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Kast KA, Sidelnik SA, Nejad SH, Suzuki J. Management of alcohol withdrawal syndromes in general hospital settings. BMJ 2025; 388:e080461. [PMID: 39778965 DOI: 10.1136/bmj-2024-080461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2025]
Abstract
The covid-19 pandemic was associated with an unprecedented increase in alcohol consumption and associated morbidity, including hospitalizations for alcohol withdrawal. Clinicians based in hospitals must be ready to identify, assess, risk-stratify, and treat alcohol withdrawal with evidence based interventions. In this clinically focused review, we outline the epidemiology, pathophysiology, clinical manifestations, screening, assessment, and treatment of alcohol withdrawal in the general hospital population. We review and summarize studies addressing the drug treatment of alcohol withdrawal syndromes in inpatient populations, with a focus on the use of benzodiazepine drugs, phenobarbital, antiseizure drugs, and α-2 adrenergic drugs. Emerging areas of interest include the use of novel alcohol biomarkers, risk stratification instruments, alternative symptom severity scales, severe withdrawal syndromes resistant to benzodiazepine drugs, and treatment protocol variations-including non-symptom-triggered and benzodiazepine-sparing protocols. We identify key areas for research including identification of populations who will benefit from non-benzodiazepine strategies, more individualized risk stratification approaches to guide treatment, and greater inclusion of gender and racial and ethnic minorities in future studies.
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Affiliation(s)
- Kristopher A Kast
- Vanderbilt University Medical Center, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - S Alex Sidelnik
- New York University Langone Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Shamim H Nejad
- Addiction Medicine Consultation Services, Psychiatry Consultation Services, Valley Medical Center, Renton, WA, USA
| | - Joji Suzuki
- Division of Addiction Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Kotani Y, Russotto V. Induction Agents for Tracheal Intubation in Critically Ill Patients. Crit Care Med 2024:00003246-990000000-00410. [PMID: 39774375 DOI: 10.1097/ccm.0000000000006506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2025]
Abstract
OBJECTIVES Concise definitive review of the use of induction agents in critically ill patients undergoing tracheal intubation and their association with outcomes. DATA SOURCES Original publications were retrieved through a PubMed search with search terms related to induction agents for tracheal intubation in critically ill patients. STUDY SELECTION We included randomized controlled trials and observational studies that reported patient outcomes. DATA EXTRACTION Data from included studies, including choice of induction agents and clinically relevant outcomes, were extracted. DATA SYNTHESIS Etomidate and ketamine have been the most studied induction agents in critical care during last years. Recent studies on etomidate investigated the clinical impact of its recognized adrenal suppression in terms of morbidity and mortality. Etomidate may carry a non-negligible mortality risk without definitive hemodynamic benefits compared with ketamine. Available data then support the use of ketamine over etomidate, since the difference in the hemodynamic profile seems to be of minor clinical relevance. No multicenter randomized studies are available comparing propofol to other induction agents but evidence from a large observational study identified an association of propofol with post-intubation cardiovascular instability in critically ill patients. Despite the observational nature of these findings cannot exclude the role of confounders, the association of propofol with post-induction cardiovascular instability is pharmacologically plausible, justifying its avoidance in favor of drugs with a better safety profile in critical care such as ketamine. CONCLUSIONS Although no definitive conclusions can be drawn based on the available evidence, recent evidence pointed out the potential negative effect of etomidate on survival and the association of propofol with cardiovascular instability. Ketamine may be considered the drug with a safer profile, widespread availability and low cost but future research should provide definitive data on optimal drug selection, its dosage in the context of critical illness and concomitant interventions to minimize the risk of peri-intubation complications.
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Affiliation(s)
- Yuki Kotani
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Vincenzo Russotto
- Department of Anesthesia and Critical Care, AOU S. Luigi Gonzaga, Orbassano, Turin, Italy
- Department of Oncology, University of Turin, Turin, Italy
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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, 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. Acta Anaesthesiol Scand 2024; 68:1161-1178. [PMID: 39198198 DOI: 10.1111/aas.14470] [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] [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 Al-Omari
- 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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4
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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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5
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Royce-Nagel G, Jarzebowski M, Wongsripuemtet P, Krishnamoorthy V, Fuller M, Ohnuma T, Treggiari M, Yaport M, Cobert J, Garrigan E, Bartz R, Raghunathan K. Use of Early Ketamine Sedation and Association With Clinical and Cost Outcomes Among Mechanically Ventilated Patients With COVID-19: A Retrospective Cohort Study. Crit Care Explor 2024; 6:e1105. [PMID: 38904975 PMCID: PMC11196078 DOI: 10.1097/cce.0000000000001105] [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: 06/22/2024] Open
Abstract
OBJECTIVES To describe the utilization of early ketamine use among patients mechanically ventilated for COVID-19, and examine associations with in-hospital mortality and other clinical outcomes. DESIGN Retrospective cohort study. SETTING Six hundred ten hospitals contributing data to the Premier Healthcare Database between April 2020 and June 2021. PATIENTS Adults with COVID-19 and greater than or equal to 2 consecutive days of mechanical ventilation within 5 days of hospitalization. INTERVENTION The exposures were early ketamine use initiated within 2 days of intubation and continued for greater than 1 day. MEASUREMENTS Primary was hospital mortality. Secondary outcomes included length of stay (LOS) in the hospital and ICUs, ventilator days, vasopressor days, renal replacement therapy (RRT), and total hospital cost. The propensity score matching analysis was used to adjust for confounders. MAIN RESULTS Among 42,954 patients, 1,423 (3.3%) were exposed to early ketamine use. After propensity score matching including 1,390 patients in each group, recipients of ketamine infusions were associated with higher hospital mortality (52.5% vs. 45.9%, risk ratio: 1.14, [1.06-1.23]), longer median ICU stay (13 vs. 12 d, mean ratio [MR]: 1.15 [1.08-1.23]), and longer ventilator days (12 vs. 11 d, MR: 1.19 [1.12-1.27]). There were no associations for hospital LOS (17 [10-27] vs. 17 [9-28], MR: 1.05 [0.99-1.12]), vasopressor days (4 vs. 4, MR: 1.04 [0.95-1.14]), and RRT (22.9% vs. 21.7%, RR: 1.05 [0.92-1.21]). Total hospital cost was higher (median $72,481 vs. $65,584, MR: 1.11 [1.05-1.19]). CONCLUSIONS In a diverse sample of U.S. hospitals, about one in 30 patients mechanically ventilated with COVID-19 received ketamine infusions. Early ketamine may have an association with higher hospital mortality, increased total cost, ICU stay, and ventilator days, but no associations for hospital LOS, vasopressor days, and RRT. However, confounding by the severity of illness might occur due to higher extracorporeal membrane oxygenation and RRT use in the ketamine group. Further randomized trials are needed to better understand the role of ketamine infusions in the management of critically ill patients.
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Affiliation(s)
- Galen Royce-Nagel
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Mary Jarzebowski
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
| | - Pattrapun Wongsripuemtet
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Bangkok, Thailand
| | - Vijay Krishnamoorthy
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Matthew Fuller
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Tetsu Ohnuma
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Miriam Treggiari
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Miguel Yaport
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Julien Cobert
- Department of Anesthesiology, University of California, San Francisco, CA
| | - Ethan Garrigan
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Raquel Bartz
- Department of Anesthesiology, Brigham and Women’s Hospital, Boston, MA
| | - Karthik Raghunathan
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
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6
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Ilg AM, Beltran CP, Shih JA, Yankama TT, Hayes MM, Moskowitz AL. Experiential Learning with Ketamine: A Mixed-Methods Exploratory Study on Prescription and Perception. Ther Clin Risk Manag 2024; 20:381-390. [PMID: 38934016 PMCID: PMC11199167 DOI: 10.2147/tcrm.s462760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Accepted: 06/09/2024] [Indexed: 06/28/2024] Open
Abstract
Background Incorporating unfamiliar therapies into practice requires effective longitudinal learning and the optimal way to achieve this is debated. Though not a novel therapy, ketamine in critical care has a paucity of data and variable acceptance, with limited research describing intensivist perceptions and utilization. The Coronavirus-19 pandemic presented a particular crisis where providers rapidly adapted analgosedation strategies to achieve prolonged, deep sedation due to a surge of severe acute respiratory distress syndrome (ARDS). Question How does clinical experience with ketamine impact the perception and attitude of clinicians toward this therapy? Methods We conducted a mixed-methods study using quantitative ketamine prescription data and qualitative focus group data. We analyzed prescription patterns of ketamine in a tertiary academic ICU during two different time points: pre-COVID-19 (March 1-June 30, 2019) and during the COVID-19 surge (March 1-June 30, 2020). Two focus groups (FG) of critical care attendings were held, and data were analyzed using the Framework Method for content analysis. Results Four-hundred forty-six medical ICU patients were mechanically ventilated (195 pre-COVID-19 and 251 during COVID-19). The COVID-19 population was more likely to receive ketamine (81[32.3%] vs 4 [2.1%], p < 0.001). Thirteen respondents participated across two FG sessions (Pre-COVID = 8, Post-COVID=5). The most prevalent attitude among our respondents was discomfort, with three key themes identified as follows: 1) lack of evidence regarding ketamine, 2) lack of personal experience, and 3) desire for more education and protocols. Conclusion Despite a substantial increase in ketamine prescription during COVID-19, intensivists continued to feel discomfort with utilization. Factors contributing to this discomfort include a lack of evidence, a lack of experience, and a desire for more education and protocols. Increase in experience with ketamine alone was not sufficient to minimize provider discomfort. These findings should inform future curricula and call for process improvement to optimize continuing education.
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Affiliation(s)
- Annette M Ilg
- Division of Emergency Critical Care, Department of Emergency Medicine, Mass General Brigham, Boston, MA, USA
| | - Christine P Beltran
- Carl J, Shapiro Institute for Education and Research, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jenny A Shih
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Pulmonary and Critical Care, Brigham and Women’s Hospital, Boston, MA, USA
| | - Tuyen T Yankama
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Margaret M Hayes
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ari L Moskowitz
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Division of Critical Care Medicine, Department of Medicine, Montefiore Medical Center, Bronx, New York, NY, USA
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7
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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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8
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Peters BJ, Kooda KJ, Brown CS, Miles TM, Kangas CA, Mara KC, Rivera M, Skrupky LP. Ketamine for Primary Analgosedation in Critically Ill Surgery and Trauma Patients Requiring Mechanical Ventilation. Crit Care Explor 2024; 6:e1041. [PMID: 38283259 PMCID: PMC10817103 DOI: 10.1097/cce.0000000000001041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024] Open
Abstract
OBJECTIVES Evaluate effectiveness and safety outcomes associated with the use of ketamine for primary analgosedation in the surgical/trauma ICU setting. DESIGN Retrospective cohort study. SETTING Academic medical center in Minnesota. PATIENTS Patients admitted to the surgical ICU between 2015 and 2019 requiring mechanical ventilation and meeting one of three definitions for ketamine primary analgosedation were included: 1) no concomitant opioid infusion, 2) ketamine monotherapy for greater than or equal to 6 hours with subsequent opioid infusion, or 3) ketamine initiated concomitantly or within 4 hours of opioid and total opioid duration less than 4 hours. INTERVENTIONS None. MEASUREMENTS Use of ketamine, analgesics, and sedatives were evaluated. Pain, sedation, and delirium assessments immediately before and during ketamine infusion were collected and compared with reported goals. Concomitant analgesics, sedatives, and psychotropics were recorded. Reported failures due to ineffectiveness and toxicity were collected. MAIN RESULTS Of 164 included patients, 88% never received a concomitant opioid infusion (primary analgosedation definition 1), 12% met alternative criteria for primary analgosedation (definitions 2 and 3). A majority, 68%, were surgical admissions and mean Acute Physiology and Chronic Health Evaluation III score was 90 (± 30). Median mechanical ventilation duration was 2.5 days (1.1-4.5) and ICU length of stay of 4.9 days (3-8). The median ketamine infusion dose and duration were 0.18 mg/kg/hr (0.1-0.3) and 30 hours (15.1-51.8). Concomitant infusions of propofol and dexmedetomidine were administered in 49% and 29% of patients, respectively. During ketamine infusion, the median percent of total pain scores at goal was 62% (33-96%), while 64% (37-91%) of Richmond Agitation Sedation Scale scores were at goal, and 47% of patients were Confusion Assessment Method-ICU positive during the ketamine infusion. Hallucinations were documented in 14% of patients and ketamine failure occurred in 11% of patients. CONCLUSIONS Ketamine may be an effective primary analgosedation option in intubated surgical ICU patients, but prospective randomized studies are needed to evaluate this strategy.
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Affiliation(s)
| | | | | | - Todd M Miles
- Department of Trauma, Critical Care, and General Surgery, Mayo Clinic, Rochester, MN
| | - Corrie A Kangas
- Department of Trauma, Critical Care, and General Surgery, Mayo Clinic, Rochester, MN
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Mariela Rivera
- Department of Trauma, Critical Care, and General Surgery, Mayo Clinic, Rochester, MN
| | - Lee P Skrupky
- Center for Clinical Knowledge Management, University of Wisconsin Health, Madison, WI
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9
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Abdildin Y, Tapinova K, Nemerenova A, Viderman D. The impact of ketamine on outcomes in critically ill patients: a systematic review with meta-analysis and trial sequential analysis of randomized controlled trials. Acute Crit Care 2024; 39:34-46. [PMID: 38476062 PMCID: PMC11002615 DOI: 10.4266/acc.2023.00829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 12/25/2023] [Accepted: 01/03/2024] [Indexed: 03/14/2024] Open
Abstract
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.
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Affiliation(s)
- Yerkin Abdildin
- Department of Mechanical and Aerospace Engineering, School of Engineering and Digital Sciences, Nazarbayev University, Astana, Kazakhstan
| | - Karina Tapinova
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Assel Nemerenova
- Department of Mechanical and Aerospace Engineering, School of Engineering and Digital Sciences, Nazarbayev University, Astana, Kazakhstan
| | - Dmitriy Viderman
- Department of Surgery, School of Medicine, Nazarbayev University, Astana, Kazakhstan
- Department of Anesthesiology, Intensive Care, and Pain Medicine, National Research Oncology Center, Astana, Kazakhstan
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10
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Savić Vujović K, Jotić A, Medić B, Srebro D, Vujović A, Žujović J, Opanković A, Vučković S. Ketamine, an Old-New Drug: Uses and Abuses. Pharmaceuticals (Basel) 2023; 17:16. [PMID: 38276001 PMCID: PMC10820504 DOI: 10.3390/ph17010016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 11/27/2023] [Accepted: 12/04/2023] [Indexed: 01/27/2024] Open
Abstract
Ketamine as an old-new drug has a variety of clinical implications. In the last 30 years, ketamine has become popular for acute use in humans. Ketamine in standard doses is principally utilized for the induction and maintenance of surgical procedures. Besides its use in anesthesia and analgesia, recent studies have shown that ketamine has found a place in the treatment of asthma, epilepsy, depression, bipolar affective disorders, alcohol and heroin addiction. Ketamine primarily functions as a noncompetitive antagonist targeting the N-methyl-D-aspartate (NMDA) receptor, but its mechanism of action is complex. It is generally regarded as safe, with low doses and short-term use typically not leading to significant adverse effects. Also, ketamine is known as a powerful psychostimulant. During the past decade, ketamine has been one of the commonly abused drugs.
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Affiliation(s)
- Katarina Savić Vujović
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, 11129 Belgrade, Serbia; (B.M.); (D.S.); (S.V.)
| | - Ana Jotić
- Clinic for Otorhinolaryngology and Maxillofacial Surgery, University Clinical Center of Serbia, Pasterova 2, 11000 Belgrade, Serbia;
| | - Branislava Medić
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, 11129 Belgrade, Serbia; (B.M.); (D.S.); (S.V.)
| | - Dragana Srebro
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, 11129 Belgrade, Serbia; (B.M.); (D.S.); (S.V.)
| | | | - Janko Žujović
- Clinical Centre of Montenegro, Centre for Abdominal Surgery, 81000 Podgorica, Montenegro;
| | - Ana Opanković
- Clinical Centre of Serbia, Clinic for Psychiatry, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
| | - Sonja Vučković
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, 11129 Belgrade, Serbia; (B.M.); (D.S.); (S.V.)
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11
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Pérez Lucendo A, Piñeiro Otero P, Matía Almudévar P, Alcántara Carmona S, López López E, Ramasco Rueda F. Individualised analgesia, sedation, delirium and comfort management strategies in the ICU: a narrative review. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:509-535. [PMID: 37742996 DOI: 10.1016/j.redare.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 03/20/2023] [Indexed: 09/26/2023]
Abstract
This group is a product of the collaboration agreement signed by SOMIAMA (Sociedad de Medicina Intensiva de Madrid) and SAR MADRID (Sociedad de Anestesiología, Reanimación y Terapéutica del Dolor de Madrid) under which the organisations agreed to create joint working groups to improve critical patient care. Pain, discomfort, agitation, and delirium cause suffering, delay discharge, and can lead to serious complications in patients admitted to medical and surgical critical care units and post-anaesthesia care units. The main objectives in this type of unit include: Ensuring the comfort of patients suffering or recovering from a critical illness.Avoiding complications associated with the measures, particularly pharmacological, taken to ensure that comfort.
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Affiliation(s)
- A Pérez Lucendo
- Servicio de Medicina Intensiva, Hospital Universitario de La Princesa, Madrid, Spain.
| | - P Piñeiro Otero
- Servicio de Anestesiología y Reanimación, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - P Matía Almudévar
- Servicio de Medicina Intensiva, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - S Alcántara Carmona
- Servicio de Medicina Intensiva, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - E López López
- Servicio de Anestesiología y Reanimación, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - F Ramasco Rueda
- Servicio de Anestesiología y Reanimación, Hospital Universitario de La Princesa, Madrid, Spain
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12
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Davydova NY, Hutner DA, Gaither KA, Singh DK, Prasad B, Davydov DR. High-Throughput Assay of Cytochrome P450-Dependent Drug Demethylation Reactions and Its Use to Re-Evaluate the Pathways of Ketamine Metabolism. BIOLOGY 2023; 12:1055. [PMID: 37626940 PMCID: PMC10451610 DOI: 10.3390/biology12081055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 08/27/2023]
Abstract
In a search for a reliable, inexpensive, and versatile technique for high-throughput kinetic assays of drug metabolism, we elected to rehire an old-school approach based on the determination of formaldehyde (FA) formed in cytochrome P450-dependent demethylation reactions. After evaluating several fluorometric techniques for FA detection, we chose the method based on the Hantzsch reaction with acetoacetanilide as the most sensitive, robust, and adaptable to high-throughput implementation. Here we provide a detailed protocol for using our new technique for automatized assays of cytochrome P450-dependent drug demethylations and discuss its applicability for high-throughput scanning of drug metabolism pathways in the human liver. To probe our method further, we applied it to re-evaluating the pathways of metabolism of ketamine, a dissociative anesthetic and potent antidepressant increasingly used in the treatment of alcohol withdrawal syndrome. Probing the kinetic parameters of ketamine demethylation by ten major cytochrome P450 (CYP) enzymes, we demonstrate that in addition to CYP2B6 and CYP3A enzymes, which were initially recognized as the primary metabolizers of ketamine, an important role is also played by CYP2C19 and CYP2D6. At the same time, the involvement of CYP2C9 suggested in the previous reports was deemed insignificant.
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Affiliation(s)
- Nadezhda Y. Davydova
- Department of Chemistry, Washington State University, Pullman, WA 99164, USA; (N.Y.D.); (D.A.H.)
| | - David A. Hutner
- Department of Chemistry, Washington State University, Pullman, WA 99164, USA; (N.Y.D.); (D.A.H.)
| | - Kari A. Gaither
- Department of Pharmaceutical Sciences, Washington State University, Spokane, WA 99202, USA; (K.A.G.); (D.K.S.); (B.P.)
| | - Dilip Kumar Singh
- Department of Pharmaceutical Sciences, Washington State University, Spokane, WA 99202, USA; (K.A.G.); (D.K.S.); (B.P.)
| | - Bhagwat Prasad
- Department of Pharmaceutical Sciences, Washington State University, Spokane, WA 99202, USA; (K.A.G.); (D.K.S.); (B.P.)
| | - Dmitri R. Davydov
- Department of Chemistry, Washington State University, Pullman, WA 99164, USA; (N.Y.D.); (D.A.H.)
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13
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Choi EJ, Kim CH, Yoon JY, Kim EJ. Ketamine-propofol (ketofol) in procedural sedation: a narrative review. J Dent Anesth Pain Med 2023; 23:123-133. [PMID: 37313271 PMCID: PMC10260354 DOI: 10.17245/jdapm.2023.23.3.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 05/15/2023] [Accepted: 05/18/2023] [Indexed: 06/15/2023] Open
Abstract
Sedation methods for dental treatment are increasingly explored. Recently, ketofol, which is a combination of ketamine and propofol, has been increasingly used because the advantages and disadvantages of propofol and ketamine complement each other and increase their effectiveness. In this review, we discuss the pharmacology of ketamine and propofol, use of ketofol in various clinical situations, and differences in efficacy between ketofol and other sedatives.
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Affiliation(s)
- Eun-Ji Choi
- Department of Dental Anesthesia and Pain Medicine, School of Dentistry, Dental Research Institute, Dental and Life Science Institute, Pusan National University, Yangsan, Republic of Korea
| | - Cheul-Hong Kim
- Department of Dental Anesthesia and Pain Medicine, School of Dentistry, Dental Research Institute, Dental and Life Science Institute, Pusan National University, Yangsan, Republic of Korea
| | - Ji-Young Yoon
- Department of Dental Anesthesia and Pain Medicine, School of Dentistry, Dental Research Institute, Dental and Life Science Institute, Pusan National University, Yangsan, Republic of Korea
| | - Eun-Jung Kim
- Department of Dental Anesthesia and Pain Medicine, School of Dentistry, Dental Research Institute, Dental and Life Science Institute, Pusan National University, Yangsan, Republic of Korea
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14
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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 PMCID: PMC11441348 DOI: 10.1097/ccm.0000000000005806] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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.
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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
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15
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De Bels D, Bousbiat I, Perriens E, Blackman S, Honoré PM. Sedation for adult ICU patients: A narrative review including a retrospective study of our own data. Saudi J Anaesth 2023; 17:223-235. [PMID: 37260674 PMCID: PMC10228859 DOI: 10.4103/sja.sja_905_22] [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: 12/29/2022] [Revised: 01/06/2023] [Accepted: 01/19/2023] [Indexed: 06/02/2023] Open
Abstract
The optimization of patients' treatment in the intensive care unit (ICU) needs a lot of information and literature analysis. Many changes have been made in the last years to help evaluate sedated patients by scores to help take care of them. Patients were completely sedated and had continuous intravenous analgesia and neuromuscular blockades. These three drug classes were the main drugs used for intubated patients in the ICU. During these last 20 years, ICU management went from fully sedated to awake, calm, and nonagitated patients, using less sedatives and choosing other drugs to decrease the risks of delirium during or after the ICU stay. Thus, the usefulness of these three drug classes has been challenged. The analgesic drugs used were primarily opioids but the use of other drugs instead is increasing to lessen or wean the use of opioids. In severe acute respiratory distress syndrome patients, neuromuscular blocking agents have been used frequently to block spontaneous respiration for 48 hours or more; however, this has recently been abolished. Optimizing a patient's comfort during hemodynamic or respiratory extracorporeal support is essential to reduce toxicity and secondary complications.
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Affiliation(s)
- David De Bels
- Intensive Care Unit, Brugmann University Hospital, Brussels, Belgium
| | - Ibrahim Bousbiat
- Intensive Care Unit, Brugmann University Hospital, Brussels, Belgium
| | - Emily Perriens
- Intensive Care Unit, Brugmann University Hospital, Brussels, Belgium
| | - Sydney Blackman
- Intensive Care Unit, Brugmann University Hospital, Brussels, Belgium
| | - Patrick M Honoré
- Department of Intensive Care, CHU UCL Godinne Namur, UCL Louvain Medical School, Yvoir, Belgium
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16
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Huang TH, Lai MC, Chen YS, Huang CW. The Roles of Glutamate Receptors and Their Antagonists in Status Epilepticus, Refractory Status Epilepticus, and Super-Refractory Status Epilepticus. Biomedicines 2023; 11:biomedicines11030686. [PMID: 36979664 PMCID: PMC10045490 DOI: 10.3390/biomedicines11030686] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 02/18/2023] [Accepted: 02/21/2023] [Indexed: 03/30/2023] Open
Abstract
Status epilepticus (SE) is a neurological emergency with a high mortality rate. When compared to chronic epilepsy, it is distinguished by the durability of seizures and frequent resistance to benzodiazepine (BZD). The Receptor Trafficking Hypothesis, which suggests that the downregulation of γ-Aminobutyric acid type A (GABAA) receptors, and upregulation of N-methyl-D-aspartate (NMDA) and α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptors play major roles in the establishment of SE is the most widely accepted hypothesis underlying BZD resistance. NMDA and AMPA are ionotropic glutamate receptor families that have important excitatory roles in the central nervous system (CNS). They are both essential in maintaining the normal function of the brain and are involved in a variety of neuropsychiatric diseases, including epilepsy. Based on animal and human studies, antagonists of NMDA and AMPA receptors have a significant impact in ending SE; albeit most of them are not yet approved to be in clinically therapeutic guidelines, due to their psychomimetic adverse effects. Although there is still a dearth of randomized, prospective research, NMDA antagonists such as ketamine, magnesium sulfate, and the AMPA antagonist, perampanel, are regarded to be reasonable optional adjuvant therapies in controlling SE, refractory SE (RSE) or super-refractory SE (SRSE), though there are still a lack of randomized, prospective studies. This review seeks to summarize and update knowledge on the SE development hypothesis, as well as clinical trials using NMDA and AMPA antagonists in animal and human studies of SE investigations.
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Affiliation(s)
- Tzu-Hsin Huang
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70142, Taiwan
- Zhengxin Neurology & Rehabilitation Center, Tainan 70459, Taiwan
| | - Ming-Chi Lai
- Department of Pediatrics, Chi-Mei Medical Center, Tainan 71004, Taiwan
| | - Yu-Shiue Chen
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70142, Taiwan
| | - Chin-Wei Huang
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70142, Taiwan
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17
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Hyland SJ, Wetshtein AM, Grable SJ, Jackson MP. Acute Pain Management Pearls: A Focused Review for the Hospital Clinician. Healthcare (Basel) 2022; 11:healthcare11010034. [PMID: 36611494 PMCID: PMC9818465 DOI: 10.3390/healthcare11010034] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/15/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Acute pain management is a challenging area encountered by inpatient clinicians every day. While patient care is increasingly complex and costly in this realm, the availability of applicable specialists is waning. This narrative review seeks to support diverse hospital-based healthcare providers in refining and updating their acute pain management knowledge base through clinical pearls and point-of-care resources. Practical guidance is provided for the design and adjustment of inpatient multimodal analgesic regimens, including conventional and burgeoning non-opioid and opioid therapies. The importance of customized care plans for patients with preexisting opioid tolerance, chronic pain, or opioid use disorder is emphasized, and current recommendations for inpatient management of associated chronic therapies are discussed. References to best available guidelines and literature are offered for further exploration. Improved clinician attention and more developed skill sets related to acute pain management could significantly benefit hospitalized patient outcomes and healthcare resource utilization.
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Affiliation(s)
- Sara J. Hyland
- Department of Pharmacy, OhioHealth Grant Medical Center, Columbus, OH 43215, USA
- Correspondence:
| | - Andrea M. Wetshtein
- Department of Pharmacy, Cleveland Clinic Fairview Hospital, Cleveland, OH 44111, USA
| | - Samantha J. Grable
- Hospice and Palliative Medicine, OhioHealth Grant Medical Center, Columbus, OH 43215, USA
| | - Michelle P. Jackson
- Hospice and Palliative Medicine, OhioHealth Grant Medical Center, Columbus, OH 43215, USA
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18
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Sivakumar S, Ghasemi M, Schachter SC. Targeting NMDA Receptor Complex in Management of Epilepsy. Pharmaceuticals (Basel) 2022; 15:ph15101297. [PMID: 36297409 PMCID: PMC9609646 DOI: 10.3390/ph15101297] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 10/17/2022] [Accepted: 10/20/2022] [Indexed: 11/05/2022] Open
Abstract
N-methyl-D-aspartate receptors (NMDARs) are widely distributed in the central nervous system (CNS) and play critical roles in neuronal excitability in the CNS. Both clinical and preclinical studies have revealed that the abnormal expression or function of these receptors can underlie the pathophysiology of seizure disorders and epilepsy. Accordingly, NMDAR modulators have been shown to exert anticonvulsive effects in various preclinical models of seizures, as well as in patients with epilepsy. In this review, we provide an update on the pathologic role of NMDARs in epilepsy and an overview of the NMDAR antagonists that have been evaluated as anticonvulsive agents in clinical studies, as well as in preclinical seizure models.
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Affiliation(s)
- Shravan Sivakumar
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
| | - Mehdi Ghasemi
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
- Correspondence: (M.G.); (S.C.S.)
| | - Steven C. Schachter
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
- Harvard Medical School, Boston, MA 02114, USA
- Consortia for Improving Medicine with Innovation & Technology (CIMIT), Boston, MA 02114, USA
- Correspondence: (M.G.); (S.C.S.)
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Tanem JM, Scott JP. Common Presentations of Rare Drug Reactions and Atypical Presentations of Common Drug Reactions in the Intensive Care Unit. Crit Care Clin 2022; 38:287-299. [DOI: 10.1016/j.ccc.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Midega TD, Chaves RCDF, Ashihara C, Alencar RM, Queiroz VNF, Zelezoglo GR, Vilanova LCDS, Olivato GB, Cordioli RL, Bravim BDA, Corrêa TD. Ketamine use in critically ill patients: a narrative review. Rev Bras Ter Intensiva 2022; 34:287-294. [PMID: 35946660 DOI: 10.5935/0103-507x.20220027-pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 05/08/2022] [Indexed: 11/20/2022] Open
Abstract
Ketamine is unique among anesthetics and analgesics. The drug is a rapid-acting general anesthetic that produces an anesthetic state characterized by profound analgesia, preserved pharyngeal-laryngeal reflexes, normal or slightly enhanced skeletal muscle tone, cardiovascular and respiratory stimulation, and occasionally a transient and minimal respiratory depression. Research has demonstrated the efficacy of its use on anesthesia, pain, palliative care, and intensive care. Recently, it has been used for postoperative and chronic pain, as an adjunct in psychotherapy, as a treatment for depression and posttraumatic stress disorder, as a procedural sedative, and as a treatment for respiratory and/or neurologic clinical conditions. Despite being a safe and widely used drug, many physicians, such as intensivists and those practicing in emergency care, are not aware of the current clinical applications of ketamine. The objective of this narrative literature review is to present the theoretical and practical aspects of clinical applications of ketamine in intensive care unit and emergency department settings.
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Affiliation(s)
- Thais Dias Midega
- Departamento de Medicina Intensiva, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | | | - Carolina Ashihara
- Departamento de Anestesiologia, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | - Roger Monteiro Alencar
- Departamento de Medicina Intensiva, Hospital Municipal Dr. Moysés Deutsch - São Paulo (SP), Brasil
| | | | | | | | | | - Ricardo Luiz Cordioli
- Departamento de Medicina Intensiva, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | - Bruno de Arruda Bravim
- Departamento de Medicina Intensiva, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | - Thiago Domingos Corrêa
- Departamento de Medicina Intensiva, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
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Casamento A, Niccol T. Efficacy and safety of ketamine in mechanically ventilated intensive care unit patients: a scoping review. CRIT CARE RESUSC 2022; 24:71-82. [PMID: 38046843 PMCID: PMC10692604 DOI: 10.51893/2022.1.oa9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: Mechanically ventilated patients account for about one-third of all admissions to the intensive care unit (ICU). Ketamine has been conditionally recommended to aid with analgesia in such patients, with low quality of evidence available to support this recommendation. We aimed to perform a narrative scoping review of the current knowledge of the use of ketamine, with a specific focus on mechanically ventilated ICU patients. Methods: We searched MEDLINE and EMBASE for relevant articles. Bibliographies of retrieved articles were examined for references of potential relevance. We included studies that described the use of ketamine for postoperative and emergency department management of pain and in the critically unwell, mechanically ventilated population. Results: There are few randomised controlled trials evaluating ketamine's utility in the ICU. The evidence is predominantly retrospective and observational in nature and the results are heterogeneous. Available evidence is summarised in a descriptive manner, with a division made between high dose and low dose ketamine. Ketamine's pharmacology and use as an analgesic agent outside of the ICU is briefly discussed, followed by evidence for use in the ICU setting, with particular emphasis on analgesia, sedation and intubation. Finally, data on adverse effects including delirium, coma, haemodynamic adverse effects, raised intracranial pressure, hypersalivation and laryngospasm are presented. Conclusions: Ketamine is used in mechanically ventilated ICU patients with several potentially positive clinical effects. However, it has a significant side effect profile, which may limit its use in these patients. The role of low dose ketamine infusion in mechanically ventilated ICU patients is not well studied and requires investigation in high quality, prospective randomised trials.
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Affiliation(s)
- Andrew Casamento
- Intensive Care Unit, Austin Health, Melbourne, VIC, Australia
- Intensive Care Unit, Northern Hospital, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
| | - Thomas Niccol
- Intensive Care Unit, Austin Health, Melbourne, VIC, Australia
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Temporal Trends and Variability in Ketamine Use for Mechanically Ventilated Adults in the United States. Ann Am Thorac Soc 2022; 19:1534-1542. [PMID: 35176218 DOI: 10.1513/annalsats.202112-1376oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale The epidemiology of continuous ketamine use in the management of critically ill adults receiving invasive mechanical ventilation (MV) in the U.S. is unknown. Objective To quantify the temporal trends and variation across U.S. hospitals in continuous ketamine use. Methods We performed a retrospective cohort study of adults (age ≥18) receiving MV who were discharged (alive or dead) from U.S. hospitals contributing data to the Premier Healthcare Database between January 2008 and September 2018. We used mixed effects multivariable logistic regression modeling (fixed effects: patient and hospital characteristics; random effect: discharge hospital) to evaluate the associations of discharge quarter and discharge hospital with continuous ketamine use (defined as a charge for intravenous ketamine on ≥2 consecutive calendar days). Results We identified 2,059,599 MV adults across 842 hospitals; of these, 7,927 (0.4%) received continuous ketamine. Ketamine use increased over time from 0.07% of all patients in quarter 1 2008 to 1.1% of all patients in quarter 3 2018. After adjustment, the odds of receiving continuous ketamine were consistently increased starting in quarter 4 2011 (odds ratio [95% confidence interval]: 1.83 [1.09-3.06] vs quarter 1 2008, p=0.023) with >10-fold increased odds starting in quarter 2 2017. Out of 842 hospitals, 486 (57.7%) used continuous ketamine on at least one cohort patient during the study period. Across these hospitals ever using ketamine, median use was 0.2% (IQR 0.08%-0.5%) with 5 hospitals using continuous ketamine in >5% of patients. The adjusted median odds ratio for discharge hospital was 3.72 (95% confidence interval: 3.37-4.13) which was higher than the odds ratio for any patient or hospital covariable other than discharge quarter. Conclusions In U.S. hospitals, use of continuous infusion ketamine increased markedly over time in critically ill patients receiving MV, with substantial variability between hospitals. Given the unique properties of ketamine as a sedative, further research is needed to assess its safety and utility in critically ill populations.
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Management of Life-Threatening Asthma. Chest 2022; 162:747-756. [DOI: 10.1016/j.chest.2022.02.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 02/07/2022] [Accepted: 02/16/2022] [Indexed: 11/22/2022] Open
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Choi JW, Shin JW. Early Combination Therapy of Ketamine and Midazolam in Patients with Refractory Status Epilepticus in Hemodynamic Unstable State. J Epilepsy Res 2021; 11:150-153. [PMID: 35087725 PMCID: PMC8767219 DOI: 10.14581/jer.21023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 11/04/2021] [Accepted: 11/04/2021] [Indexed: 01/25/2023] Open
Abstract
The use of anesthetics is inevitable to suppress seizure activity in refractory status epilepticus (RSE). Hypotension, which is a critical side effect observed when treating RSE using a higher dosage of anesthetics that enhance γ-aminobutyric acid (GABA) activity, often requires vasopressor agents. Concomitant treatment with N-methyl-D-aspartate (NMDA) receptor antagonists, such as ketamine, could be effective in prolonged refractory SE, while maintaining stable blood pressure owing to the blockage of catecholamine reuptake in the systemic circulation. We report two cases of patients who had RSE with hemodynamic instability treated promptly with an early combination of ketamine and low-dose midazolam. The combination treatment effectively suppressed epileptic discharge with less hemodynamic side effects; moreover, a low dose of midazolam was required when combined with ketamine therapy. The initial combination of a third-line therapy that blocks NMDA receptors with enhanced GABAergic activity could be useful in RSE. Further studies are necessary in many variable etiologies of SE.
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Affiliation(s)
- Jung-Won Choi
- Department of Neurology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Jung-Won Shin
- Department of Neurology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
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Abstract
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.
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Seak YS, Nor J, Tuan Kamauzaman TH, Arithra A, Islam MA. Efficacy and Safety of Intranasal Ketamine for Acute Pain Management in the Emergency Setting: A Systematic Review and Meta-Analysis. J Clin Med 2021; 10:jcm10173978. [PMID: 34501425 PMCID: PMC8432265 DOI: 10.3390/jcm10173978] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 08/07/2021] [Accepted: 08/31/2021] [Indexed: 02/06/2023] Open
Abstract
Due to overcrowding, personnel shortages, or problematic intravenous (IV) cannulation, acute pain management is often sub-optimal in emergency departments (EDs). The objective of this systematic review and meta-analysis was to evaluate the efficacy and safety of intranasal (IN) ketamine for adult acute pain in the emergency setting. We searched and identified studies up to 21 May 2021 via PubMed, Scopus, Web of Science, Cochrane Database, and Google Scholar. The random-effects model with 95% confidence intervals (CIs) was used to estimate mean differences (MDs) and odds ratios (ORs). The I2 statistic and Cochran’s Q test were used to determine heterogeneity. The protocol was registered in PROSPERO (CRD42020213391). Seven randomised controlled trials were included with a total of 1760 patients. There was no significant difference in pain scores comparing IN ketamine with IV analgesics or placebo at 5 (MD 0.94, p = 0.26), 15 (MD 0.15, p = 0.74), 25 (MD 0.24, p = 0.62), 30 (MD −0.05, p = 0.87), and 60 (MD −0.42, p = 0.53) minutes. There was also no significant difference in the need for rescue analgesics between IN ketamine and IV analgesics (OR 1.66, 95% CI: 0.57−4.86, p = 0.35, I2 = 70%). Only mild adverse effects were observed in patients who received IN ketamine. Our results suggest that IN ketamine is non-inferior to IV analgesics and may have a role in acute pain management among adults in the ED.
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Affiliation(s)
- Yee Sin Seak
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia; (Y.S.S.); (T.H.T.K.); (A.A.)
- Hospital Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
| | - Junainah Nor
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia; (Y.S.S.); (T.H.T.K.); (A.A.)
- Hospital Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
- Correspondence: (J.N.); (M.A.I.)
| | - Tuan Hairulnizam Tuan Kamauzaman
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia; (Y.S.S.); (T.H.T.K.); (A.A.)
- Hospital Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
| | - Ariff Arithra
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia; (Y.S.S.); (T.H.T.K.); (A.A.)
- Hospital Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
| | - Md Asiful Islam
- Department of Haematology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
- Correspondence: (J.N.); (M.A.I.)
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Amer M, Maghrabi K, Bawazeer M, Alshaikh K, Shaban M, Rizwan M, Amin R, De Vol E, Baali M, Altewerki M, Bano M, Alkhaldi F, Alenazi S, Hijazi M. Adjunctive ketamine for sedation in critically ill mechanically ventilated patients: an active-controlled, pilot, feasibility clinical trial. J Intensive Care 2021; 9:54. [PMID: 34462007 PMCID: PMC8404029 DOI: 10.1186/s40560-021-00569-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 08/25/2021] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Ketamine has been shown to decrease sedative requirements in intensive care unit (ICU). Randomized trials are limited on patient-centered outcomes. We designed this pilot trial to evaluate the feasibility of a large randomized controlled trial (RCT) testing the effect of ketamine as an adjunct analgosedative compared with standard of care alone as a control group (CG) in critically ill patients with mechanical ventilation (MV). We also provided preliminary evidence on clinically relevant outcomes to plan a larger trial. MATERIAL AND METHODS Pilot, active-controlled, open-label RCT was conducted at medical, surgical, and transplant ICUs at a large tertiary and quaternary care medical institution (King Faisal Specialist Hospital and Research Center, Saudi Arabia). The study included adult patients who were intubated within 24 h, expected to require MV for the next calendar day, and had institutional pain and sedation protocol initiated. Patients were randomized in a 1:1 ratio to adjunct ketamine infusion 1-2 μg/kg/min for 48 h or CG alone. RESULTS Of 437 patients screened from September 2019 through November 2020, 83 (18.9%) patients were included (43 in CG and 40 in ketamine) and 352 (80.5%) were excluded. Average enrollment rate was 3-4 patients/month. Consent and protocol adherence rates were adequate (89.24% and 76%, respectively). Demographics were balanced between groups. Median MV duration was 7 (interquartile range [IQR] 3-9.25 days) in ketamine and 5 (IQR 2-8 days) in CG. Median VFDs was 19 (IQR 0-24.75 days) in ketamine and 19 (IQR 0-24 days) in the CG (p = 0.70). More patients attained goal Richmond Agitation-Sedation Scale at 24 and 48 h in ketamine (67.5% and 73.5%, respectively) compared with CG (52.4% and 66.7%, respectively). Sedatives and vasopressors cumulative use, and hemodynamic changes were similar. ICU length-of-stay was 12.5 (IQR 6-21.2 days) in ketamine, compared with 12 (IQR 5.5-23 days) in CG. No serious adverse events were observed in either group. CONCLUSIONS Ketamine as an adjunct analgosedative agent appeared to be feasible and safe with no negative impact on outcomes, including hemodynamics. This pilot RCT identified areas of improvement in study protocol before conducting a large, adequately powered, multicenter RCT which is likely justified to investigate ketamine association with patient-centered outcomes further. Trial registration ClinicalTrials.gov: NCT04075006. Registered on 30 August 2019. Current controlled trials: ISRCTN14730035. Registered on 3 February 2020.
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Affiliation(s)
- Marwa Amer
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Center, (MBC # 11), PO Box 3354, Riyadh, 11211, Kingdom of Saudi Arabia. .,College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
| | - Khalid Maghrabi
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.,Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mohammed Bawazeer
- Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Kamel Alshaikh
- Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mohammad Shaban
- Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Muhammad Rizwan
- Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Rashid Amin
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Center, (MBC # 11), PO Box 3354, Riyadh, 11211, Kingdom of Saudi Arabia
| | - Edward De Vol
- Biostatistics, Epidemiology & Scientific Computing Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mawadah Baali
- Biostatistics, Epidemiology & Scientific Computing Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Malak Altewerki
- Department of Neurosciences, Residency Training Program, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mehreen Bano
- Departments of Nursing, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Fawziah Alkhaldi
- Departments of Nursing, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Sanaa Alenazi
- Departments of Nursing, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mohammed Hijazi
- Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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Balakrishna A, Walsh EC, Hamidi A, Berg S, Austin D, Pino RM, Hanidziar D, Chang MG, Bittner EA. An examination of sedation requirements and practices for mechanically ventilated critically ill patients with COVID-19. Am J Health Syst Pharm 2021; 78:1952-1961. [PMID: 33993212 PMCID: PMC8194529 DOI: 10.1093/ajhp/zxab202] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Preliminary reports suggest that critically ill patients with coronavirus disease 2019 (COVID-19) infection requiring mechanical ventilation may have markedly increased sedation needs compared with non-mechanically ventilated patients. We conducted a study to examine sedative use for this patient population within multiple intensive care units (ICUs) of a large academic medical center. METHODS A retrospective, single-center cohort study of sedation practices for critically ill patients with COVID-19 during the first 10 days of mechanical ventilation was conducted in 8 ICUs at Massachusetts General Hospital, Boston, MA. The study population was a sequential cohort of 86 critically ill, mechanically ventilated patients with COVID-19. Data characterizing the sedative medications, doses, drug combinations, and duration of administration were collected daily and compared to published recommendations for sedation of critically ill patients without COVID-19. The associations between drug doses, number of drugs administered, baseline patient characteristics, and inflammatory markers were investigated. RESULTS Among the study cohort, propofol and hydromorphone were the most common initial drug combination, with these medications being used on a given day in up to 100% and 88% of patients, respectively. The doses of sedative and analgesic infusions increased for patients over the first 10 days, reaching or exceeding the upper limits of published dosage guidelines for propofol (48% of patients), dexmedetomidine (29%), midazolam (7.7%), ketamine (32%), and hydromorphone (38%). The number of sedative and analgesic agents simultaneously administered increased over time for each patient, with more than 50% of patients requiring 3 or more agents by day 2. Compared with patients requiring 3 or fewer agents, as a group patients requiring more than 3 agents were of younger age, had an increased body mass index, increased serum ferritin and lactate dehydrogenase concentrations, had a lower PaO2:FIO2 (ratio of arterial partial pressure of oxygen to fraction of inspired oxygen), and were more likely to receive neuromuscular blockade. CONCLUSION Our study confirmed the clinical impression of elevated sedative use in critically ill, mechanically ventilated patients with COVID-19 relative to guideline-recommended sedation practices in other critically ill populations.
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Affiliation(s)
- Aditi Balakrishna
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Elisa C Walsh
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Arzo Hamidi
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Sheri Berg
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel Austin
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard M Pino
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Dusan Hanidziar
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marvin G Chang
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward A Bittner
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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McKinley K, Panakos P, Yousef D. Characterization of ketamine usage in a large tertiary-care emergency department. Am J Emerg Med 2021; 47:149-153. [PMID: 33812331 DOI: 10.1016/j.ajem.2021.03.074] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 03/24/2021] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Ketamine is a phencyclidine derivative first used in clinical practice in the 1970's. Specifically within the emergency department (ED), ketamine is utilized for a wide variety of indications including but not limited to procedural sedation, rapid sequence intubation, agitation, and pain. As providers continue to utilize ketamine more frequently and for additional indications, additional data describing its safety and efficacy in the ED setting is warranted. OBJECTIVES To describe current trends in ketamine usage within a large tertiary-care Emergency Department. METHODS All patients receiving intravenous (IV) or intramuscular (IM) ketamine within the Emergency Department between January 1, 2019 and December 31, 2019 were eligible for study inclusion. Patients were excluded from the study if they were less than 18 years of age, pregnant, or incarcerated. Data was collected using a report of ketamine removal from the ED automatic dispensing cabinets, with administration confirmed by electronic medical record review. RESULTS During the study period, 170 patients received 195 doses of ketamine for the indications of agitation, procedural sedation, rapid sequence intubation, pain, sedation, seizure, status asthmaticus, and unknown. Patients were mostly male (74%) with a mean age of 45 years (range 20-97 years). The most common indications for ketamine administration were agitation and procedural sedation. For agitation, ketamine was utilized as first line therapy in 45% of patients. Seventy-seven percent of these patients did not require an additional sedative agent up to 60 min after ketamine administration. Procedural sedations were most commonly orthopedic reductions, and ketamine was given more frequently in combination with propofol than as monotherapy. Five percent of patients had an adverse event documented in the electronic medical record, with a single incidence of ketamine induced laryngospasm requiring intubation. CONCLUSION This descriptive review supports the versatility, safety, and efficacy of ketamine use within a large, tertiary-care, academic emergency department. Larger, prospective studies are warranted to draw further conclusions regarding ideal ketamine utilization within the emergency department.
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Affiliation(s)
- Kelly McKinley
- Jackson Memorial Hospital Department of Pharmacy, 1611 NW 12(th) Ave, Miami, FL 33136, United States.
| | - Patricia Panakos
- Jackson Memorial Hospital Emergency Department, 1611 NW 12(th) Ave, Miami, FL 33136, United States.
| | - Daniel Yousef
- Jackson Memorial Hospital Department of Pharmacy, 1611 NW 12(th) Ave, Miami, FL 33136, United States.
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The Implementation of Protocol-Based Utilization of Neuromuscular Blocking Agent Using Clinical Variables in Acute Respiratory Distress Syndrome Patients. Crit Care Explor 2021; 3:e0371. [PMID: 33786447 PMCID: PMC7994065 DOI: 10.1097/cce.0000000000000371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Supplemental Digital Content is available in the text. Objectives: The recent conflicting data on the mortality benefit of neuromuscular blocking agents in acute respiratory distress syndrome and the potential adverse effects of continuous neuromuscular blocking agent necessitates that these medications should be used judiciously with dose reduction in mind. The aims of the study were to improve the process of care by provider education of neuromuscular blocking agent titration and monitoring and to determine the impact of clinical endpoint based neuromuscular blocking agent titration protocol. Design: We conducted a proof-of-concept historically controlled study of protocol-based intervention standardizing paralytic monitoring and titration using clinical variables. Education of the protocol was provided to ICU staff via bedside teaching and workshops. The primary outcomes were the time to reach goal paralysis and cumulative neuromuscular blocking agent dose. Secondary outcomes included maintenance of deeper sedation (Richmond Agitation and Sedation Scale –5) prior to neuromuscular blocking agent initiation, total time on mechanical ventilation, length of stay, and mortality. Setting: Medical ICU at a quaternary academic hospital between March 2019 and June 2020. Patients: Adult severe acute respiratory distress syndrome (Pao2/Fio2 <150) patients requiring neuromuscular blocking agent for greater than or equal to 12 hours. Eighty-two patients fulfilled inclusion criteria, 46 in the control group and 36 in the intervention group. Interventions: Education and implementation of standardized protocol. Measurements and Main Results: Compared with the control group, the time to reach goal paralysis in the intervention group was shorter (8.55 ± 9.4 vs 2.63 ± 5.9 hr; p < 0.0001) on significantly lower dose of cisatracurium (total dose 1,897.96 ± 1,241.0 vs 562.72 ± 546.7 mg; p < 0.0001 and the rate 5.84 ± 2.66 vs 1.99 ± 0.95 µg/kg/min; p < 0.0001). Deeper sedation was achieved at the time of initiation of neuromuscular blocking agent in the intervention arm (mean Richmond Agitation and Sedation Scale –3.3 ± 1.9 vs –4.3 ± 1.7; p = 0.015). There was no significant difference in total time on mechanical ventilation, length of ICU stay, length of hospital stay, and mortality between the two groups. Conclusions: Implementation of comprehensive education, standardization of sedation prior to neuromuscular blocking agent initiation, integration of clinical variables in determining paralysis achievement, and proper use of peripheral nerve stimulation served as optimal strategies for the titration and monitoring of neuromuscular blocking agent in acute respiratory distress syndrome. This reduced drug utilization while continuing to achieve benefit without causing adverse effects.
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Godoy DA, Badenes R, Pelosi P, Robba C. Ketamine in acute phase of severe traumatic brain injury "an old drug for new uses?". CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:19. [PMID: 33407737 PMCID: PMC7788834 DOI: 10.1186/s13054-020-03452-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 12/22/2020] [Indexed: 01/02/2023]
Abstract
Maintaining an adequate level of sedation and analgesia plays a key role in the management of traumatic brain injury (TBI). To date, it is unclear which drug or combination of drugs is most effective in achieving these goals. Ketamine is an agent with attractive pharmacological and pharmacokinetics characteristics. Current evidence shows that ketamine does not increase and may instead decrease intracranial pressure, and its safety profile makes it a reliable tool in the prehospital environment. In this point of view, we discuss different aspects of the use of ketamine in the acute phase of TBI, with its potential benefits and pitfalls.
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Affiliation(s)
- Daniel Agustin Godoy
- Neurointensive Care Unit, Sanatorio Pasteur, Catamarca, Argentina.,Intensive Care Unit, Hospital Carlos Malbran, Catamarca, Argentina
| | - Rafael Badenes
- Anesthesiology and Surgical-Trauma Intensive Care, University Clinic Hospital, Valencia, Spain.,Department of Surgery, University of Valencia, Valencia, Spain.,INCLIVA Research Medical Institute, Valencia, Valencia, Spain
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy. .,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.
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Drug dosing in the critically ill obese patient-a focus on sedation, analgesia, and delirium. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:315. [PMID: 32513237 PMCID: PMC7282067 DOI: 10.1186/s13054-020-03040-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/27/2020] [Indexed: 12/12/2022]
Abstract
Practice guidelines provide clear evidence-based recommendations for the use of drug therapy to manage pain, agitation, and delirium associated with critical illness. Dosing recommendations however are often based on strategies used in patients with normal body habitus. Recommendations specific to critically ill patients with extreme obesity are lacking. Nonetheless, clinicians must craft dosing regimens for this population. This paper is intended to help clinicians design initial dosing regimens for medications commonly used in the management of pain, agitation, and delirium in critically ill patients with extreme obesity. A detailed literature search was conducted with an emphasis on obesity, pharmacokinetics, and dosing. Relevant manuscripts were reviewed and strategies for dosing are provided.
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