Abstract

A short cut review was carried out to establish whether physostigmine has a role in the management of gammahydroxybutyrate (GHB) ingestion. 18 papers were found using the reported searches, of which one was a review that incorporated all other relevant papers. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of this review are tabulated. It is concluded that the evidence for the use of physostigmine for the treatment of GHB ingestion is poor. Local advice should be followed.

Three part question

In [patients with gammahydroxybutyrate ingestion] does [treatment with physostigmine] [reduce the neccessity for intubation and duration of unconsciousness]?

Clinical scenario

A 25 year old man is brought to the emergency department after collapsing in a club. His friends report ingestion of Gammahydroxybutyrate (GHB) and alcohol. His Glasgow Coma Scale score is 3 on arrival and he is intermittently apnoeic. When you attempt to intubate him he seems to rouse but quickly becomes unresponsive again once you stop. You ask for anaesthetic help. The anaesthetic registrar has a similar experience on attempting intubation. You are sure you have read that physostigmine can be used to avoid intubation in this situation. You wonder if you have remembered correctly.

Search strategy

MEDLINE using the OVID interface 1966 to January Week 1 2006

Embase using the OVID interface 1980 to 2006 Week 02

[exp Hydroxybutyrates/OR GHB.mp OR gammahydroxybutyrate.mp.] AND [physostigmine.mp. or exp Physostigmine/] Limit to Humans and English Language

The Cochrane Library Issue 4 2005

[Hydroxybutyrates {MeSH explode all trees} OR gammahydroxybutyrate {all fields}] AND [physostigmine {MeSH explode all trees}].

Search outcome

18 papers were found of which one was a systematic review. All other relevant papers were included in the review.

Comment(s)

As noted in the review by Traub et al, the evidence for and against the use of physostigmine is of poor quality. Only two papers (involving six patients) are set in the emergency department, while those in the anaesthetic room are uncontrolled. This matters since the recovery from GHB induced anaesthesia is relatively rapid and it is therefore difficult to draw conclusions from uncontrolled studies.

CLINICAL BOTTOM LINE

The evidence for the use of physostigmine is of low quality. Local advice should be followed.