The most common reason one would not choose an oral route and would instead elect to use nasal or buccal routes is due to delays in onset of oral medications and due to gastric acid destruction and first pass metabolism of drug resulting in very low levels available to the blood stream. Failure to utilize the nose brain path also occurs with oral (and buccal) medications - resulting in much slower drug delivery to the brain. Interestingly, oral medications are also commonly refused by 30% of pediatric patients making them completely ineffective in this situation. Buccal medications also require a cooperative patient who will retain the medication within their buccal and sublingual mucosal areas and not swallow or spit it out. In fact, even when buccal medications are administered to volunteers in research settings, only about 56% remains in the oral cavity for absorption. Even nasal drug delivery can have problems depending on the delivery method. Yuen et al report that in % of pediatric patients they were unable to dispense drops into the nose due to resistance to this delivery technique. While nasal delivery is possible the majority of the time, to overcome these delivery issues a number of device have been developed that enhance delivery - these are discussed in the delivery techniques section of this web site.
As far as we can tell, while currently blinded, the time to onset of sedation has ranged anywhere from 6 minutes to just over 20 minutes. Patients who reached adequate sedation did not ever require "rescue" doses of additional ketamine to complete the laceration repairs, which were limited to simple lacerations less than 5 cm and did not require a consult service to perform the repair. Recovery times have been comparable to patients who have received IV ketamine. Unfortunately, since we are still blinded at this time, we cannot make any further comments regarding a specific dose and its effect.
No new trials were found for inclusion in this update. Four studies involving 1943 participants with acute sinusitis met our inclusion criteria. The trials were well-designed and double-blind and studied INCS versus placebo or no intervention for 15 or 21 days. The rates of loss to follow-up were 7%, 11%, 41% and 10%. When we combined the results from the three trials included in the meta-analysis, participants receiving INCS were more likely to experience resolution or improvement in symptoms than those receiving placebo (73% versus %; risk ratio (RR) ; 95% confidence interval (CI) to ). Higher doses of INCS had a stronger effect on improvement of symptoms or complete relief: for mometasone furoate 400 µg versus 200 µg (RR ; 95% CI to versus RR ; 95% CI to ). No significant adverse events were reported and there was no significant difference in the drop-out and recurrence rates for the two treatment groups and for groups receiving higher doses of INCS.