INTRODUCTION: Ketamine is a N-methyl-D-aspartate (NMDA) receptor antagonist that promotes bronchodilation through several mechanisms: blocking NDMA receptors to prevent bronchoconstriction, decreasing nitric oxide production in pulmonary tissues to reduce bronchospasm, and reducing inflammation to reverse histamine-induced bronchoconstriction. These properties suggest intravenous (IV) ketamine has a role in the management of status asthmaticus, particularly in refractory cases, but data remains limited.CASE PRESENTATION: Six patients (age 56 AE16 years, 33.3% female) receiving IV ketamine for status asthmaticus at a single center were identified through retrospective chart review. All six patients received nebulized bronchodilators, steroids, and magnesium prior to ketamine therapy, and required intubation. They were treated with IV ketamine bolus and infusion (ranging 0.5-2 mg/kg/hr). Pre and post treatment pH and CO2 improved overall (pH range 6.89-7.23 with mean 7.05 improving to 7.11-7.35, mean 7.21; pCO2 ranging 72-130 mm Hg with mean 98 decreasing to 30-78 mm Hg, mean 58). Two patients had recrudescence of symptoms with decreased tidal volumes (500 to 280 mL in one case, 580 to 420 mL in second case) and increased peak pressures after stopping the ketamine infusion without weaning. They improved with re-initiation and gradual weaning of ketamine infusion without further recurrence. Two other patients underwent gradual weaning of ketamine without recrudescence.DISCUSSION: In this single center, retrospective case series, IV ketamine was shown to demonstrate overall improvement in pH, pCO2. Only one patient had significant tachycardia and hypertension which improved with midazolam. Slow weaning of ketamine infusions seemed to prevent recurrence of symptoms in four of six patients receiving infusion, although two patients did not have recurrence of symptoms after abrupt discontinuation. CONCLUSIONS:In cases of refractory status asthmaticus, IV ketamine should be considered as an adjunctive therapy. Additional studies are needed to determine ideal infusion rates and weaning regimen before discontinuation.
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