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Amer M, Hylander Møller M, Alshahrani M, Shehabi Y, Arabi YM, Alshamsi F, Ingi Sigurðsson M, Rehn M, Chew MS, Kalliomäki ML, Lewis K, Al-Suwaidan FA, Al-Dorzi HM, Al-Fares A, Alsadoon N, Bell CM, Groth CM, Parke R, Mehta S, Wischmeyer PE, Al-Omari A, Olkkola KT, Alhazzani W. Ketamine Analgo-sedation for Mechanically Ventilated Critically Ill Adults: A Rapid Practice Guideline from the Saudi Critical Care Society and the Scandinavian Society of Anesthesiology and Intensive Care Medicine. Anesth Analg 2024:00000539-990000000-00925. [PMID: 39207913 DOI: 10.1213/ane.0000000000007173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
BACKGROUND This Rapid Practice Guideline (RPG) aimed to provide evidence‑based recommendations for ketamine analgo-sedation (monotherapy and adjunct) versus non-ketamine sedatives or usual care in adult intensive care unit (ICU) patients on invasive mechanical ventilation (iMV) and to identify knowledge gaps for future research. METHODS The RPG panel comprised 23 multinational multidisciplinary panelists, including a patient representative. An up-to-date systematic review and meta-analysis constituted the evidence base. The Grading Recommendations, Assessment, Development, and Evaluation approach, and the evidence-to-decision framework were used to assess the certainty of evidence and to move from evidence to decision/recommendation. The panel provided input on the balance of the desirable and undesirable effects, certainty of evidence, patients' values and preferences, costs, resources, equity, feasibility, acceptability, and research priorities. RESULTS Data from 17 randomized clinical trials (n=898) and 9 observational studies (n=1934) were included. There was considerable uncertainty about the desirable and undesirable effects of ketamine monotherapy for analgo-sedation. The evidence was very low certainty and downgraded for risk of bias, indirectness, and inconsistency. Uncertainty or variability in values and preferences were identified. Costs, resources, equity, and acceptability were considered varied. Adjunctive ketamine therapy had no effect on mortality (within 28 days) (relative risk [RR] 0.99; 95% confidence interval [CI] 0.76 to 1.27; low certainty), and may slightly reduce iMV duration (days) (mean difference [MD] -0.05 days; 95% CI -0.07 to -0.03; low certainty), and uncertain effect on the cumulative dose of opioids (mcg/kg/h morphine equivalent) (MD -11.6; 95% CI -20.4 to -2.7; very low certainty). Uncertain desirable effects (cumulative dose of sedatives and vasopressors) and undesirable effects (adverse event rate, delirium, arrhythmia, hepatotoxicity, hypersalivation, use of physical restraints) were also identified. A possibility of important uncertainty or variability in patient-important outcomes led to a balanced effect that favored neither the intervention nor the comparison. Cost, resources, and equity were considered varied. CONCLUSION The RPG panel provided two conditional recommendations and suggested (1) against using ketamine as monotherapy analgo-sedation in critically ill adults on iMV when other analgo-sedatives are available; and (2) using ketamine as an adjunct to non-ketamine usual care sedatives (e.g., opioids, propofol, dexmedetomidine) or continuing with non-ketamine usual care sedatives alone. Large-scale trials should provide additional evidence.
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Affiliation(s)
- Marwa Amer
- Medical/Critical Pharmacy Division, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
- College of Medicine and Pharmacy, Alfaisal University, Riyadh, Saudi Arabia
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Guidelines in Intensive Care Medicine, Development and Evaluation (GUIDE) Group, The Research Institute of St. Joe's, Hamilton, Canada
| | - Mohammed Alshahrani
- Department of Emergency and Critical Care, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Yahya Shehabi
- School of Clinical Sciences, Monash University, Clayton Campus, Victoria
- Clinical School of Medicine, University of New South Wales, Randwick Campus, New South Wales, Australia
| | - Yaseen M Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Alain, United Arab Emirates
| | - Martin Ingi Sigurðsson
- Faculty of Medicine, University of Iceland, Iceland
- Division of Anaesthesia and Intensive Care Medicine, Landspitali-The National University Hospital of Iceland, Iceland
| | - Marius Rehn
- Division of Prehospital Services, Air Ambulance Department, Oslo University Hospital, Oslo, Norway
- The Norwegian Air Ambulance Foundation, Oslo, Norway
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | | | - Kimberley Lewis
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Faisal A Al-Suwaidan
- Division of Neurology, Department of Medicine, Security Forces Hospital, Riyadh, Saudi Arabia
- Neurology Clinical Lead, Ministry of Health, Saudi Arabia
- College of Medicine, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
- College of Medicine, Dar Al-Uloom University, Riyadh, Saudi Arabia
| | - Hasan M Al-Dorzi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdulrahman Al-Fares
- Department of Anesthesia, Critical Care Medicine and Pain Medicine, Al-Amiri Hospital, Minister of Health, Kuwait City, Kuwait
- Kuwait Extracorporeal Life Support Program, Al-Amiri Center for Advance Respiratory and Cardiac Failure, Ministry of Health, Kuwait City, Kuwait
| | - Naif Alsadoon
- Alshaya International Trading Company, Riyadh, Saudi Arabia
| | - Carolyn M Bell
- Medical University of South Carolina Hospital Authority, Charleston, SC
- Medical University of South Carolina College of Pharmacy, Charleston, SC
| | | | - Rachael Parke
- School of Nursing University of Auckland, New Zealand
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - Sangeeta Mehta
- Dept. of Medicine, Mount Sinai Hospital; Interdepartmental Division of Intensive Care Medicine, Toronto, Canada
| | - Paul E Wischmeyer
- Deptartments of Anesthesiology and Surgery, Duke University School of Medicine, Durham, NC
| | - Awad Al-Omari
- Dr Sulaiman Al-Habib Medical Group, Critical Care Department, Riyadh, Saudi Arabia
| | - Klaus T Olkkola
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Waleed Alhazzani
- Guidelines in Intensive Care Medicine, Development and Evaluation (GUIDE) Group, The Research Institute of St. Joe's, Hamilton, Canada
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
- Department of Critical Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Scientific Research Center, Directorate General of Armed Forces Medical Services, Riyadh, Saudi Arabia
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Amer M, Møller MH, Alshahrani M, Shehabi Y, Arabi YM, Alshamsi F, Sigurðsson MI, Rehn M, Chew MS, Kalliomäki ML, Lewis K, Al-Suwaidan FA, Al-Dorzi HM, Al-Fares A, Alsadoon N, Bell CM, Groth CM, Parke R, Mehta S, Wischmeyer PE, Omeri A, Olkkola KT, Alhazzani W. Ketamine analgo-sedation for mechanically ventilated critically ill adults: A rapid practice guideline from the Saudi Critical Care Society and the Scandinavian Society of Anesthesiology and Intensive Care Medicine. Acta Anaesthesiol Scand 2024. [PMID: 39198198 DOI: 10.1111/aas.14470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 05/16/2024] [Accepted: 05/29/2024] [Indexed: 09/01/2024]
Abstract
BACKGROUND This Rapid Practice Guideline (RPG) aimed to provide evidence-based recommendations for ketamine analgo-sedation (monotherapy and adjunct) versus non-ketamine sedatives or usual care in adult intensive care unit (ICU) patients on invasive mechanical ventilation (iMV) and to identify knowledge gaps for future research. METHODS The RPG panel comprised 23 multinational multidisciplinary panelists, including a patient representative. An up-to-date systematic review and meta-analysis constituted the evidence base. The Grading Recommendations, Assessment, Development, and Evaluation approach, and the evidence-to-decision framework were used to assess the certainty of evidence and to move from evidence to decision/recommendation. The panel provided input on the balance of the desirable and undesirable effects, certainty of evidence, patients' values and preferences, costs, resources, equity, feasibility, acceptability, and research priorities. RESULTS Data from 17 randomized clinical trials (n = 898) and nine observational studies (n = 1934) were included. There was considerable uncertainty about the desirable and undesirable effects of ketamine monotherapy for analgo-sedation. The evidence was very low certainty and downgraded for risk of bias, indirectness, and inconsistency. Uncertainty or variability in values and preferences were identified. Costs, resources, equity, and acceptability were considered varied. Adjunctive ketamine therapy had no effect on mortality (within 28 days) (relative risk [RR] 0.99; 95% confidence interval [CI] 0.76 to 1.27; low certainty), and may slightly reduce iMV duration (days) (mean difference [MD] -0.05 days; 95% CI -0.07 to -0.03; low certainty), and uncertain effect on the cumulative dose of opioids (mcg/kg/h morphine equivalent) (MD -11.6; 95% CI -20.4 to -2.7; very low certainty). Uncertain desirable effects (cumulative dose of sedatives and vasopressors) and undesirable effects (adverse event rate, delirium, arrhythmia, hepatotoxicity, hypersalivation, use of physical restraints) were also identified. A possibility of important uncertainty or variability in patient-important outcomes led to a balanced effect that favored neither the intervention nor the comparison. Cost, resources, and equity were considered varied. CONCLUSION The RPG panel provided two conditional recommendations and suggested (1) against using ketamine as monotherapy analgo-sedation in critically ill adults on iMV when other analgo-sedatives are available; and (2) using ketamine as an adjunct to non-ketamine usual care sedatives (e.g., opioids, propofol, dexmedetomidine) or continuing with non-ketamine usual care sedatives alone. Large-scale trials should provide additional evidence.
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Affiliation(s)
- Marwa Amer
- Medical/Critical Pharmacy Division, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
- College of Medicine and Pharmacy, Alfaisal University, Riyadh, Saudi Arabia
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Guidelines in Intensive Care Medicine, Development and Evaluation (GUIDE) Group, The Research Institute of St. Joe's, Hamilton, Canada
| | - Mohammed Alshahrani
- Department of Emergency and Critical Care, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Yahya Shehabi
- School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
- Clinical School of Medicine, University of New South Wales, Randwick Campus, New South Wales, Australia
| | - Yaseen M Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Alain, United Arab Emirates
| | - Martin Ingi Sigurðsson
- Faculty of Medicine, University of Iceland, Reykjavík, Iceland
- Division of Anaesthesia and Intensive Care Medicine, Landspitali-The National University Hospital of Iceland, Reykjavík, Iceland
| | - Marius Rehn
- Division of Prehospital Services, Air Ambulance Department, Oslo University Hospital, Oslo, Norway
- The Norwegian Air Ambulance Foundation, Oslo, Norway
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | | | - Kimberley Lewis
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Faisal A Al-Suwaidan
- Division of Neurology, Department of Medicine, Security Forces Hospital, Riyadh, Saudi Arabia
- Neurology Clinical Lead, Ministry of Health, Riyadh, Saudi Arabia
- College of Medicine, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
- College of Medicine, Dar Al-Uloom University, Riyadh, Saudi Arabia
| | - Hasan M Al-Dorzi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdulrahman Al-Fares
- Department of Anesthesia, Critical Care Medicine and Pain Medicine, Al-Amiri Hospital, Minister of Health, Kuwait City, Kuwait
- Kuwait Extracorporeal Life Support Program, Al-Amiri Center for Advance Respiratory and Cardiac Failure, Ministry of Health, Kuwait City, Kuwait
| | - Naif Alsadoon
- Alshaya International Trading Company, Riyadh, Saudi Arabia
| | - Carolyn M Bell
- Medical University of South Carolina Hospital Authority, Charleston, South Carolina, USA
- Medical University of South Carolina College of Pharmacy, Charleston, South Carolina, USA
| | | | - Rachael Parke
- School of Nursing University of Auckland, Auckland, New Zealand
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - Sangeeta Mehta
- Department of Medicine, Mount Sinai Hospital; Interdepartmental Division of Intensive Care Medicine, Toronto, Canada
| | - Paul E Wischmeyer
- Deptartments of Anesthesiology and Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Awad Omeri
- Critical Care Department, Dr Sulaiman Al-Habib Medical Group, Riyadh, Saudi Arabia
| | - Klaus T Olkkola
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Waleed Alhazzani
- Guidelines in Intensive Care Medicine, Development and Evaluation (GUIDE) Group, The Research Institute of St. Joe's, Hamilton, Canada
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
- Department of Critical Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Scientific Research Center, Directorate General of Armed Forces Medical Services, Riyadh, Saudi Arabia
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Alwakeel M, Wang Y, Torbic H, Sacha GL, Wang X, Abi Fadel F, Duggal A. Impact of Sedation Practices on Mortality in COVID-19-Associated Adult Respiratory Distress Syndrome Patients: A Multicenter Retrospective Descriptive Study. J Intensive Care Med 2024; 39:646-654. [PMID: 38193291 DOI: 10.1177/08850666231224395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
Background: Reduction in sedation exposure is an important metric in intensive care unit (ICU) patients. However, challenges arose during the coronavirus disease-2019 (COVID-19) pandemic in adhering to this practice, driven by concerns on transmission and disease severity issues. Accordingly, diverse sedation approaches emerged, although the effect on mortality has not been studied thoroughly. Methods: Retrospective cohort study in the medical ICU of seven hospitals within a major Health System in Northeast Ohio. We included all adult patients admitted with COVID-19 requiring invasive mechanical ventilation (IMV) from March 2020 to December 2021. Results: Study included 2394 COVID-19 patients requiring IMV. Across waves, sample included 55-63% male subjects, with an average age of 61-68 years (P < 0.001), Acute Physiologic and Chronic Health Evaluation (APACHE)-III score 65.8-68.9 (P = 0.37), median IMV duration 8-10 days (P = 0.14), and median ICU duration 9.8-11.6 days (P = 0.084). Propofol remained the primary sedative (84-92%; P = 0.089). Ketamine use increased from the first (9.7%) to fourth (19%) wave (P = 0.002). Midazolam use decreased from the first (27.4%) to third (9.4%) wave (P = 0.001). Dexmedetomidine use declined from 35% to 27-28% (P = 0.002) after the first wave. A multivariable regression analysis indicated clinical variables explained 34% of the variation in hospital mortality (R2). Factors associated with higher mortality included age [aOR = 1.059 (95% CI 1.049-1.069); P < 0.001], COVID-19 wave, especially fourth wave [aOR = 2.147, (95% CI 1.370-3.365); P = 0.001], and higher number of vasopressors [aOR = 31.636, (95% CI 17.603-56.856); P < 0.001]. Addition of sedative medications to a second model led to an increase in the R2 by only 1.6% to 35.6% [aOR = 1 (95% CI 1-1); P > 0.05] for propofol, ketamine, and midazolam. Dexmedetomidine demonstrated a decrease in the odds of mortality [aOR = 0.96 (95% CI 0.94-0.97); P < 0.001]. Conclusion: Mortality in critical COVID-19 patients was mostly driven by illness severity, and the choice of sedation might have minimal impact when other factors are controlled.
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Affiliation(s)
- Mahmoud Alwakeel
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Yan Wang
- Department of Anesthesiology, Boston Medical Center, Boston, Massachusetts, USA
| | - Heather Torbic
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Xiaofeng Wang
- Qualitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Francois Abi Fadel
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Abhijit Duggal
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Phan B, Agyemang A, Klein W, Thapamagar SB. Continuous Infusion of Ketamine in Mechanically Ventilated Patients with SARS-CoV-2. Crit Care Res Pract 2024; 2024:7765932. [PMID: 38766546 PMCID: PMC11101250 DOI: 10.1155/2024/7765932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 04/22/2024] [Accepted: 04/27/2024] [Indexed: 05/22/2024] Open
Abstract
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.
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Affiliation(s)
- Brian Phan
- Department of Pharmacy, Riverside University Health System, Moreno Valley, California, USA
- Department of Internal Medicine, University of California, Riverside School of Medicine, Riverside, California, USA
| | - Afua Agyemang
- Department of Pharmacy, Allegheny General Hospital, Pittsburg, Pennsylvania, USA
| | - Walter Klein
- Department of Internal Medicine, University of California, Riverside School of Medicine, Riverside, California, USA
- Department of Medicine, Riverside University Health System, Moreno Valley, California, USA
- Department of Medicine, Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Suman B. Thapamagar
- Department of Medicine, Riverside University Health System, Moreno Valley, California, USA
- Department of Medicine, Loma Linda University School of Medicine, Loma Linda, California, USA
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Aljuhani O, Al Sulaiman K, Korayem GB, Altebainawi AF, Alshaya A, Nahari M, Alsamnan K, Alkathiri MA, Al-Dosari BS, Alenazi AA, Alsohimi S, Alnajjar LI, Alfaifi M, AlQussair N, Alanazi RM, Alhmoud MF, Alanazi NL, Alkofide H, Alenezi AM, Vishwakarma R. Ketamine-based Sedation Use in Mechanically Ventilated Critically Ill Patients with COVID-19: A Multicenter Cohort Study. Saudi Pharm J 2024; 32:102061. [PMID: 38596319 PMCID: PMC11002878 DOI: 10.1016/j.jsps.2024.102061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 04/01/2024] [Indexed: 04/11/2024] Open
Abstract
Backgrounds Ketamine possesses analgesia, anti-inflammation, anticonvulsant, and neuroprotection properties. However, the evidence that supports its use in mechanically ventilated critically ill patients with COVID-19 is insufficient. The study's goal was to assess ketamine's effectiveness and safety in critically ill, mechanically ventilated (MV) patients with COVID-19. Methods Adult critically ill patients with COVID-19 were included in a multicenter retrospective-prospective cohort study. Patients admitted between March 1, 2020, and July 31, 2021, to five ICUs in Saudi Arabia were included. Eligible patients who required MV within 24 hours of ICU admission were divided into two sub-cohort groups based on their use of ketamine (Control vs. Ketamine). The primary outcome was the length of stay (LOS) in the hospital. P/F ratio differences, lactic acid normalization, MV duration, and mortality were considered secondary outcomes. Propensity score (PS) matching was used (1:2 ratio) based on the selected criteria. Results In total, 1,130 patients met the eligibility criteria. Among these, 1036 patients (91.7 %) were in the control group, whereas 94 patients (8.3 %) received ketamine. The total number of patients after PS matching, was 264 patients, including 88 patients (33.3 %) who received ketamine. The ketamine group's LOS was significantly lower (beta coefficient (95 % CI): -0.26 (-0.45, -0.07), P = 0.008). Furthermore, the PaO2/FiO2 ratio significantly improved 24 hours after the start of ketamine treatment compared to the pre-treatment period (6 hours) (124.9 (92.1, 184.5) vs. 106 (73.1, 129.3; P = 0.002). Additionally, the ketamine group had a substantially shorter mean time for lactic acid normalization (beta coefficient (95 % CI): -1.55 (-2.42, -0.69), P 0.01). However, there were no significant differences in the duration of MV or mortality. Conclusions Ketamine-based sedation was associated with lower hospital LOS and faster lactic acid normalization but no mortality benefits in critically ill patients with COVID-19. Thus, larger prospective studies are recommended to assess the safety and effectiveness of ketamine as a sedative in critically ill adult patients.
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Affiliation(s)
- Ohoud Aljuhani
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Khalid Al Sulaiman
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center-King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard – Health Affairs, Riyadh, Saudi Arabia
- Saudi Critical Care Pharmacy Research (SCAPE) Platform, Riyadh, Saudi Arabia
- Saudi Society for Multidisciplinary Research Development and Education (SCAPE Society), Riyadh, Saudi Arbia
| | - Ghazwa B. Korayem
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah bint Abdulrahman University, P.O. Box 84428, Riyadh 11671, Saudi Arabia
| | - Ali F. Altebainawi
- Pharmaceutical Care Services, King Salman Specialist Hospital, Hail Health Cluster, Hail, Saudi Arabia
- Department of Clinical Pharmacy, College of Pharmacy, University of Hail, Hail, Saudi Arabia
| | - Abdulrahman Alshaya
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center-King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard – Health Affairs, Riyadh, Saudi Arabia
| | - Majed Nahari
- Pharmaceutical Care Services, King Abdullah bin Abdulaziz University Hospital, Riyadh, Saudi Arabia
| | - Khuzama Alsamnan
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah bint Abdulrahman University, P.O. Box 84428, Riyadh 11671, Saudi Arabia
| | - Munirah A. Alkathiri
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Bodoor S. Al-Dosari
- Pharmaceutical Care Services, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Abeer A. Alenazi
- Pharmaceutical Care Department, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Samiah Alsohimi
- Pharmaceutical Care Department, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Lina I. Alnajjar
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah bint Abdulrahman University, P.O. Box 84428, Riyadh 11671, Saudi Arabia
| | - Mashael Alfaifi
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Nora AlQussair
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Reem M. Alanazi
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Munirah F. Alhmoud
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Nadin L. Alanazi
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Hadeel Alkofide
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Aljawharah M. Alenezi
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ramesh Vishwakarma
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
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Wyler D, Torjman MC, Leong R, Baram M, Denk W, Long SC, Gawel RJ, Viscusi ER, Wainer IW, Schwenk ES. Observational study of the effect of ketamine infusions on sedation depth, inflammation, and clinical outcomes in mechanically ventilated patients with SARS-CoV-2. Anaesth Intensive Care 2024; 52:105-112. [PMID: 38006606 DOI: 10.1177/0310057x231201184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2023]
Abstract
Severely ill patients with COVID-19 are challenging to sedate and often require high-dose sedation and analgesic regimens. Ketamine can be an effective adjunct to facilitate sedation of critically ill patients but its effects on sedation level and inflammation in COVID-19 patients have not been studied. This retrospective, observational cohort study evaluated the effect of ketamine infusions on inflammatory biomarkers and clinical outcomes in mechanically ventilated patients with SARS-CoV-2 infection. A total of 186 patients were identified (47 received ketamine, 139 did not). Patients who received ketamine were significantly younger than those who did not (mean (standard deviation) 59.2 (14.2) years versus 66.3 (14.4) years; P = 0.004), but there was no statistically significant difference in body mass index (P = 0.25) or sex distribution (P = 0.91) between groups. Mechanically ventilated patients who received ketamine infusions had a statistically significant reduction in Richmond Agitation-Sedation Scale score (-3.0 versus -2.0, P < 0.001). Regarding inflammatory biomarkers, ketamine was associated with a reduction in ferritin (P = 0.02) and lactate (P = 0.01), but no such association was observed for C-reactive protein (P = 0.27), lactate dehydrogenase (P = 0.64) or interleukin-6 (P = 0.87). No significant association was observed between ketamine administration and mortality (odds ratio 0.971; 95% confidence interval 0.501 to 1.882; P = 0.93). Ketamine infusion was associated with improved sedation depth in mechanically ventilated COVID-19 patients and provided a modest anti-inflammatory benefit but did not confer benefit with respect to mortality or intensive care unit length of stay.
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Affiliation(s)
- David Wyler
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, USA
| | - Marc C Torjman
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, USA
| | - Ron Leong
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, USA
| | - Michael Baram
- Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, USA
| | - William Denk
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Sara C Long
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, USA
| | - Richard J Gawel
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, USA
| | - Eugene R Viscusi
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, USA
| | | | - Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, USA
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