Adjunct Ketamine Use in the Management of Severe Ethanol Withdrawal

Pizon, Anthony F.; Lynch, Michael J.; Benedict, Neal; Yanta, Joseph H.; Frisch, Adam; Menke, Nathan B.; Swartzentruber, Greg S.; King, Andrew; Abesamis, Michael G.; Kane‐Gill, Sandra L.

doi:10.1097/ccm.0000000000003204

Cited by 29 publications

(24 citation statements)

References 10 publications

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“…92 Non-dissociative effects associated with ketamine administration included mild sedation, agitation, nausea and vomiting, headaches, dizziness, blurred vision, dry or numb mouth, delirium, irritability, sensory changes, urination problems, vertigo and drowsiness; these were overwhelmingly reported to dissipate within 1-2 h of ketamine infusion. 3,6,12,14,15,35,40,41,43,47,52,58,[69][70][71][72]78,82,83,85,87,[89][90][91]93,101,103,104,108,110 We found no reports of ketamine use/misuse following treatment with ketamine, nor is there evidence of transition from medical to non-medical ketamine use. 12,54…”

Section: Adverse Effects and Risksmentioning

confidence: 63%

Ketamine for the treatment of mental health and substance use disorders: comprehensive systematic review

et al. 2021

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Background In the past two decades, subanaesthetic doses of ketamine have been demonstrated to have rapid and sustained antidepressant effects, and accumulating research has demonstrated ketamine's therapeutic effects for a range of psychiatric conditions. Aims In light of these findings surrounding ketamine's psychotherapeutic potential, we systematically review the extant evidence on ketamine's effects in treating mental health disorders. Method The systematic review protocol was registered in PROSPERO (identifier CRD42019130636). Human studies investigating the therapeutic effects of ketamine in the treatment of mental health disorders were included. Because of the extensive research in depression, bipolar disorder and suicidal ideation, only systematic reviews and meta-analyses were included. We searched Medline and PsycINFO on 21 October 2020. Risk-of-bias analysis was assessed with the Cochrane Risk of Bias tools and A Measurement Tool to Assess Systematic Reviews (AMSTAR) Checklist. Results We included 83 published reports in the final review: 33 systematic reviews, 29 randomised controlled trials, two randomised trials without placebo, three non-randomised trials with controls, six open-label trials and ten retrospective reviews. The results were presented via narrative synthesis. Conclusions Systematic reviews and meta-analyses provide support for robust, rapid and transient antidepressant and anti-suicidal effects of ketamine. Evidence for other indications is less robust, but suggests similarly positive and short-lived effects. The conclusions should be interpreted with caution because of the high risk of bias of included studies. Optimal dosing, modes of administration and the most effective forms of adjunctive psychotherapeutic support should be examined further.

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Section: Adverse Effects and Risksmentioning

confidence: 63%

Ketamine for the treatment of mental health and substance use disorders: comprehensive systematic review

et al. 2021

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“…However, a larger retrospective analysis [47] shows no benefit of additive gabapentin compared with only lorazepam therapy for AWS. Ketamine 0.15-0.3 mg/kg/h was reported to be a useful adjunct to BZO in a small retrospective analysis [48], shortening LOS in intensive care.…”

Section: Therapy Of Suspected Aws In the Perioperative Settingmentioning

confidence: 98%

Perioperative Management of Alcohol Withdrawal Syndrome

et al. 2020

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Background: In the perioperative course, alcohol withdrawal syndrome (AWS) can occur in any setting, especially in aero-digestive and acute trauma surgery. Challenging issues are the overlap of other forms of delirium in perioperative and intensive care settings as well as general anesthesia masking the onset of withdrawal symptoms. In contrast to other etiologies of delirium, the pathophysiology and thus treatment strategy of AWS is different: the key point is the tolerance to GABAergic molecules of alcohol-dependent subjects resulting in central nervous hyperactivity once the effect of alcohol or other GABA-stimulating agents is decreased. Summary: Despite limitations due to insufficient accuracy of self-reporting questionnaires and limited feasibility in emergency settings, the AUDIT and the shortened AUDIT-C are the standard tools for detection of alcohol use disorders (AUD), as well as predicting AWS risk and severity in approximately half of these AUD patients. The most important risk factors for AWS are a high blood alcohol concentration at hospital admission, AWS episodes in medical history, and lack of control of alcohol use. Patients considered at risk for severe AWS must be treated with prophylactic medication before the onset of symptoms. Thiamine supplementation is required for all malnourished alcohol-dependent patients. Writing down alcohol-related diagnoses in the medical records requires the patient's presumed consent after shared decision-making. These reports should remain strictly confidential if the patient desires. Psychological support for the perioperative period as well as the following course should be offered to all AUD patients including support in short-and long-term detoxification. Alternative diagnoses must be ruled out with no timely delay, especially if fever and coma are the leading symptoms. The backbone of AWS therapy is the symptom-triggered administration of intravenous benzodiazepines (BZO) in escalating doses until the aimed revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar) or Richmond Agitation-Sedation Scale (RASS) score is achieved. Clonidine, dexmedetomidine, baclofen, ketamine, and neuroleptics may be used as symptom-orientated adjuncts. The therapeutic administration of ethanol or clomethiazole is considered to be harmful in critically ill patients after the onset of AWS. General supportive and intensive care including high-dose thiamine supplementation are mandatory in severe AWS cases. The timely differential diagnosis of delirium is important-and AWS is a diagnosis of exclusion-because BZO are strongly recommended for AWS patients but may not be the treatment of

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“…There are few studies of ketamine for management of SAWS. Existing data suggest an association between the use of ketamine and decreased ICU and hospital length of stay ( 241 ). Data regarding propofol therapy for SAWS are limited to retrospective cohort studies.…”

Section: Section 3: Establishing Best Practices To Improve Clinical Outcomes (T 3 Research)mentioning

confidence: 99%

Research Needs for Inpatient Management of Severe Alcohol Withdrawal Syndrome: An Official American Thoracic Society Research Statement

Steel¹,

Afshar²,

Edwards³

et al. 2021

Am J Respir Crit Care Med

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Background: Severe alcohol withdrawal syndrome (SAWS) is highly morbid, costly, and common among hospitalized patients, yet minimal evidence exists to guide inpatient management. Research needs in this field are broad, spanning the translational science spectrum. Goals: This research statement aims to describe what is known about SAWS, identify knowledge gaps, and offer recommendations for research in each domain of the Institute of Medicine T 0 –T 4 continuum to advance the care of hospitalized patients who experience SAWS. Methods: Clinicians and researchers with unique and complementary expertise in basic, clinical, and implementation research related to unhealthy alcohol consumption and alcohol withdrawal were invited to participate in a workshop at the American Thoracic Society 2019 International Conference. The committee was subdivided into four groups on the basis of interest and expertise: T 0 –T 1 (basic science research with translation to humans), T 2 (research translating to patients), T 3 (research translating to clinical practice), and T 4 (research translating to communities). A medical librarian conducted a pragmatic literature search to facilitate this work, and committee members reviewed and supplemented the resulting evidence, identifying key knowledge gaps. Results: The committee identified several investigative opportunities to advance the care of patients with SAWS in each domain of the translational science spectrum. Major themes included 1 ) the need to investigate non–γ-aminobutyric acid pathways for alcohol withdrawal syndrome treatment; 2 ) harnessing retrospective and electronic health record data to identify risk factors and create objective severity scoring systems, particularly for acutely ill patients with SAWS; 3 ) the need for more robust comparative-effectiveness data to identify optimal SAWS treatment strategies; and 4 ) recommendations to accelerate implementation of effective treatments into practice. Conclusions: The dearth of evidence supporting management decisions for hospitalized patients with SAWS, many of whom require critical care, represents both a call to action and an opportunity for the American Thoracic Society and larger scientific communities to improve care for a vulnerable patient population. This report highlights basic, clinical, and implementation research that diverse experts agree will have the greatest impact on improving care for hospitalized patients with SAWS.

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Adjunct Ketamine Use in the Management of Severe Ethanol Withdrawal

Cited by 29 publications

References 10 publications

Ketamine for the treatment of mental health and substance use disorders: comprehensive systematic review

Ketamine for the treatment of mental health and substance use disorders: comprehensive systematic review

Perioperative Management of Alcohol Withdrawal Syndrome

Research Needs for Inpatient Management of Severe Alcohol Withdrawal Syndrome: An Official American Thoracic Society Research Statement

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