Ketamine Infusion for Adjunct Sedation in Mechanically Ventilated Adults

Groetzinger, Lara; Rivosecchi, Ryan; Bain, William; Bahr, Marshall; Chin, Katherine; McVerry, Bryan J.; Barbash, Ian J.

doi:10.1002/phar.2065

Cited by 43 publications

(77 citation statements)

References 18 publications

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“…These results coincide with a study that found adjunctive continuous infusion ketamine used for light sedation promoted concomitant sedative reduction while increasing the number of documented goal Riker Sedation‐Agitation Scale scores in 24 hours . Our results further add to these findings with a time‐dependent, dose‐quantitative analysis of analgosedative requirements, inclusion of comprehensive concomitant analgesic‐sedative infusions, and unique identification of population characteristics associated with positive ketamine response in the general ICU population.…”

Section: Discussionsupporting

confidence: 89%

“…Continuous infusion ketamine dosing observed in the current study falls within broad published data ranges of 0.125 to 2 mg/kg/hour for analgosedative effects . We chose to report ketamine dosing as μg/kg/minute per institutional practice – translated median doses used within the current study range from 0.3 to 0.4 mg/kg/hour.…”

Section: Discussionmentioning

confidence: 96%

“…Reservations for liberal use of ketamine are related to possible development of emergence reactions manifesting as frank delirium, overstimulation of the central sympathomimetic system, and unknown patient tolerance or comprehensive adverse effect profile when administered as a continuous infusion . Current data are limited by small sample sizes, lack of consistent dosing and therapeutic intent, varying definitions and targets of ideal sedation ranges, and inconsistent concomitant pharmacotherapy combinations . Ketamine's appropriate dosing, utility and tolerance as an adjunctive agent, effect on delirium, and adverse effect profile when utilized in the broad critically ill population remains unclear.…”

mentioning

confidence: 99%

“…1,2,[6][7][8] Ketamine has gained momentum within the ICU analgosedative realm given its unique pharmacologic profile and new evidence assessing its use as an adjunctive continuous infusion analgosedative agent in mechanically ventilated patients. [9][10][11] It serves as a dissociative agent and rapidly acting general anesthetic with both sedative and analgesic properties due to N-methylᴅ-aspartate receptor antagonism, µ and j opioid receptor agonism, and suppression of associated pain signaling pathways, including inhibition of nociceptive central hypersensitization. 1,[9][10][11][12] In addition to concurrent sedative and analgesic effects, ketamine preserves respiratory effort, airway reflexes, and cardiovascular stability in nonintubated patients.…”

mentioning

confidence: 99%

“…[9][10][11] It serves as a dissociative agent and rapidly acting general anesthetic with both sedative and analgesic properties due to N-methylᴅ-aspartate receptor antagonism, µ and j opioid receptor agonism, and suppression of associated pain signaling pathways, including inhibition of nociceptive central hypersensitization. 1,[9][10][11][12] In addition to concurrent sedative and analgesic effects, ketamine preserves respiratory effort, airway reflexes, and cardiovascular stability in nonintubated patients. [9][10][11][12][13][14] These qualities, in addition to low cost and a relatively wide therapeutic index for routine indications, such as bolus administration for procedural sedation, have made ketamine an attractive option for use as an analgosedative in the critically ill population.…”

mentioning

confidence: 99%

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Continuous Infusion Ketamine for Adjunctive Analgosedation in Mechanically Ventilated, Critically Ill Patients

et al. 2019

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Objective Ketamine is an N‐methyl‐D‐aspartate antagonist with emerging evidence assessing its use as a continuous infusion agent to provide concomitant analgesia and sedation. The role of ketamine as adjunctive therapy in mechanically ventilated patients is unclear. This study sought to investigate the impact of adjunctive continuous infusion ketamine on concomitant analgesic and sedative dosing while providing goal comfort in mechanically ventilated patients. Methods This retrospective two‐center intrapatient comparison study included mechanically ventilated adult ICU patients who received continuous infusion ketamine with at least one other analgesic or sedative infusion. The primary outcome assessed percent relative change in concomitant analgesic‐sedative doses 24 hours after ketamine initiation. Secondary outcomes included percent of Richmond Agitation and Sedation Score (RASS) assessments at goal, adverse effects, and delirium incidence. Exploratory evaluation of independent factors associated with ketamine responders (50% or more relative reduction in analgesic‐sedative dosing requirements at 24 hrs) and nonresponders (less than 50% relative reduction) was performed using multivariate logistic regression. Results Overall, 104 patients were included. A total of 160 concomitant analgesic‐sedative infusions were used in combination with ketamine, most commonly fentanyl (98 [61.3%]) and propofol (46 [28.8%]). A 20% (interquartile range [IQR] −63.6 to 0.0, p<0.001) relative reduction in total analgesic‐sedative infusion pharmacotherapy was achieved at 24 hours after ketamine initiation. Analgesic and sedative infusion doses decreased at 24 hours (fentanyl: pre, 175 μg/hr [IQR 100–200 μg/hr] vs post, 125 μg/hr [IQR 50–200 μg/hr], p<0.001; propofol: pre, 42.5 μg/kg/min [IQR 20.0–60.0 μg/kg/min] vs post, 20.0 μg/kg/min [IQR 3.8–31.3 μg/kg/min], p<0.001). Median percent time within goal RASS improved after ketamine initiation (pre, 7.1% [0–40%] vs post, 25% [0–66.7%], p=0.005). No differences were observed in secondary outcomes between responders and nonresponders, except a longer non‐ICU hospital length of stay in responders. Independent factors associated with ketamine response included a lower body mass index, higher starting dose of ketamine, lower severity of illness, and need for multiple concomitant analgesic‐sedative infusions before initiation of ketamine. Conclusions Adjunctive continuous infusion ketamine promotes analgesic and sedative dose‐sparing effects in mechanically ventilated patients while improving time spent within goal sedation range. Further prospective research is warranted.

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Section: Discussionsupporting

confidence: 89%

Section: Discussionmentioning

confidence: 96%

mentioning

confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

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Continuous Infusion Ketamine for Adjunctive Analgosedation in Mechanically Ventilated, Critically Ill Patients

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Analgesia and Sedation Strategies in Mechanically Ventilated Adults with COVID‐19

Adams¹,

Altshuler

Barlow

et al. 2020

Pharmacotherapy

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Evidence-based management of analgesia and sedation in COVID-19-associated acute respiratory distress syndrome remains limited. Non-guideline recommended analgesic and sedative medication regimens and deeper sedation targets have been employed for patients with COVID-19 due to exaggerated analgesia and sedation requirements with extended durations of mechanical ventilation. This, coupled with a desire to minimize nurse entry into COVID-19 patient rooms, marked obesity, altered end-organ function, and evolving medication shortages, presents numerous short-and long-term challenges. Alternative analgesic and sedative agents and regimens may pose safety risks and require judicious bedside management for appropriate use. The purpose of this commentary is to provide considerations and solutions for designing safe and effective analgesia and sedation strategies for adult patients with considerable ventilator dyssynchrony and sedation requirements, such as COVID-19.

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Therapeutic Approaches to the Neurologic Manifestations of COVID-19

2022

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As of May 2022, there have been more than 527 million infections with severe acute respiratory disease coronavirus type 2 (SARS-CoV-2) and over 6.2 million deaths from Coronavirus Disease 2019 (COVID-19) worldwide. COVID-19 is a multisystem illness with important neurologic consequences that impact long-term morbidity and mortality. In the acutely ill, the neurologic manifestations of COVID-19 can include distressing but relatively benign symptoms such as headache, myalgias, and anosmia; however, entities such as encephalopathy, stroke, seizures, encephalitis, and Guillain-Barre Syndrome can cause neurologic injury and resulting disability that persists long after the acute pulmonary illness. Furthermore, as many as one-third of patients may experience persistent neurologic symptoms as part of a Post-Acute Sequelae of SARS-CoV-2 infection (Neuro-PASC) syndrome. This Neuro-PASC syndrome can affect patients who required hospitalization for COVID-19 or patients who did not require hospitalization and who may have had minor or no pulmonary symptoms. Given the large number of individuals affected and the ability of neurologic complications to impair quality of life and productivity, the neurologic manifestations of COVID-19 are likely to have major and long-lasting personal, public health, and economic consequences. While knowledge of disease mechanisms and therapies acquired prior to the pandemic can inform us on how to manage patients with the neurologic manifestations of COVID-19, there is a critical need for improved understanding of specific COVID-19 disease mechanisms and development of therapies that target the neurologic morbidities of COVID-19. This current perspective reviews evidence for proposed disease mechanisms as they inform the neurologic management of COVID-19 in adult patients while also identifying areas in need of further research.

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Ketamine Infusion for Adjunct Sedation in Mechanically Ventilated Adults

Abstract: Continuous ketamine infusion for adjunct light sedation was well tolerated in a cohort of critically ill adults, with an acceptable safety profile. Prospective studies of ketamine infusion are warranted to further establish its efficacy as a sedative in this population.

Cited by 43 publications

References 18 publications

Continuous Infusion Ketamine for Adjunctive Analgosedation in Mechanically Ventilated, Critically Ill Patients

Continuous Infusion Ketamine for Adjunctive Analgosedation in Mechanically Ventilated, Critically Ill Patients

Analgesia and Sedation Strategies in Mechanically Ventilated Adults with COVID‐19

Therapeutic Approaches to the Neurologic Manifestations of COVID-19

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