TUGAS ANALISA JOURNAL DENGAN FORMAT PICOT

MATA KULIAH EVIDENCE BASED PRAKTICE

DOSEN : dr. Muhammad Rodli, Sp AN

Penyusun : I Wayan Suryawidana

NIM 2213063AJ

1. JUDUL JOURNAL : Etomidate versus ketamine for emergency endotracheal intubation: a

randomized clinical trial
Gerald Matchett 1, Irina Gasanova 2, Christina A Riccio 2, Dawood Nasir 2, Mary C
Sunna 3, Brian J Bravenec 2, Omaira Azizad 2, Brian Farrell 3, Abu Minhajuddin 4 5, Jesse W
Stewart 2, Lawrence W Liang 2, Tiffany Sun Moon 2, Pamela E Fox 2, Callie G
Ebeling 2, Miakka N Smith 2, Devin Trousdale 2, Babatunde O Ogunnaike 2; EvK Clinical
Trial Collaborators

Analisa PICOT :

a. P : Population
801 critically ill patients requiring emergency intubation were randomly assigned 1:1
by computer-generated, pre-randomized sealed envelopes
b. I : Intervention
801 critically ill patients requiring emergency intubation were randomly assigned 1:1
by computer-generated, pre-randomized sealed envelopes to receive etomidate
(0.2-0.3 mg/kg, n = 400) or ketamine (1-2 mg/kg, n = 401) for sedation prior to
intubation. The pre-specified primary endpoint of the trial was Day 7 survival.
Secondary endpoints included Day 28 survival.
c. C : Comparation
While the primary outcome of Day 7 survival was greater in patients randomized to
ketamine, there was no significant difference in survival by Day 28.
d. O : Outcome
Of the 801 enrolled patients, 396 were analyzed in the etomidate arm, and 395 in
the ketamine arm. Day 7 survival was significantly lower in the etomidate arm than
in the ketamine arm (77.3% versus 85.1%, difference - 7.8, 95% confidence interval -
13, - 2.4, p = 0.005). Day 28 survival rates for the two groups were not significantly
different (etomidate 64.1%, ketamine 66.8%, difference - 2.7, 95% confidence
interval - 9.3, 3.9, p = 0.294).
e. T : Time
Tahun 2015
2. JUDUL JOURNAL : Perioperative Methadone and Ketamine for Postoperative Pain
Control in Spinal Surgical Patients: A Randomized, Double-blind, Placebo-controlled
Trial
Glenn S Murphy, Michael J Avram, Steven B Greenberg, Jessica Benson, Sara
Bilimoria, Colleen E Maher, Kevin Teister, Joseph W Szokol
Analisa PICOT :

a. P : Population
130 spinal surgery patients were randomized
b. I : Intervention
In this randomized, double-blind, placebo-controlled trial, 130 spinal surgery patients
were randomized to receive either methadone at 0.2 mg/kg (ideal body weight)
intraoperatively and a 5% dextrose in water infusion for 48 h postoperatively
(methadone group) or 0.2 mg/kg methadone intraoperatively and a ketamine
infusion (0.3 mg · kg-1 · h-1 infusion [no bolus] intraoperatively and then 0.1 mg · kg-
1 · h-1 for next 48 h [both medications dosed at ideal body weight];
methadone/ketamine group). Anesthetic care was standardized in all patients.
Intravenous hydromorphone use on postoperative day 1 was the primary outcome.
Pain scores, intravenous and oral opioid requirements, and patient satisfaction with
pain management were assessed for the first 3 postoperative days.
c. C : Comparation
This study therefore tested the primary hypothesis that patients recovering from
spinal fusion surgery who are given ketamine and methadone use less
hydromorphone on the first postoperative day than those give methadone alone.
d. O : Outcome
Median (interquartile range) intravenous hydromorphone requirements were lower in
the methadone/ketamine group on postoperative day 1 (2.0 [1.0 to 3.0] vs. 4.6 [3.2 to
6.6] mg in the methadone group, median difference [95% CI] 2.5 [1.8 to 3.3] mg; P <
0.0001) and postoperative day 2. In addition, fewer oral opioid tablets were needed in
the methadone/ketamine group on postoperative day 1 (2 [0 to 3] vs. 4 [0 to 8] in the
methadone group; P = 0.001) and postoperative day 3. Pain scores at rest, with
coughing, and with movement were lower in the methadone/ketamine group at 23 of
the 24 assessment times. Patient-reported satisfaction scores were high in both study
groups.
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3. JUDUL JOURNAL : Perioperative Methadone and Ketamine for Postoperative Pain
Control in Spinal Surgical Patients: A Randomized, Double-blind, Placebo-controlled
Trial
Glenn S Murphy, Michael J Avram, Steven B Greenberg, Jessica Benson, Sara
Bilimoria, Colleen E Maher, Kevin Teister, Joseph W Szokol
Analisa PICOT :
a. P : Population
130 spinal surgery patients were randomized
b. I : Intervention
In this randomized, double-blind, placebo-controlled trial, 130 spinal surgery patients
were randomized to receive either methadone at 0.2 mg/kg (ideal body weight)
intraoperatively and a 5% dextrose in water infusion for 48 h postoperatively
(methadone group) or 0.2 mg/kg methadone intraoperatively and a ketamine
infusion (0.3 mg · kg-1 · h-1 infusion [no bolus] intraoperatively and then 0.1 mg · kg-
1 · h-1 for next 48 h [both medications dosed at ideal body weight];
methadone/ketamine group). Anesthetic care was standardized in all patients.
Intravenous hydromorphone use on postoperative day 1 was the primary outcome.
Pain scores, intravenous and oral opioid requirements, and patient satisfaction with
pain management were assessed for the first 3 postoperative days.
c. C : Comparation
 in the methadone/ketamine group on postoperative day 1 (2.0 [1.0 to 3.0] vs. 4.6 [3.2
to 6.6] mg in the methadone group, median difference [95% CI] 2.5 [1.8 to 3.3] mg; P
< 0.0001) and postoperative day 2. In addition, fewer oral opioid tablets were needed
in the methadone/ketamine group on postoperative day 1 (2 [0 to 3] vs. 4 [0 to 8] in
the methadone group; P = 0.001)
d. O : Outcome
Median (interquartile range) intravenous hydromorphone requirements were lower in
the methadone/ketamine group on postoperative day 1 (2.0 [1.0 to 3.0] vs. 4.6 [3.2 to
6.6] mg in the methadone group, median difference [95% CI] 2.5 [1.8 to 3.3] mg; P <
0.0001) and postoperative day 2. In addition, fewer oral opioid tablets were needed in
the methadone/ketamine group on postoperative day 1 (2 [0 to 3] vs. 4 [0 to 8] in the
methadone group; P = 0.001) and postoperative day 3. Pain scores at rest, with
coughing, and with movement were lower in the methadone/ketamine group at 23 of
the 24 assessment times. Patient-reported satisfaction scores were high in both study
groups.
e. T : Time
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4. Judul Journal : Perioperative intravenous ketamine for acute postoperative pain in
adults
Elina Cv Brinck 1, Elina Tiippana, Michael Heesen, Rae Frances Bell, Sebastian
Straube, R Andrew Moore, Vesa Kontinen
Analisa PICOT :

a. P : Population

with 8341 participants. Ketamine was given to 4588 participants and 3753 participants
served as controls.

b. I : Intervention

We included 130 studies with 8341 participants. Ketamine was given to 4588 participants
and 3753 participants served as controls. Types of surgery included ear, nose or throat
surgery, wisdom tooth extraction, thoracotomy, lumbar fusion surgery, microdiscectomy,
hip joint replacement surgery, knee joint replacement surgery, anterior cruciate ligament
repair, knee arthroscopy, mastectomy, haemorrhoidectomy, abdominal surgery, radical
prostatectomy, thyroid surgery, elective caesarean section, and laparoscopic surgery.

c. C : Comparation

Racemic ketamine bolus doses were predominantly 0.25 mg to 1 mg, and infusions 2 to 5
µg/kg/minute; 10 studies used only S-ketamine and one only R-ketamine. Risk of bias was
generally low or uncertain, except for study size; most had fewer than 50 participants per
treatment arm, resulting in high heterogeneity, as expected, for most analyses. We did not
stratify the main analysis by type of surgery or any other factor, such as dose or timing of
ketamine administration, and used a non-stratified analysis.Perioperative intravenous
ketamine reduced postoperative opioid consumption over 24 hours by 8 mg morphine
equivalents (95% CI 6 to 9; 19% from 42 mg consumed by participants given placebo,
moderate-quality evidence; 65 studies, 4004 participants). Over 48 hours, opioid
consumption was 13 mg lower (95% CI 10 to 15; 19% from 67 mg with placebo, moderate-
quality evidence; 37 studies, 2449 participants).Perioperative intravenous ketamine reduced
pain at rest at 24 hours by 5/100 mm on a visual analogue scale (95% CI 4 to 7; 19% lower
from 26/100 mm with placebo, high-quality evidence; 82 studies, 5004 participants), and at
48 hours by 5/100 mm (95% CI 3 to 7; 22% lower from 23/100 mm, high-quality evidence; 49
studies, 2962 participants). Pain during movement was reduced at 24 hours (6/100 mm, 14%
lower from 42/100 mm, moderate-quality evidence; 29 studies, 1806 participants), and 48
hours (6/100 mm, 16% lower from 37 mm, low-quality evidence; 23 studies, 1353
participants).Results for primary outcomes were consistent when analysed by pain at rest or
on movement, operation type, and timing of administration, or sensitivity to study size and
pain intensity. No analysis by dose was possible. There was no difference when nitrous oxide
was used. We downgraded the quality of the evidence once if numbers of participants were
large but small-study effects were present, or twice if numbers were small and small-study
effects likely but testing not possible.Ketamine increased the time for the first postoperative
analgesic request by 54 minutes (95% CI 37 to 71 minutes), from a mean of 39 minutes with
placebo (moderate-quality evidence; 31 studies, 1678 participants). Ketamine reduced the
area of postoperative hyperalgesia by 7 cm² (95% CI -11.9 to -2.2), compared with placebo
(very low-quality evidence; 7 studies 333 participants). We downgraded the quality of
 evidence because of small-study effects or because the number of participants was below
400.CNS adverse events occurred in 52 studies, while 53 studies reported of absence of CNS
adverse events. Overall, 187/3614 (5%) participants receiving ketamine and 122/2924 (4%)
receiving control treatment experienced an adverse event (RR 1.2, 95% CI 0.95 to 1.4; high-
quality evidence; 105 studies, 6538 participants). Ketamine reduced postoperative nausea
and vomiting from 27% with placebo to 23% with ketamine (RR 0.88, 95% CI 0.81 to 0.96;
the number needed to treat to prevent one episode of postoperative nausea and vomiting
with perioperative intravenous ketamine administration was 24 (95% CI 16 to 54; high-
quality evidence; 95 studies, 5965 participants).

d. O : Outcome

Perioperative intravenous ketamine probably reduces postoperative analgesic consumption

and pain intensity. Results were consistent in different operation types or timing of ketamine
administration, with larger and smaller studies, and by higher and lower pain intensity. CNS
adverse events were little different with ketamine or control. Perioperative intravenous
ketamine probably reduces postoperative nausea and vomiting by a small extent, of
arguable clinical relevance.

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5. Judul Journal : Low-dose Ketamine For Acute Pain Control in the Emergency
Department: A Systematic Review and Meta-analysis
Nathan Balzer 1, Shelley L McLeod 2 3, Chris Walsh 4, Keerat Grewal 1 3
Analisa PICOT :
a. P : Population
Eight RCTs were included with a total of 1,191 patients
b. I : Intervention
There was no significant difference in reported mean pain scores between LDK and
morphine within the first 60 minutes after analgesia administration and a slight
difference in pain scores favoring morphine at 60 to 120 minutes. The need for rescue
medication was also similar between groups (RR = 1.26, 95% CI = 0.50 to 3.16), as
was the proportion of patients who experienced nausea (RR = 0.97, 95% CI = 0.63 to
1.49) and hypoxia (RR = 0.38, 95% CI = 0.10 to 1.41). All outcomes were judged to
have low certainty in the evidence.
c. C : Comparation
LDK and morphine within the first 60 minutes after analgesia administration and a
slight difference in pain scores favoring morphine at 60 to 120 minutes.
d. O : Outcome
Eight RCTs were included with a total of 1,191 patients (LDK = 598, morphine = 593).
There was no significant difference in reported mean pain scores between LDK and
morphine within the first 60 minutes after analgesia administration and a slight
difference in pain scores favoring morphine at 60 to 120 minutes. The need for rescue
medication was also similar between groups (RR = 1.26, 95% CI = 0.50 to 3.16), as
was the proportion of patients who experienced nausea (RR = 0.97, 95% CI = 0.63 to
1.49) and hypoxia (RR = 0.38, 95% CI = 0.10 to 1.41). All outcomes were judged to
have low certainty in the evidence.
e. T : Time
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