentioned in the “Discussion” section that Jamal et al. had found no significant difference of “pain score during reduction” between the two groups. Jamal et al (2011) had studied intravenous ketamine [0.5 mg/kg titrated every 3 min with maximum of 2 mg/kg] vs midazolam [0.05 mg/kg titrated every 3 min with maximum of 7.5 mg] + fentanyl [1 mcg/kg once], and found both equally effective with more side effects in the ketamine group.
Cevik et al (2013) also mentioned that they had analyzed “Pain score during reduction” which again would not have been possible in my opinion. However, they had mentioned the doses of each drug clearly whereas, authors of this study (Abdolrazaghnejad and Banaie, 2017) had blindly written the same sentence [The higher incidence of recovery agitation may be explained with the use of higher doses of ketamine and lower doses of midazolam in midazolam-ketamine combination used in this study] of that article (Cevik et al.2013). This sentence is not at all applicable for this study (Abdolrazaghnejad and Banaie, 2017), as the authors had not mentioned the doses anywhere in that article.
There is no mentioning about “Placebo’ group anywhere in that article, although it is stated as “Prospective, double blind, placebo-controlled study “in the abstract (Abdolrazaghnejad and Banaie, 2017).
There are at many places, the same sentences of that article (Cevik et al. 2013) are written in this article (Abdolrazaghnejad and Banaie, 2017), which I have noted during closer look on these two articles.
Godambe et al (2003) have used VAS for “parental perception of pain” only, in the pediatric population. Kennedy et al (1998) had also used observational distress scores, and parental-report as tools to assess the efficacy of ketamine vs fentanyl sedation, in pediatric patients.
Another point that is intriguing for me is that the “discharge time” is significantly lesser in the midazolam-ketamine group than in the midazolam-fentanyl group despite the fact that the adverse effects [nausea, vomiting, vertigo, recovery agitation etc.] being significantly higher in the former group (Abdolrazaghnejad and Banaie, 2017).
M. S. Raghuraman
Department of Anesthesiology, Shri Sathya Sai Medical College and Research Institute, Sri Balaji Vidyapeeth University, Chennai, India. drraghuram70@gmail.com ; ORCID iD
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