Ketamine sedation in mechanically ventilated patients: A systematic review and meta-analysis

Impact of Prolonged Continuous Ketamine Infusions in Critically Ill Children: A Prospective Cohort Study

BACKGROUND

Ketamine has been considered as an adjunct for children who do not reach their predefined target sedation depth. However, there is limited evidence regarding the use of ketamine as a prolonged infusion (i.e., >24 hours) in the pediatric intensive care unit (PICU).

OBJECTIVE

We sought to evaluate the safety and effectiveness of continuous ketamine infusion for >24 hours in mechanically ventilated children.

METHODS

We conducted a prospective cohort study in a tertiary PICU from January 2020 to December 2022. The primary outcome was the incidence of adverse events (AEs) after ketamine initiation. The secondary outcome included assessing the median proportion of time the patient spent on the Richmond Agitation-Sedation Scale (RASS) goal after ketamine infusion. Patients were also divided into two groups based on the sedative regimen, ketamine-based or non-ketamine-based, to assess the incidence of delirium.

RESULTS

A total of 269 patients were enrolled: 73 in the ketamine group and 196 in the non-ketamine group. The median infusion rate of ketamine was 1.4 mg/kg/h. Delirium occurred in 16 (22%) patients with ketamine and 15 (7.6%) patients without ketamine (p = 0.006). After adjusting for covariates, logistic regression showed that delirium was associated with comorbidities (odds ratio [OR] 4.2), neurodevelopmental delay (OR 0.23), fentanyl use (OR 7.35), and ketamine use (OR 4.17). Thirty-one (42%) of the patients experienced at least one AE following ketamine infusion. Other AEs likely related to ketamine were hypertension (n = 4), hypersecretion (n = 14), tachycardia (n = 6), and nystagmus (n = 2). There were no significant changes in hemodynamic variables 24 h after the initiation of ketamine. Regarding the secondary outcomes, patients were at their goal RASS level for a median of 76% (range 68-80.5%) of the time in the 24 hours before ketamine initiation, compared with 84% (range 74.5-90%) of the time during the 24 h after ketamine initiation (p < 0.001). The infusion rate of ketamine did not significantly affect concomitant analgesic and sedative infusions. The ketamine group experienced a longer duration of mechanical ventilation and a longer length of stay in the PICU and hospital than the non-ketamine group.

CONCLUSION

The use of ketamine infusion in PICU patients may be associated with an increased rate of adverse events, especially delirium. High-quality studies are needed before ketamine can be broadly recommended or adopted earlier in the sedation protocol.

Continuous Infusion of Ketamine in Mechanically Ventilated Patients with SARS-CoV-2

Background

Widespread drug shortages led to higher utilization of ketamine in our intensive care unit, especially among patients with SARS-CoV-2.

Objectives

To evaluate the impact of continuous infusion of ketamine on vasopressor requirements in patients with SARS-CoV-2.

Method

This was a single-center, retrospective, cohort study comparing mechanically ventilated (MV), adult patients with SARS-CoV-2 receiving either propofol or ketamine for at least 72 hours.

Results

84 patients (mean age of 61-year-old, 68% male) were analyzed. 31 patients received ketamine, and 53 patients received propofol. Mean vasopressor doses were not significantly different between ketamine and propofol groups at prespecified timepoints. However, mean arterial pressures (MAP) were higher in the ketamine group at 24 h, 48 h, and 96 h postsedative initiation. The median opioid infusion requirements were 3 vs. 12.5 mg/hr (p < 0.0001) for ketamine and propofol groups, respectively. Comparing to propofol, C-reactive protein (CRP) values were significantly lower in the ketamine group at 24 h (7.53 vs. 15.9 mg/dL, p=0.03), 48 h (5.23 vs. 14.1 mg/dL, p=0.0083), and 72 h (6.4 vs. 12.1 mg/dL, p=0.0085).

Conclusion

In patients with SARS-CoV-2 on MV, there was no difference in the vasopressor requirement in patients receiving ketamine compared to propofol. Nevertheless, the use of ketamine was associated with higher MAP, reductions in CRP in select timepoints, and overall lower opioid requirements.

The impact of ketamine on outcomes in critically ill patients: a systematic review with meta-analysis and trial sequential analysis of randomized controlled trials

BACKGROUND

This meta-analysis aims to evaluate the effects of ketamine in critically ill intensive care unit (ICU) patients.

METHODS

We searched for randomized controlled trials (RCTs) in PubMed, Scopus, and the Cochrane Library; the search was performed initially in January but was repeated in December of 2023. We focused on ICU patients of any age. We included studies that compared ketamine with other traditional agents used in the ICU. We synthesized evidence using RevMan v5.4 and presented the results as forest plots. We also used trial sequential analysis (TSA) software v. 0.9.5.10 Beta and presented results as TSA plots. For synthesizing results, we used a random-effects model and reported differences in outcomes of two groups in terms of mean difference (MD), standardized MD, and risk ratio with 95% confidence interval. We assessed the risk of bias using the Cochrane RoB tool for RCTs. Our outcomes were mortality, pain, opioid and midazolam requirements, delirium rates, and ICU length of stay.

RESULTS

Twelve RCTs involving 805 ICU patients (ketamine group, n=398; control group, n=407) were included in the meta-analysis. The ketamine group was not superior to the control group in terms of mortality (in five studies with 318 patients), pain (two studies with 129 patients), mean and cumulative opioid consumption (six studies with 494 patients), midazolam consumption (six studies with 304 patients), and ICU length of stay (three studies with 270 patients). However, the model favored the ketamine group over the control group in delirium rate (four studies with 358 patients). This result is significant in terms of conventional boundaries (alpha=5%) but is not robust in sequential analysis. The applicability of the findings is limited by the small number of patients pooled for each outcome.

CONCLUSIONS

Our meta-analysis did not demonstrate differences between ketamine and control groups regarding any outcome except delirium rate, where the model favored the ketamine group over the control group. However, this result is not robust as sensitivity analysis and trial sequential analysis suggest that more RCTs should be conducted in the future.

Ketamine as adjunctive or monotherapy for post-intubation sedation in patients with trauma on mechanical ventilation: A rapid review

Background

The effectiveness of ketamine as adjunctive or monotherapy for post-intubation sedation in adults with trauma on mechanical ventilation is unclear.

Methods

A rapid review of systematic reviews of randomized controlled trials, then randomized controlled trials or observational studies was conducted searching three electronic databases (PubMed, Embase, Cochrane Library) and one clinical trial registry on June 1, 2022. We used a prespecified protocol following Cochrane rapid review methods.

Results

We identified eight systematic reviews of randomized controlled trials and observational studies. Among the included reviews, only the most relevant, up to date, highest quality-assessed reviews and reviews that reported on critical outcomes were considered. Adjunctive ketamine showed a morphine sparing effect (MD -13.19 µmg kg-1 h-1, 95 % CI -22.10 to -4.28, moderate certainty of evidence, 6 RCTs), but no to little effect on midazolam sparing effect (MD 0.75 µmg kg-1 h-1, 95 % CI -1.11 to 2.61, low certainty of evidence, 6 RCTs) or duration of mechanical ventilation in days (MD -0.17 days, 95 % CI -3.03 to 2.69, moderate certainty of evidence, 3 RCTs).Adjunctive ketamine therapy may reduce mortality (OR 0.88, 95 % CI 0.54 to 1.43, P = 0.60, very low certainty of evidence, 5 RCTs, n = 3076 patients) resulting in 30 fewer deaths per 1000, ranging from 132 fewer to 87 more, but the evidence is very uncertain. Ketamine results in little to no difference in length of ICU stay (MD 0.04 days, 95 % CI -0.12 to 0.20, high certainty of evidence, 5 RCTs n = 390 patients) or length of hospital stay (MD -0.53 days, 95 % CI -1.36 to 0.30, high certainty of evidence, 5 RCTs, n = 277 patients).Monotherapy may have a positive effect on respiratory and haemodynamic outcomes, however the evidence is very uncertain.

Conclusion

Adjunctive ketamine for post-intubation analgosedation results in a moderate meaningful net benefit but there is uncertainty for benefit and harms as monotherapy.

Ketamine: A Practical Review for the Consultation-Liaison Psychiatrist

BACKGROUND

Ketamine is a noncompetitive N-methyl-D-aspartate-receptor antagonist often used for sedation and management of acute agitation in general hospital settings. Many hospitals now include ketamine as part of their standard agitation protocol, and consultation-liaison psychiatrists frequently find themselves treating patients who have received ketamine, despite lack of clear recommendations for management.

OBJECTIVE

Conduct a nonsystematic narrative review regarding the use of ketamine for agitation and continuous sedation, including benefits and adverse psychiatric effects. Compare ketamine to more traditional agents of agitation control. Provide consultation-liaison psychiatrists with a summary of available knowledge and recommendations for managing patients receiving ketamine.

METHODS

A literature review was performed using PubMed, querying published articles from inception to March 2023 for articles related to use of ketamine for agitation or continuous sedation and side effects including psychosis and catatonia.

RESULTS

A total of 37 articles were included. Ketamine was found to have multiple benefits, including shorter time to adequate sedation for agitated patients when compared to haloperidol ± benzodiazepines and unique advantages for continuous sedation. However, ketamine carries significant medical risks including high rates of intubation. Ketamine appears to induce a syndrome that mimics schizophrenia in healthy controls, and such effects are more pronounced and longer-lasting in patients with schizophrenia. Evidence regarding rates of delirium with ketamine for continuous sedation is mixed and requires further investigation before the agent is widely adopted for this purpose. Finally, the diagnosis of "excited delirium syndrome" and use of ketamine to treat this controversial syndrome warrants critical evaluation.

CONCLUSIONS

Ketamine carries many potential benefits and can be an appropriate medication for patients with profound undifferentiated agitation. However, intubation rates remain high, and ketamine may worsen underlying psychotic disorders. It is essential that consultation-liaison psychiatrists understand the advantages, disadvantages, biased administration, and areas of limited knowledge regarding ketamine.

Safety and feasibility of continuous ketamine infusion for analgosedation in medical and cardiac ICU patients who received mechanical ventilation support: A retrospective cohort study

Purpose

To assess the effect of continuous ketamine administration in patients admitted to medical and cardiac intensive care units (ICUs) and received mechanical ventilation support.

Methods

We conducted a retrospective cohort study between March 2012 and June 2020 at an academy-affiliated tertiary hospital. Adult patients who received mechanical ventilation support for over 24 h and continuous ketamine infusion for at least 8 h were included. The primary outcome was immediate hemodynamic safety after continuous ketamine infusion. The secondary outcomes included immediate delirium, pain, and use of sedation.

Results

Of all 12,534 medical and cardiac ICU patients, 564 were eligible for the analysis. Ketamine was used for 33.3 (19.0–67.5) h and the median continuous infusion dose was 0.11 (0.06–0.23) mcg/kg/h. Of all patients, 469 (83.2%) received continuous ketamine infusion concomitant with analgosedation. Blood pressure and vasopressor inotropic scores did not change after continuous ketamine infusion. Heart rate decreased significantly from 106.9 (91.4–120.9) at 8 h before ketamine initiation to 99.8% (83.9–114.4) at 24 h after ketamine initiation. In addition, the respiratory rate decreased from 21.7 (18.6–25.4) at 8 h before ketamine initiation to 20.1 (17.0–23.0) at 24 h after ketamine initiation. Overall opioid usage was significantly reduced: 3.0 (0.0–6.0) mcg/kg/h as fentanyl equivalent dose at 8 h before ketamine initiation to 1.0 (0.0–4.1) mcg/kg/h as fentanyl equivalent dose at 24 h post-ketamine initiation. However, the use of sedatives and antipsychotic medications did not decrease. In addition, ketamine did not increase the incidence of delirium within 24 h after ketamine infusion.

Conclusion

Ketamine may be a safe and feasible analgesic for medical and cardiac ICU patients who received mechanical ventilation support as an opioid-sparing agent without adverse hemodynamic effects.

A Comparative Analysis Between Ketamine Versus Combination of Midazolam and Haloperidol for Rapid Safe Control of Agitated Patients in Emergency Department: A Systematic Review

We aim to discuss the efficacy and adverse effects of using ketamine in agitated patients in the emergency department (ED) compared with the combination therapy of haloperidol with benzodiazepine.

This systematic review followed Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines. An electronic search from PubMed/Medline, Cochrane library, and Google Scholar was conducted from their inception to 30^th April 2022. We included agitated patients in ED who were given infusion with ketamine only. Our comparative group was patients infused with combined therapy of haloperidol and benzodiazepine. We did not include letters, case reports, abstracts, conference papers, appraisals, reviews, and studies where full text was unavailable. We did not put any language restrictions.

Three studies were selected in our manuscript (one cohort and two randomized controlled trials). All three studies showed that ketamine was used to achieve sedation in less time than the other group. However, two studies reported significantly more adverse effects in ketamine-infused groups.

We concluded that ketamine use is superior when its primary focus is to sedate the patient as quickly as possible, but it carries some side effects that should be considered. However, we still need more studies assessing the efficacy of ketamine in agitated patients presenting in the ED.

Multicenter Retrospective Review of Ketamine Use in the ICU

IMPORTANCE:

The response of ICU patients to continuously infused ketamine when it is used for analgesia and/or sedation remains poorly established.

OBJECTIVES:

To describe continuous infusion (CI) ketamine use in critically ill patients, including indications, dose and duration, adverse effects, patient outcomes, time in goal pain/sedation score range, exposure to analgesics/sedatives, and delirium.

DESIGN, SETTING, AND PARTICIPANTS:

Multicenter, retrospective, observational study from twenty-five diverse institutions in the United States. Patients receiving CI ketamine between January 2014 and December 2017.

MAIN OUTCOMES AND MEASURES:

Chart review evaluating institutional and patient demographics, ketamine indication, dose, administration, and adverse effects. Pain/sedation scores, cumulative doses of sedatives and analgesics, and delirium screenings in the 24 hours prior to ketamine were compared with those at 0–24 hours and 25–48 hours after.

RESULTS:

A total of 390 patients were included (median age, 54.5 yr; interquartile range, 39–65 yr; 61% males). Primary ICU types were medical (35.3%), surgical (23.3%), and trauma (17.7%). Most common indications were analgesia/sedation (n = 357, 91.5%). Starting doses were 0.2 mg/kg/hr (0.1–0.5 mg/kg/hr) and continued for 1.6 days (0.6–2.9 d). Hemodynamics in the first 4 hours after ketamine were variable (hypertension 24.0%, hypotension 23.5%, tachycardia 19.5%, bradycardia 2.3%); other adverse effects were minimal. Compared with 24 hours prior, there was a significant increase in proportion of time spent within goal pain score after ketamine initiation (24 hr prior: 68.9% [66.7–72.6%], 0–24 hr: 78.6% [74.3–82.5%], 25–48 hr: 80.3% [74.6–84.3%]; p < 0.001) and time spent within goal sedation score (24 hr prior: 57.1% [52.5–60.0%], 0–24 hr: 64.1% [60.7–67.2%], 25–48 hr: 68.9% [65.5–79.5%]; p < 0.001). There was also a significant reduction in IV morphine (mg) equivalents (24 hr prior: 120 [25–400], 0–24 hr: 118 [10–363], 25–48 hr: 80 [5–328]; p < 0.005), midazolam (mg) equivalents (24 hr prior: 11 [4–67], 0–24 hr: 6 [0–68], 25–48 hr: 3 [0–57]; p < 0.001), propofol (mg) (24 hr prior: 942 [223–4,018], 0–24 hr: 160 [0–2,776], 25–48 hr: 0 [0–1,859]; p < 0.001), and dexmedetomidine (µg) (24 hr prior: 1,025 [276–1,925], 0–24 hr: 285 [0–1,283], 25–48 hr: 0 [0–826]; p < 0.001). There was no difference in proportion of time spent positive for delirium (24 hr prior: 43.0% [17.0–47.0%], 0–24 hr: 39.5% [27.0–43.8%], 25–48 hr: 0% [0–43.7%]; p = 0.233). Limitations to these data include lack of a comparator group, potential for confounders and selection bias, and varying pain and sedation practices that may have changed since completion of the study.

CONCLUSIONS AND RELEVANCE:

There is variability in the use of CI ketamine. Hemodynamic instability was the most common adverse effect. In the 48 hours after ketamine initiation compared with the 24 hours prior, proportion of time spent in goal pain/sedation score range increased and exposure to other analgesics/sedatives decreased.

Impact of Ketamine on Analgosedative Consumption in Critically Ill Patients: A Systematic Review and Meta-Analysis

Objective:

The aim of this study was to synthesize evidence available on continuous infusion ketamine versus nonketamine regimens for analgosedation in critically ill patients.

Data sources

A search of MEDLINE, EMBASE, CINAHL, CDSR, and ClinicalTrials.gov was performed from database establishment to November 2021 using the following search terms: critical care, ICU, ketamine, sedation, and anesthesia. All studies included the primary outcome of interest: daily opioid and/or sedative consumption.

Study selection and data extraction

Relevant human studies were considered. Randomized controlled trials (RCT), quasi-experimental studies, and observational cohort studies were eligible. Two reviewers independently screened articles, extracted data, and appraised studies using the Cochrane RoB and ROBINS-I tools.

Data synthesis

A total of 13 RCTs, 5 retrospective, and 1 prospective cohort study were included (2255 participants). The primary analysis of six RCTs demonstrated reduced opioid consumption with ketamine regimens (n = 494 participants, −13.19 µg kg⁻¹ h⁻¹ morphine equivalents, 95% CI −22.10 to −4.28, P = 0.004). No significant difference was observed in sedative consumption, duration of mechanical ventilation (MV), ICU or hospital length of stay (LOS), intracranial pressure, and mortality. Small sample size of studies may have limited ability to detect true differences between groups.

Relevance to patient care and clinical practice

This meta-analysis examining ketamine use in critically ill patients is the first restricting analysis to RCTs and includes up-to-date publication of trials. Findings may guide clinicians in consideration and dosing of ketamine for multimodal analgosedation.

Conclusion

Results suggest ketamine as an adjunct analgosedative has the potential to reduce opioid exposure in postoperative and MV patients in the ICU. More RCTs are required before recommending routine use of ketamine in select populations.

The AIR-SED Study: A Multicenter Cohort Study of SEDation Practices, Deep Sedation, and Coma Among Mechanically Ventilated AIR Transport Patients

Supplemental Digital Content is available in the text.

OBJECTIVES:

To characterize prehospital air medical transport sedation practices and test the hypothesis that modifiable variables related to the monitoring and delivery of analgesia and sedation are associated with prehospital deep sedation.

DESIGN:

Multicenter, retrospective cohort study.

SETTING:

A nationwide, multicenter (approximately 130 bases) air medical transport provider.

PATIENTS:

Consecutive, adult mechanically ventilated air medical transport patients treated in the prehospital environment (January 2015 to December 2020).

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

All data involving sedation (medications, monitoring) were recorded. Deep sedation was defined as: 1) Richmond Agitation-Sedation Scale of –3 to –5; 2) Ramsay Sedation Scale of 5 or 6; or 3) Glasgow Coma Scale of less than or equal to 9. Coma was defined as being unresponsive and based on median sedation depth: 1) Richmond Agitation-Sedation Scale of –5; 2) Ramsay of 6; or 3) Glasgow Coma Scale of 3. A total of 72,148 patients were studied. Prehospital deep sedation was observed in 63,478 patients (88.0%), and coma occurred in 42,483 patients (58.9%). Deeply sedated patients received neuromuscular blockers more frequently and were less likely to have sedation depth documented with a validated sedation depth scale (i.e., Ramsay or Richmond Agitation-Sedation Scale). After adjusting for covariates, a multivariable logistic regression model demonstrated that the use of longer-acting neuromuscular blockers (i.e., rocuronium and vecuronium) was an independent predictor of deep sedation (adjusted odds ratio, 1.28; 95% CI, 1.22–1.35; p < 0.001), while use of a validated sedation scale was associated with a lower odds of deep sedation (adjusted odds ratio, 0.29; 95% CI, 0.27–0.30; p < 0.001).

CONCLUSIONS:

Deep sedation (and coma) is very common in mechanically ventilated air transport patients and associated with modifiable variables related to the monitoring and delivery of analgesia and sedation. Sedation practices in the prehospital arena and associated clinical outcomes are in need of further investigation.

Impact of ketamine as an adjunct sedative in acute respiratory distress syndrome due to COVID-19 Pneumonia

Purpose

Deep sedation is sometimes needed in acute respiratory distress syndrome. Ketamine is a sedative that has been shown to have analgesic and sedating properties without having a detrimental impact on hemodynamics. This pharmacological profile makes ketamine an attractive sedative, potentially reducing the necessity for other sedatives and vasopressors, but there are no studies evaluating its effect on these medications in patients requiring deep sedation for acute respiratory distress syndrome.

Materials and methods

This is a retrospective, observational study in a single center, quaternary care hospital in southeast Texas. We looked at adults with COVID-19 requiring mechanical ventilation from March 2020 to September 2020.

Results

We found that patients had less propofol requirements at 72 h after ketamine initiation when compared to 24 h (median 34.2 vs 54.7 mg/kg, p = 0.003). Norepinephrine equivalents were also significantly lower at 48 h than 24 h after ketamine initiation (median 38 vs 62.8 mcg/kg, p = 0.028). There was an increase in hydromorphone infusion rates at all three time points after ketamine was introduced.

Conclusions

In this cohort of patients with COVID-19 ARDS who required mechanical ventilation receiving ketamine we found propofol sparing effects and vasopressor requirements were reduced, while opioid infusions were not.

Exploring Ketamine Analgosedation Use and Its Effect on Incident Delirium in Critically Ill Adults

Ketamine is increasingly being used for analgosedation, but its effect on delirium remains unclear. We compared delirium risk variables and ketamine analgosedation use between adults who developed incident delirium and those who did not, evaluated whether ketamine analgosedation increases delirium risk, and compared ICU delirium characteristics, treatments, and outcomes between ketamine and nonketamine patients with delirium.

DESIGN

Secondary, subgroup analysis of a cohort study.

SETTING

Single, 36-bed mixed medical-surgical ICU in the Netherlands from July 2016 to February 2020.

PATIENTS

Consecutive adults were included. Patients admitted after elective surgery, not expected to survive greater than or equal to 48 hours, admitted with delirium, or where delirium occurred prior to ketamine use were excluded.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Trained ICU nurses evaluated patients without coma (Richmond Agitation Sedation Scale. -4/-5) every 8 hours with the Confusion Assessment Method ICU; a delirium day was defined by greater than or equal to1 + Confusion Assessment Method ICU and/or scheduled antipsychotic use. Among 11 variables compared between the delirium and nondelirium groups (Baseline: age, Charlson Comorbidity score, cognitive impairment, admission type, and Acute Physiology and Chronic Health Evaluation-IV score, daily ICU [until delirium occurrence or discharge]: Sequential Organ Failure Assessment score, coma, benzodiazepine, opioid, and ketamine use) and total ICU days, 7 (age, Charlson score, Sequential Organ Failure Assessment score, coma, benzodiazepine, opioid, and ketamine use) were significantly different and were entered, along with delirium occurrence, in a logistic regression model. A total of 332 of 925 of patients (36%) developed delirium. Ketamine use was greater in patients with delirium (54 [16%] vs 4 [0.7%]; p < 0.01). Ketamine use (adjusted odds ratio, 5.60; 95% CI, 1.09-29.15), age (adjusted odds ratio, 1.03; 95% CI, 1.01-1.06), coma (adjusted odds ratio, 2.10; 95% CI, 1.15-3.78), opioid use (adjusted odds ratio, 171.17; 95% CI, 66.45-553.68), and benzodiazepine use (adjusted odds ratio, 34.07; 95% CI, 8.12-235.34) were each independently and significantly associated with increased delirium. Delirium duration, motoric subtype, delirium treatments, and outcomes were not different between the ketamine and nonketamine groups.

CONCLUSIONS

Ketamine analgosedation may contribute to increased ICU delirium. The characteristics of ketamine and nonketamine delirium are similar. Further prospective research is required to evaluate the magnitude of risk for delirium with ketamine use.

High sedation needs of critically ill COVID-19 ARDS patients-A monocentric observational study

BACKGROUND

Therapy of severely affected coronavirus patient, requiring intubation and sedation is still challenging. Recently, difficulties in sedating these patients have been discussed. This study aims to describe sedation practices in patients with 2019 coronavirus disease (COVID-19)-induced acute respiratory distress syndrome (ARDS).

METHODS

We performed a retrospective monocentric analysis of sedation regimens in critically ill intubated patients with respiratory failure who required sedation in our mixed 32-bed university intensive care unit. All mechanically ventilated adults with COVID-19-induced ARDS requiring continuously infused sedative therapy admitted between April 4, 2020, and June 30, 2020 were included. We recorded demographic data, sedative dosages, prone positioning, sedation levels and duration. Descriptive data analysis was performed; for additional analysis, a logistic regression with mixed effect was used.

RESULTS

In total, 56 patients (mean age 67 (±14) years) were included. The mean observed sedation period was 224 (±139) hours. To achieve the prescribed sedation level, we observed the need for two or three sedatives in 48.7% and 12.8% of the cases, respectively. In cases with a triple sedation regimen, the combination of clonidine, esketamine and midazolam was observed in most cases (75.7%). Analgesia was achieved using sufentanil in 98.6% of the cases. The analysis showed that the majority of COVID-19 patients required an unusually high sedation dose compared to those available in the literature.

CONCLUSION

The global pandemic continues to affect patients severely requiring ventilation and sedation, but optimal sedation strategies are still lacking. The findings of our observation suggest unusual high dosages of sedatives in mechanically ventilated patients with COVID-19. Prescribed sedation levels appear to be achievable only with several combinations of sedatives in most critically ill patients suffering from COVID-19-induced ARDS and a potential association to the often required sophisticated critical care including prone positioning and ECMO treatment seems conceivable.

Interhospital Transfer of Patients With Acute Pulmonary Embolism (PE): Challenges and Opportunities

Acute pulmonary embolism (PE) is associated with significant morbidity and mortality. The management paradigm for acute PE has evolved in recent years with wider availability of advanced treatment modalities ranging from catheter-directed reperfusion therapies to mechanical circulatory support. This evolution has coincided with the development and implementation of institutional pulmonary embolism response teams (PERT) nationwide and internationally. Because most institutions are not equipped or staffed for advanced PE care, patients often require transfer to centers with more comprehensive resources, including PERT expertise. One of the unmet needs in current PE care is an organized approach to the process of interhospital transfer (IHT) of critically ill PE patients. In this review, we discuss medical optimization and support of patients before and during transfer, transfer checklists, defined roles of emergency medical services, and the roles and responsibilities of referring and receiving centers involved in the IHT of acute PE patients.

Consensus for the management of analgesia, sedation and delirium in adults with COVID-19-associated acute respiratory distress syndrome

Objective

To propose agile strategies for a comprehensive approach to analgesia, sedation, delirium, early mobility and family engagement for patients with COVID-19-associated acute respiratory distress syndrome, considering the high risk of infection among health workers, the humanitarian treatment that we must provide to patients and the inclusion of patients’ families, in a context lacking specific therapeutic strategies against the virus globally available to date and a potential lack of health resources.

Methods

A nonsystematic review of the scientific evidence in the main bibliographic databases was carried out, together with national and international clinical experience and judgment. Finally, a consensus of recommendations was made among the members of the Committee for Analgesia, Sedation and Delirium of the Sociedad Argentina de Terapia Intensiva.

Results

Recommendations were agreed upon, and tools were developed to ensure a comprehensive approach to analgesia, sedation, delirium, early mobility and family engagement for adult patients with acute respiratory distress syndrome due to COVID-19.

Discussion

Given the new order generated in intensive therapies due to the advancing COVID-19 pandemic, we propose to not leave aside the usual good practices but to adapt them to the particular context generated. Our consensus is supported by scientific evidence and national and international experience and will be an attractive consultation tool in intensive therapies.

Sedation in the Intensive Care Unit

Purpose of Review

This narrative review illustrates literature over the last 5 years relating to sedation delivery to mechanically ventilated adult patients in intensive care units.

Recent Findings

There has been an increase in dexmedetomidine-related publications but although systematic reviews suggest dexmedetomidine reduces delirium, agitation, and length of stay, clinical trials have not supported these findings. It is likely to be useful for the managing patients with persisting agitation. Guidelines continue to recommend lightly sedating patients but considerable variation remains in clinical practice and in research trials. Protocols with no sedative infusions and morphine boluses as needed are feasible and safe, while educational interventions can decrease sedation-related adverse events.

Summary

Research trials have mainly focused on individual drugs rather than practice. Given evidence is slow to translate into practice; work is needed to understand and respond to the concerns of clinicians regarding deep sedation and agitation.

Challenges in Sedation Management in Critically Ill Patients with COVID-19: a Brief Review

Purpose of Review

To highlight the challenges associated with providing sedation and analgesia to critically ill patients with coronavirus disease 2019 (COVID-19) and also understand the pathophysiological alterations induced by the disease process as well as the logistical difficulties encountered by providers caring for these patients. We also discuss the rationale and risks associated with the use of common sedative agents specifically within the context of COVID-19 and provide evidence-based management strategies to help manage sedation and analgesia in such patients.

Recent Findings

A significant proportion of patients with COVID-19 require intensive care and mechanical ventilation, thus requiring sedation and analgesia. These patients tend to require higher doses of sedative medications and often for long periods of time. Most of the commonly used sedative and analgesic agents carry unique risks that should be considered within the context of the unique pathophysiology of COVID-19, the logistical issues the disease poses, and the ongoing drug shortages.

Summary

With little attention being paid to sedation practices specific to patients with COVID-19 in critical care literature and minimal mention in national guidelines, there is a significant gap in knowledge. We review the existing literature to discuss the unique challenges that providers face while providing sedation and analgesia to critically ill patients with COVID-19 and propose evidence-based management strategies.

Assessment and management of agitation, sleep, and mental illness in the surgical ICU

PURPOSE OF REVIEW

Increased focus on patient-centered outcomes, mental health, and delirium prevention makes this review timely and relevant for critical care.

RECENT FINDINGS

This review focuses on patient-centered outcomes in the ICU, highlighting the latest research to promote brain health and psychological recovery during and after perioperative critical illness. Topics include sedation in the obese patient, delirium severity assessments, the role of the Psychiatry Consultation-Liaison in the ICU, Post-intensive care syndrome, and the importance of family engagement in the COVID era.

SUMMARY

Highlighting new research, such as novel implementation strategies in addition to a lack of research in certain areas like sleep in the ICU may lead to innovation and establishment of evidence-based practices in critical care. Perioperative brain health is multifaceted, and an increase in multidisciplinary interventions may help improve outcomes and decrease morbidity in ICU survivors.

Adjunct low-dose ketamine infusion vs standard of care in mechanically ventilated critically ill patients at a Tertiary Saudi Hospital (ATTAINMENT Trial): study protocol for a randomized, prospective, pilot, feasibility trial

Background

A noticeable interest in ketamine infusion for sedation management has developed among critical care physicians for critically ill patients. The 2018 Pain, Agitation/sedation, Delirium, Immobility, and Sleep disruption guideline suggested low-dose ketamine infusion as an adjunct to opioid therapy to reduce opioid requirements in post-surgical patients in the intensive care unit (ICU). This was, however, rated as conditional due to the very low quality of evidence. Ketamine has favorable characteristics, making it an especially viable alternative for patients with respiratory and hemodynamic instability. The Analgo-sedative adjuncT keTAmine Infusion iN Mechanically vENTilated ICU patients (ATTAINMENT) trial aims to assess the effect and safety of adjunct low-dose continuous infusion of ketamine as an analgo-sedative compared to standard of care in critically ill patients on mechanical ventilation (MV) for ≥ 24 h.

Methods/design

This trial is a prospective, randomized, active controlled, open-label, pilot, feasibility study of adult ICU patients (> 14 years old) on MV. The study will take place in the adult ICUs in the King Faisal Specialist Hospital and Research Center (KFSH&RC), Riyadh, Saudi Arabia, and will enroll 80 patients. Patients will be randomized post-intubation into two groups: the intervention group will receive an adjunct low-dose continuous infusion of ketamine plus standard of care. Ketamine will be administered over a period of 48 h at a fixed infusion rate of 2 μg/kg/min (0.12 mg/kg/h) in the first 24 h followed by 1 μg/kg/min (0.06 mg/kg/h) in the second 24 h. The control group will receive standard of care in the ICU (propofol and/or fentanyl and/or midazolam) according to the KFSH&RC sedation and analgesia protocol as clinically appropriate. The primary outcome is MV duration until ICU discharge, death, extubation, or 28 days post-randomization, whichever comes first.

Discussion

The first patient was enrolled on 1 September 2019. As of 10 October 2019, a total of 16 patients had been enrolled. We expect to complete the recruitment by 31 December 2020. The findings of this pilot trial will likely justify further investigation for the role of adjunct low-dose ketamine infusion as an analgo-sedative agent in a larger, multicenter, randomized controlled trial.

Trial registration

ClinicalTrials.gov: NCT04075006. Registered on 30 August 2019. Current controlled trials: ISRCTN14730035. Registered on 3 February 2020.