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

Purpose

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

Methods

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

Results

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

Conclusion

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

Chirality of Central Nervous System (CNS) Acting Drugs: A Formidable Therapeutic Hurdle Against CNS Diseases

BACKGROUND

Over fifty percent of drugs being used clinically are chiral and 90% of them are racemates. Unfortunately, they have both adverse and beneficial effects on body systems.

METHODS

Because of the erratic effects of chiral compounds on body functional systems, literature search was carried out with a view to identify CNS chiral drugs, their clinical advantages and disadvantages, unique physicochemical properties and structural modifications into safer drugs.

RESULTS

Findings have shown that majority of CNS and non-CNS acting drugs have chiral functional groups that may occur as either dextrorotatory (clockwise) or levorotatory (anticlockwise) or racemates which are inert. Sometimes, the enantiomers (optical isomers) could undergo keto-enol tautomerism, appearing in either acidic or basic or inert form. Chiral CNS acting drugs have agonistic and antagonistic effects, clinical advantages, disadvantages, and special clinical applications, possible modifications for better therapeutic effects and possible synthesis of more potent drugs from racemates. Clockwise chirality may be more effective and safer than the drugs with anticlockwise chirality. When chiral drugs are in racemate state they become inert and may be safer than when they are single. Also, diastereoisomers may be more dangerous than stereoisomers.

CONCLUSION

Therefore, chiral compounds should be adequately studied in lab rodents and primates, and their mechanisms of actions should be comprehensively understood before being used in clinical setting. Since many of them are toxic, their use should be based on principle of individualized medicine. Their molecular weights, functional groups, metabolites, polymers and stereoisomers could be valuable tools for their modifications.

Sedation and analgesia for procedures in the pediatric emergency room

OBJECTIVE

Children and adolescents often require sedation and analgesia in emergency situations. With the emergence of new therapeutic options, the obsolescence of others, and recent discoveries regarding already known drugs, it became necessary to review the literature in this area.

DATA SOURCES

Non-systematic review in the PubMed database of studies published up to December 2016, including original articles, review articles, systematic reviews, and meta-analyses. References from textbooks, publications from regulatory agencies, and articles cited in reviews and meta-analyses through active search were also included.

DATA SYNTHESIS

Based on current literature, the concepts of sedation and analgesia, the necessary care with the patient before, during, and after sedoanalgesia, and indications related to the appropriate choice of drugs according to the procedure to be performed and their safety profiles are presented.

CONCLUSIONS

The use of sedoanalgesia protocols in procedures in the pediatric emergency room should guide the professional in the choice of medication, the appropriate material, and in the evaluation of discharge criteria, thus assuring quality in care.