1
|
Vollmer NJ, Wieruszewski ED, Nei AM, Mara KC, Rabinstein AA, Brown CS. Impact of Continuous Infusion Ketamine Compared to Continuous Infusion Benzodiazepines on Delirium in the Intensive Care Unit. J Intensive Care Med 2024:8850666241253541. [PMID: 38778678 DOI: 10.1177/08850666241253541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Purpose: The purpose of this study was to evaluate rates of delirium or coma-free days between continuous infusion sedative-dose ketamine and continuous infusion benzodiazepines in critically ill patients. Materials and Methods: In this single-center, retrospective cohort adult patients were screened for inclusion if they received continuous infusions of either sedative-dose ketamine or benzodiazepines (lorazepam or midazolam) for at least 24 h, were mechanically ventilated for at least 48 h and admitted to the intensive care unit of a large quaternary academic center between 5/5/2018 and 12/1/2021. Results: A total of 165 patients were included with 64 patients in the ketamine group and 101 patients in the benzodiazepine group (lorazepam n = 35, midazolam n = 78). The primary outcome of median (IQR) delirium or coma-free days within the first 28 days of hospitalization was 1.2 (0.0, 3.7) for ketamine and 1.8 (0.7, 4.6) for benzodiazepines (p = 0.13). Patients in the ketamine arm spent a significantly lower proportion of time with RASS -3 to +4, received significantly higher doses and longer durations of propofol and fentanyl infusions, and had a significantly longer intensive care unit length of stay. Conclusions: The use of sedative-dose ketamine had no difference in delirium or coma-free days compared to benzodiazepines.
Collapse
Affiliation(s)
| | - Erin D Wieruszewski
- Department of Pharmacy, Mayo Clinic Hospital, Rochester, MN, USA
- Department of Emergency Medicine, Mayo Clinic Hospital, Rochester, MN, USA
| | - Andrea M Nei
- Department of Pharmacy, Mayo Clinic Hospital, Rochester, MN, USA
| | - Kristin C Mara
- Department of Quantitative Health Sciences, Mayo Clinic Hospital, Rochester, MN, USA
| | | | - Caitlin S Brown
- Department of Pharmacy, Mayo Clinic Hospital, Rochester, MN, USA
- Department of Emergency Medicine, Mayo Clinic Hospital, Rochester, MN, USA
| |
Collapse
|
2
|
Leong AY, Burry L, Fiest KM, Doig CJ, Niven DJ. Does pain optimisation impact delirium outcomes in critically ill patients? A systematic review and meta-analysis protocol. BMJ Open 2024; 14:e078395. [PMID: 38262636 PMCID: PMC10806641 DOI: 10.1136/bmjopen-2023-078395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 12/20/2023] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND Untreated pain is associated with short-term and long-term consequences, including post-traumatic stress disorder and insomnia. Side effects of some analgesic medications include dysphoria, hallucinations and delirium. Therefore, both untreated pain and analgesic medications may be risk factors for delirium. Delirium is associated with longer length of stay or cognitive impairment. Our systematic review and meta-analysis will examine the relationship between pain or analgesic medications with delirium occurrence, duration and severity among critically ill adults. METHODS AND ANALYSIS MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of controlled trials and a review of recent conference abstracts will be searched without restriction from inception to 15 May 2023. Study inclusion criteria are: (1) age≥18 years admitted to intensive care; (2) report a measure of pain, analgesic medications and delirium; (3) study design-randomised controlled trial, quasiexperimental designs and observational cohort and case-control studies excluding case reports. Study exclusion criteria are: (1) alcohol withdrawal delirium or delirium tremens; or (2) general anaesthetic emergence delirium; or (3) lab or animal studies. Risk of bias will be assessed with the Risk of Bias V.2 and risk of bias in non-randomised studies tools. There is no language restriction. Occurrence estimates will be transformed using the Freeman-Tukey double arcsine. Point estimates will be pooled using Hartung-Knapp Sidik-Jonkman random effects meta-analysis to estimate a pooled risk ratio. Statistical heterogeneity will be estimated with the I2 statistic. Risk of small study effects will be assessed using funnel plots and Egger test. Studies will be analysed for time-varying and unmeasured confounding using E values. ETHICS AND DISSEMINATION Ethical approval is not required as this is an analysis of published aggregated data. We will share our findings at conferences and in peer-reviewed journals. PROSPERO REGISTRATION NUMBER The finalised protocol was submitted to the International Prospective Register of Systematic Reviews (PROSPERO ID: CRD42022367715).
Collapse
Affiliation(s)
- Amanda Y Leong
- Department of Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Pharmacy Services, Alberta Health Services, Calgary, Alberta, Canada
| | - Lisa Burry
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Lunenfeld-Tanebaum Research Institute and Departments of Pharmacy and Medicine, Mount Sinai Hospital, Sinai Health, Toronto, Ontario, Canada
| | - Kirsten M Fiest
- Department of Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christopher J Doig
- Department of Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Daniel J Niven
- Department of Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
3
|
Evanoff AB, Baig M, Taylor JB, Beach SR. Ketamine: A Practical Review for the Consultation-Liaison Psychiatrist. J Acad Consult Liaison Psychiatry 2023; 64:521-532. [PMID: 37301324 DOI: 10.1016/j.jaclp.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 04/15/2023] [Accepted: 06/01/2023] [Indexed: 06/12/2023]
Abstract
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.
Collapse
Affiliation(s)
- Anastasia B Evanoff
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Department of Psychiatry, McLean Hospital, Belmont, MA.
| | - Mirza Baig
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Department of Psychiatry, McLean Hospital, Belmont, MA
| | - John B Taylor
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | - Scott R Beach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| |
Collapse
|
4
|
Laws JC, Vance EH, Betters KA, Anderson JJ, Fleishman S, Bonfield CM, Wellons JC, Xu M, Slaughter JC, Giuse DA, Patel N, Jordan LC, Wolf MS. Acute Effects of Ketamine on Intracranial Pressure in Children With Severe Traumatic Brain Injury. Crit Care Med 2023; 51:563-572. [PMID: 36825892 DOI: 10.1097/ccm.0000000000005806] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
OBJECTIVES The acute cerebral physiologic effects of ketamine in children have been incompletely described. We assessed the acute effects of ketamine on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) in children with severe traumatic brain injury (TBI). DESIGN In this retrospective observational study, patients received bolus doses of ketamine for sedation or as a treatment for ICP crisis (ICP > 20 mm Hg for > 5 min). Administration times were synchronized with ICP and CPP recordings at 1-minute intervals logged in an automated database within the electronic health record. ICP and CPP were each averaged in epochs following drug administration and compared with baseline values. Age-based CPP thresholds were subtracted from CPP recordings and compared with baseline values. Trends in ICP and CPP over time were assessed using generalized least squares regression. SETTING A 30-bed tertiary care children's hospital PICU. PATIENTS Children with severe TBI who underwent ICP monitoring. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We analyzed data from 33 patients, ages 1 month to 16 years, 22 of whom received bolus doses of ketamine, with 127 doses analyzed. Demographics, patient, and injury characteristics were similar between patients who did versus did not receive ketamine boluses. In analysis of the subset of ketamine doses used only for sedation, there was no significant difference in ICP or CPP from baseline. Eighteen ketamine doses were given during ICP crises in 11 patients. ICP decreased following these doses and threshold-subtracted CPP rose. CONCLUSIONS In this retrospective, exploratory study, ICP did not increase following ketamine administration. In the setting of a guidelines-based protocol, ketamine was associated with a reduction in ICP during ICP crises. If these findings are reproduced in a larger study, ketamine may warrant consideration as a treatment for intracranial hypertension in children with severe TBI.
Collapse
Affiliation(s)
- Jennifer C Laws
- Division of Critical Care Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - E Haley Vance
- Division of Pediatric Neurological Surgery, Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Kristina A Betters
- Division of Critical Care Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Jessica J Anderson
- Department of Pharmacy, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
| | | | - Christopher M Bonfield
- Division of Pediatric Neurological Surgery, Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - John C Wellons
- Division of Pediatric Neurological Surgery, Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Meng Xu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - James C Slaughter
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Dario A Giuse
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Neal Patel
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Lori C Jordan
- Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Michael S Wolf
- Division of Critical Care Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
- Division of Pediatric Neurological Surgery, Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN
| |
Collapse
|
5
|
Beckwith N, Probert J, Rosenbaum BL, Bains A, Angelucci VC, Morfin Rodriguez AE, London S, Zollman JW, Soto Ordoñez A, Kontos N, Smith FA, Celano CM, Beach SR. Demographic Features, Physical Examination Findings, and Medication Use in Hospitalized, Delirious Patients With and Without COVID-19 Infection: A Retrospective Study. J Acad Consult Liaison Psychiatry 2023; 64:35-44. [PMID: 35948255 PMCID: PMC9357932 DOI: 10.1016/j.jaclp.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/25/2022] [Accepted: 07/29/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Delirium is common in the setting of infection with severe acute respiratory syndrome coronavirus 2. Anecdotal evidence and case reports suggest that patients with delirium in the setting of Coronavirus 2019 (COVID-19) may exhibit specific features, including increased tone, abulia, and alogia. OBJECTIVE To determine whether differences exist in sociodemographic and medical characteristics, physical examination findings, and medication use in delirious patients with and without COVID-19 infection referred for psychiatric consultation. METHODS We undertook an exploratory, retrospective chart review of 486 patients seen by the psychiatry consultation service at a tertiary care hospital from March 10 to May 15, 2020. Delirious patients were diagnosed via clinical examination by a psychiatric consultant, and these patients were stratified by COVID-19 infection status. The strata were described and compared using bivariate analyses across sociodemographic, historical, objective, and treatment-related variables. RESULTS A total of 109 patients were diagnosed with delirium during the study period. Thirty-six were COVID-19+. Median age was 63 years and did not differ between groups. COVID-19+ patients with delirium were more likely to present from nursing facilities (39% vs 11%; Fisher's exact test; P = 0.001) and have a history of schizophrenia (11% vs 0%; Fisher's exact test; P = 0.011). Myoclonus (28% vs 4%; P = 0.002), hypertonia (36% vs 10%; P = 0.003), withdrawal (36% vs 15%; P = 0.011), akinesia (19% vs 6%; P = 0.034), abulia (19% vs 3%; P = 0.004), and alogia (25% vs 8%; P = 0.012) were more common in COVID-19+ patients. COVID-19+ delirious patients were significantly more likely to have received ketamine (28% vs 7%; P = 0.006), alpha-adrenergic agents besides dexmedetomidine (36% vs 14%; P = 0.014), and enteral antipsychotics (92% vs 66%; P = 0.007) at some point. CONCLUSIONS Patients with COVID-19 delirium referred for psychiatric consultation are more likely to reside in nursing facilities and have a history of schizophrenia than delirious patients without COVID-19. Patients with delirium in the setting of COVID-19 may exhibit features consistent with akinetic mutism. Psychiatrists must assess for such features, as they may influence management choices and the risk of side effects with agents commonly used in the setting of delirium.
Collapse
Affiliation(s)
- Noor Beckwith
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Julia Probert
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA; McLean Hospital, Belmont, MA
| | - Blake L Rosenbaum
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA; McLean Hospital, Belmont, MA
| | - Ashika Bains
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Victoria C Angelucci
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA; McLean Hospital, Belmont, MA
| | - Alejandra E Morfin Rodriguez
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA; McLean Hospital, Belmont, MA
| | - Stephanie London
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA; McLean Hospital, Belmont, MA
| | - Joshua W Zollman
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA; McLean Hospital, Belmont, MA
| | - Andrea Soto Ordoñez
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA; McLean Hospital, Belmont, MA
| | - Nicholas Kontos
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Felicia A Smith
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Christopher M Celano
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Scott R Beach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| |
Collapse
|
6
|
Blecha S, Zeman F, Rohr M, Dodoo-Schittko F, Brandstetter S, Karagiannidis C, Apfelbacher C, Bein T. Association of analgosedation with psychiatric symptoms and health-related quality of life in ARDS survivors: Post hoc analyses of the DACAPO study. PLoS One 2022; 17:e0275743. [PMID: 36269731 PMCID: PMC9586389 DOI: 10.1371/journal.pone.0275743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 09/22/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The acute respiratory distress syndrome (ARDS) is a life-threatening condition with the risk of developing hypoxia and thus requires for invasive mechanical ventilation a long-term analgosedation. Yet, prolonged analgosedation may be a reason for declining health-related quality of life (HRQoL) and the development of psychiatric disorders. METHODS We used data from the prospective observational nation‑wide ARDS study across Germany (DACAPO) to investigate the influence of sedation and analgesia on HRQoL and the risk of psychiatric symptoms in ARDS survivors 3, 6 and 12 months after their discharge from the intensive care unit (ICU). HRQoL was measured with the Physical and Mental Component Scale of the Short‑Form 12 Questionnaire (PCS‑12, MCS‑12). The prevalence of psychiatric symptoms (depression and post‑traumatic stress disorder [PTSD]) was assessed using the Patient Health Questionnaire‑9 and the Post‑Traumatic Stress Syndrome‑14. The associations of analgosedation with HRQoL and psychiatric symptoms were investigated by means of multivariable linear regression models. RESULTS The data of 134 ARDS survivors (median age [IQR]: 55 [44-64], 67% men) did not show any significant association between analgosedation and physical or mental HRQoL up to 1 year after ICU discharge. Multivariable linear regression analysis (B [95%‑CI]) yielded a significant association between symptoms of psychiatric disorders and increased cumulative doses of ketamine up to 6 months after ICU discharge (after 3 months: depression: 0.15 [0.05, 0.25]; after 6 months: depression: 0.13 [0.03, 0.24] and PTSD: 0.42 [0.04, 0.80)]). CONCLUSIONS Up to 1 year after ICU discharge, analgosedation did not influence HRQoL of ARDS survivors. Prolonged administration of ketamine during ICU treatment, however, was positively associated with the risk of psychiatric symptoms. The administration of ketamine to ICU patients with ARDS should be with caution. TRIAL REGISTRATION Clinicaltrials.gov: NCT02637011 (Registered 15 December 2015, retrospectively registered).
Collapse
Affiliation(s)
- Sebastian Blecha
- Department of Anaesthesiology, University Medical Centre Regensburg, Regensburg, Germany,* E-mail:
| | - Florian Zeman
- Centre of Clinical Studies, University Medical Centre Regensburg, Regensburg, Germany
| | - Magdalena Rohr
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany
| | - Frank Dodoo-Schittko
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany
| | - Susanne Brandstetter
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany
| | - Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Cologne, Germany
| | - Christian Apfelbacher
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany
| | - Thomas Bein
- Faculty of Medicine, University of Regensburg, Regensburg, Germany
| | | |
Collapse
|
7
|
Jung H, Lee J, Ahn HY, Yang JH, Suh GY, Ko RE, Chung CR. Safety and feasibility of continuous ketamine infusion for analgosedation in medical and cardiac ICU patients who received mechanical ventilation support: A retrospective cohort study. PLoS One 2022; 17:e0274865. [PMID: 36137164 PMCID: PMC9499237 DOI: 10.1371/journal.pone.0274865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 09/07/2022] [Indexed: 12/16/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Hohyung Jung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jihye Lee
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyun Young Ahn
- Department of Pharmaceutical Services, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeong Hoon Yang
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University, Seoul, Republic of Korea
| | - Ryoung-Eun Ko
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- * E-mail: (REK); (CRC)
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University, Seoul, Republic of Korea
- * E-mail: (REK); (CRC)
| |
Collapse
|
8
|
Abstract
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.
Collapse
|
9
|
Chan K, Burry LD, Tse C, Wunsch H, De Castro C, Williamson DR. Impact of Ketamine on Analgosedative Consumption in Critically Ill Patients: A Systematic Review and Meta-Analysis. Ann Pharmacother 2022; 56:1139-1158. [PMID: 35081769 PMCID: PMC9393656 DOI: 10.1177/10600280211069617] [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] [Indexed: 11/25/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Katalina Chan
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Novo Nordisk Canada Inc, Mississauga, ON, Canada
| | - Lisa D Burry
- Department of Pharmacy and Medicine, Sinai Health System, Toronto, ON, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Christopher Tse
- Department of Pharmacy, Princess Margaret Hospital, Toronto, ON, Canada
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Charmaine De Castro
- Sidney Liswood Health Sciences Library, Sinai Health System, Toronto, ON, Canada
| | - David R Williamson
- Faculté de Pharmacie, Université de Montréal, Montréal, QC, Canada.,Pharmacy Department and Research Center, CIUSSS du nord-de-l'Île-de-Montréal, Sacré-Cœur Hospital, Montréal, QC, Canada
| |
Collapse
|