Baruch Krauss

Publications of Baruch Krauss

• Who owns deep sedation?

  Authors: Steven M Green, Baruch Krauss

  Annals of emergency medicine. 03/2011; 57(5):470-4.

• Videos in clinical medicine. Intraosseous catheter placement in children.

  Authors: Joshua Nagler, Baruch Krauss

  The New England journal of medicine. 02/2011; 364(8):e14.

• Ketofol for procedural sedation? Pro and con.

  Authors: Steven M Green, Gary Andolfatto, Baruch Krauss

  Annals of emergency medicine. 01/2011; 57(5):444-8.

• Clinical practice guideline for emergency department ketamine dissociative sedation: 2011 update.

  Authors: Steven M Green, Mark G Roback, Robert M Kennedy, Baruch Krauss

  Annals of emergency medicine. 01/2011; 57(5):449-61.

  We update an evidence-based clinical practice guideline for the administration of the dissociative agent ketamine for emergency department procedural sedation and analgesia. Substantial new researchWe update an evidence-based clinical practice guideline for the administration of the dissociative agent ketamine for emergency department procedural sedation and analgesia. Substantial new research warrants revision of the widely disseminated 2004 guideline, particularly with respect to contraindications, age recommendations, potential neurotoxicity, and the role of coadministered anticholinergics and benzodiazepines. We critically discuss indications, contraindications, personnel requirements, monitoring, dosing, coadministered medications, recovery issues, and future research questions for ketamine dissociative sedation.

• The taming of ketamine-40 years later.

  Authors: Steven M Green, Baruch Krauss

  Annals of emergency medicine. 11/2010; 57(2):115-6.

• Laryngospasm during emergency department ketamine sedation: a case-control study.

  Authors: Steven M Green, Mark G Roback, Baruch Krauss

  Pediatric emergency care. 10/2010; 26(11):798-802.

  The objective of this study was to assess predictors of emergency department (ED) ketamine-associated laryngospasm using case-control techniques. We performed a matched case-control analysis of aThe objective of this study was to assess predictors of emergency department (ED) ketamine-associated laryngospasm using case-control techniques. We performed a matched case-control analysis of a sample of 8282 ED ketamine sedations (including 22 occurrences of laryngospasm) assembled from 32 prior published series. We sequentially studied the association of each of 7 clinical variables with laryngospasm by assigning 4 controls to each case while matching for the remaining 6 variables. We then used univariate statistics and conditional logistic regression to analyze the matched sets. We found no statistical association of age, dose, oropharyngeal procedure, underlying physical illness, route, or coadministered anticholinergics with laryngospasm. Coadministered benzodiazepines showed a borderline association in the multivariate but not univariate analysis that was considered anomalous. This case-control analysis of the largest available sample of ED ketamine-associated laryngospasm did not demonstrate evidence of association with age, dose, or other clinical factors. Such laryngospasm seems to be idiosyncratic, and accordingly, clinicians administering ketamine must be prepared for its rapid identification and management. Given no evidence that they decrease the risk of laryngospasm, coadministered anticholinergics seem unnecessary.

• Anticholinergics and ketamine sedation in children: a secondary analysis of atropine versus glycopyrrolate.

  Authors: Steven M Green, Mark G Roback, Baruch Krauss

  Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 02/2010; 17(2):157-62.

  Adjunctive anticholinergics are commonly administered during emergency department (ED) ketamine sedation in children under the presumption that drying oral secretions should decrease the likelihoodAdjunctive anticholinergics are commonly administered during emergency department (ED) ketamine sedation in children under the presumption that drying oral secretions should decrease the likelihood of airway and respiratory adverse events. Pharmacologic considerations suggest that glycopyrrolate might exhibit a superior adverse effect profile to atropine. The authors contrasted the adverse events noted with use of each of these anticholinergics in a large multicenter observational database of ketamine sedations. This was a secondary analysis of an observational database of 8,282 ED ketamine sedations assembled from 32 prior series. The authors compared the relative incidence of six adverse events (airway and respiratory adverse events, laryngospasm, apnea, emesis, recovery agitation, and clinically important recovery agitation) between children who received coadministered atropine, glycopyrrolate, or no anticholinergic. Multivariable analysis using the specific anticholinergic as a covariate was performed, while controlling for other known predictors. Atropine was associated with less vomiting (5.3%) than either glycopyrrolate (10.7%) or no anticholinergic (11.4%) in both unadjusted and multivariable analyses. Glycopyrrolate was associated with significantly more airway and respiratory adverse events (6.4%) than either atropine (3.3%) or no anticholinergic (3.0%) and similarly more clinically important recovery agitation (2.1% vs. 1.2 and 1.3%). There were, however, no differences noted in odds of laryngospasm and apnea. This secondary analysis unexpectedly found that the coadministered anticholinergic atropine exhibited a superior adverse event profile to glycopyrrolate during ketamine sedation. Any such advantage requires confirmation in a separate trial; however, our data cast doubt on the traditional premise that glycopyrrolate might be superior. Further, neither anticholinergic showed efficacy in decreasing airway and respiratory adverse events.

• Predictors of Emesis and Recovery Agitation With Emergency Department Ketamine Sedation: An Individual-Patient Data Meta-Analysis of 8,282 Children.

  Authors: Steven M Green, Mark G Roback, Baruch Krauss, Lance Brown, Ray G McGlone, Dewesh Agrawal, Michele McKee, Markus Weiss, Raymond D Pitetti, Mark A Hostetler, Joe E Wathen, Greg Treston, Barbara M Garcia Pena, Andreas C Gerber, Joseph D Losek

  Annals of emergency medicine. 06/2009;

  STUDY OBJECTIVE: Ketamine is widely used in emergency departments (EDs) to facilitate painful procedures; however, existing descriptors of predictors of emesis and recovery agitation are derived fromSTUDY OBJECTIVE: Ketamine is widely used in emergency departments (EDs) to facilitate painful procedures; however, existing descriptors of predictors of emesis and recovery agitation are derived from relatively small studies. METHODS: We pooled individual-patient data from 32 ED studies and performed multiple logistic regression to determine which clinical variables would predict emesis and recovery agitation. The first phase of this study similarly identified predictors of airway and respiratory adverse events. RESULTS: In 8,282 pediatric ketamine sedations, the overall incidence of emesis, any recovery agitation, and clinically important recovery agitation was 8.4%, 7.6%, and 1.4%, respectively. The most important independent predictors of emesis are unusually high intravenous (IV) dose (initial dose of >/=2.5 mg/kg or a total dose of >/=5.0 mg/kg), intramuscular (IM) route, and increasing age (peak at 12 years). Similar risk factors for any recovery agitation are low IM dose (<3.0 mg/kg) and unusually high IV dose, with no such important risk factors for clinically important recovery agitation. CONCLUSION: Early adolescence is the peak age for ketamine-associated emesis, and its rate is higher with IM administration and with unusually high IV doses. Recovery agitation is not age related to a clinically important degree. When we interpreted it in conjunction with the separate airway adverse event phase of this analysis, we found no apparent clinically important benefit or harm from coadministered anticholinergics and benzodiazepines and no increase in adverse events with either oropharyngeal procedures or the presence of substantial underlying illness. These and other results herein challenge many widely held views about ED ketamine administration.

• Procedural Sedation and Analgesia Outcomes in Children After Discharge From the Emergency Department: Ketamine Versus Fentanyl/Midazolam.

  Authors: Alisa McQueen, Robert O Wright, Maya M Kido, Erica Kaye, Baruch Krauss

  Annals of emergency medicine. 06/2009;

  STUDY OBJECTIVE: Although the safety and efficacy of procedural sedation and analgesia in the pediatric emergency department (ED) has been established, the prevalence of adverse events afterSTUDY OBJECTIVE: Although the safety and efficacy of procedural sedation and analgesia in the pediatric emergency department (ED) has been established, the prevalence of adverse events after discharge has not been well studied. We compare the postdischarge incidence of adverse behavioral events and vomiting and hypothesize that ketamine would be associated with increased adverse behaviors. METHODS: We conducted a prospective observational study of postdischarge behavioral changes and vomiting after sedation with ketamine, ketamine/midazolam, or fentanyl/midazolam. Families were administered a Post Hospital Behavior Questionnaire (PHBQ), with higher scores indicating more adverse behaviors (anxiety, sleep disturbances). We used linear and logistic regression to model PHBQ scores and logistic regression to model vomiting risk adjusting for age, sex, procedure, length of procedure, and parental presence as potential confounders. RESULTS: Seven hundred eighty-six children were enrolled and 554 children (61% boys; mean age 7.5+/-4.5 years) were contacted. The prevalence of postdischarge vomiting was 18%, but the prevalence of adverse behavioral changes was low. When adjusted for potential confounders, the odds of a higher PHBQ score increased among patients receiving fentanyl/midazolam (fentanyl/midazolam odds ratio [OR] 2.6, 95% confidence interval [CI] 1.08 to 6.03, P=.03; ketamine OR 1.7, 95% CI 0.84 to 3.57; ketamine/midazolam OR 0.5, 95% CI 0.26 to 1.07). CONCLUSION: Procedural sedation and analgesia in the ED is well tolerated. Though postdischarge vomiting occurs with some frequency, there is a low prevalence of adverse behavioral events after discharge. The use of fentanyl/midazolam was associated with higher adverse behavioral scores.

• Predictors of Airway and Respiratory Adverse Events With Ketamine Sedation in the Emergency Department: An Individual-Patient Data Meta-analysis of 8,282 Children.

  Authors: Steven M Green, Mark G Roback, Baruch Krauss, Lance Brown, Ray G McGlonefcem, Dewesh Agrawal, Michele McKee, Markus Weiss, Raymond D Pitetti, Mark A Hostetler, Joe E Wathen, Greg Treston, Barbara M Garcia Pena, Andreas C Gerber, Joseph D Losek

  Annals of emergency medicine. 02/2009;

  STUDY OBJECTIVE: Although ketamine is one of the most commonly used sedatives to facilitate painful procedures for children in the emergency department (ED), existing studies have not been largeSTUDY OBJECTIVE: Although ketamine is one of the most commonly used sedatives to facilitate painful procedures for children in the emergency department (ED), existing studies have not been large enough to identify clinical factors that are predictive of uncommon airway and respiratory adverse events. METHODS: We pooled individual-patient data from 32 ED studies and performed multiple logistic regressions to determine which clinical variables would predict airway and respiratory adverse events. RESULTS: In 8,282 pediatric ketamine sedations, the overall incidence of airway and respiratory adverse events was 3.9%, with the following significant independent predictors: younger than 2 years (odds ratio [OR] 2.00; 95% confidence interval [CI] 1.47 to 2.72), aged 13 years or older (OR 2.72; 95% CI 1.97 to 3.75), high intravenous dosing (initial dose >/=2.5 mg/kg or total dose >/=5.0 mg/kg; OR 2.18; 95% CI 1.59 to 2.99), coadministered anticholinergic (OR 1.82; 95% CI 1.36 to 2.42), and coadministered benzodiazepine (OR 1.39; 95% CI 1.08 to 1.78). Variables without independent association included oropharyngeal procedures, underlying physical illness (American Society of Anesthesiologists class >/=3), and the choice of intravenous versus intramuscular route. CONCLUSION: Risk factors that predict ketamine-associated airway and respiratory adverse events are high intravenous doses, administration to children younger than 2 years or aged 13 years or older, and the use of coadministered anticholinergics or benzodiazepines.

• Consensus-Based Recommendations for Standardizing Terminology and Reporting Adverse Events for Emergency Department Procedural Sedation and Analgesia in Children.

  Authors: Maala Bhatt, Robert M Kennedy, Martin H Osmond, Baruch Krauss, John D McAllister, J Mark Ansermino, Lisa M Evered, Mark G Roback

  Annals of emergency medicine. 12/2008;

  Children commonly require sedation and analgesia for procedures in the emergency department. Establishing accurate adverse event and complications rates from the available literature has beenChildren commonly require sedation and analgesia for procedures in the emergency department. Establishing accurate adverse event and complications rates from the available literature has been difficult because of the difficulty in aggregating results from previous studies that have used varied terminology to describe the same adverse events and outcomes. Further, serious adverse events occur infrequently, necessitating the study of large numbers of children to assess safety. These limitations prevent the establishment of a sufficiently large database on which evidence-based practice guidelines may be based. We assembled a panel of pediatric sedation researchers and experts to develop consensus-based recommendations for standardizing procedural sedation and analgesia terminology and reporting of adverse events. Our goal was to create a uniform reporting mechanism for future studies to facilitate the aggregation and comparison of results.

• Capnography: a valuable tool for airway management.

  Authors: Joshua Nagler, Baruch Krauss

  Emergency medicine clinics of North America. 12/2008; 26(4):881-97.

  Capnography provides continuous, dynamic assessment of the ventilatory status of patients. Carbon dioxide physiology and the technology utilized in end-tidal carbon dioxide monitor devices areCapnography provides continuous, dynamic assessment of the ventilatory status of patients. Carbon dioxide physiology and the technology utilized in end-tidal carbon dioxide monitor devices are reviewed. Clinical applications with regard to ventilation and airway management are discussed, including: verification of endotracheal tube placement, continuous monitoring of tube position, monitoring during procedural sedation and in the obtunded patient, and assessment of patients with respiratory illnesses. Current guidelines for use of capnography within emergency medicine are included. Potential future applications are also presented.

• Supplemental oxygen during propofol sedation: yes or no?

  Authors: Steven M Green, Baruch Krauss

  Annals of emergency medicine. 08/2008; 52(1):9-10.

• Barriers to Propofol Use in Emergency Medicine.

  Authors: Steven M Green, Baruch Krauss

  Annals of emergency medicine. 03/2008;

  Propofol is rapidly becoming one of the most popular procedural sedation and analgesia agents in emergency medicine. However, in many hospitals emergency physicians lack access to this potentPropofol is rapidly becoming one of the most popular procedural sedation and analgesia agents in emergency medicine. However, in many hospitals emergency physicians lack access to this potent sedative. This article details the evidence and politics underlying this area of controversy, the nature and authority of hospital-wide sedation policies, and discussion of the most common criticisms of emergency department use of propofol.

• Training and credentialing in procedural sedation and analgesia in children: lessons from the United States model.

  Authors: Baruch Krauss, Steven M Green

  Paediatric anaesthesia. 02/2008; 18(1):30-5.

• Capnography for procedural sedation and analgesia in the emergency department.

  Authors: Baruch Krauss, Dean R Hess

  Annals of emergency medicine. 09/2007; 50(2):172-81.

  Although it is standard of care for patient safety monitoring in anesthesia, capnography is not routinely used for emergency department procedural sedation and analgesia. We discuss the use ofAlthough it is standard of care for patient safety monitoring in anesthesia, capnography is not routinely used for emergency department procedural sedation and analgesia. We discuss the use of capnography as a diagnostic monitoring modality for procedural sedation and analgesia, focusing on the physiology and interpretation of the CO2 waveform and recognition of normal, abnormal, and drug-induced ventilatory patterns.

• Fasting and emergency department procedural sedation and analgesia: a consensus-based clinical practice advisory.

  Authors: Steven M Green, Mark G Roback, James R Miner, John H Burton, Baruch Krauss

  Annals of emergency medicine. 05/2007; 49(4):454-61.

  Emergency physicians frequently administer procedural sedation and analgesia to nonfasted patients; however, they currently have no specific guidelines to aid them in preprocedural riskEmergency physicians frequently administer procedural sedation and analgesia to nonfasted patients; however, they currently have no specific guidelines to aid them in preprocedural risk stratification. We assembled a committee of leading emergency physician sedation researchers to develop a consensus-based clinical practice advisory for this purpose. Our goal was to create a tool to permit emergency physicians to identify prudent limits of sedation depth and timing in light of fasting status and individual patient risk factors. The advisory is not intended to assert a legal standard of practice or absolute requirement. It is expected that emergency physicians will at times appropriately deviate from it according to individualized judgment and unique clinical circumstances.

• Procedural sedation and analgesia research: state of the art.

  Authors: James R Miner, Baruch Krauss

  Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 03/2007; 14(2):170-8.

  The authors review the current state of procedural sedation and analgesia research and clinical practice in adults and children, discuss the limitations in research methodology, and propose futureThe authors review the current state of procedural sedation and analgesia research and clinical practice in adults and children, discuss the limitations in research methodology, and propose future areas of investigation.

• Should I give ketamine i.v. or i.m.?

  Authors: Steven M Green, Baruch Krauss

  Annals of emergency medicine. 12/2006; 48(5):613-4.

• 15-second triage tool. The use of capnography for the rapid assessment & triage of critically injured patients & victims of chemical terrorism.

  Authors: Baruch Krauss, A J Heightman

  JEMS : a journal of emergency medical services. 07/2006; 31(6):60-2, 64-6, 68.