Adverse Cardiovascular Effects of Ketamine Infusion in Patients with Catecholamine-Dependent Heart Failure

Christ, Günter; Mundigler, Gerald; Merhaut, C.; Zehetgruber, Manfred; Kratochwill, C; Gisslinger, Heinz; Siostrzonek, Peter

doi:10.1177/0310057x9702500308

Cited by 59 publications

(63 citation statements)

References 9 publications

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“…Under normal conditions, ketamine stimulates the sympathetic system by increasing circulating catecholamine concentrations (31). Ketamine, however, exhibits potentially negative cardiovascular effects in patients with catecholamine-dependent heart failure (32) or other critical illnesses in which catecholamine is excessively mobilized. Therefore, it may be that the stress of severe burns weakened the sympathetic stimulation and therefore, the cardiac inhibition effect of ketamine became dominant in severe thermal injury.…”

Section: Discussionmentioning

confidence: 99%

Combination of ketamine and xylazine exacerbates cardiac dysfunction in severely scalded rats during the shock stage

Feng

Chai

Chu

et al. 2013

Experimental and Therapeutic Medicine

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Cardiac inhibition due to burn injury and anesthetics have been documented previously. However, little is known about their combined effects on cardiac function. The aim of the present study was to observe the effects of a ketamine/xylazine (K/X) combination on the cardiac function of rats with severe scalds and compare them with those of avertin. Adult rats were randomly distributed into four groups: the KXB group (scalds anesthetized with K/X, n=10), the KXC group (sham scalds anesthetized with K/X, n=10), the AVB group (scalds anesthetized with avertin, n=10) and the AVC group (sham scalds anesthetized with avertin, n=10). Ketamine and xylazine were administered at 25 and 6 mg/kg, respectively, and avertin at 200 mg/kg before full-thickness scalds or sham scalds of 30% total body surface area (TBSA) were produced. Echocardiographic parameters were assessed following injury. The heart rate (HR) in the KXB group was fatally low during the study period. Fractional shortening (FS%) and ejection fraction (EF) in the KXB group were extremely low initially and remained low. The left ventricular end-diastolic volume (LVEDV) and left ventricular end-systolic volume (LVESV) were reduced in the burned rats. Serum levels of cardiac troponin I (cTnI) were significantly higher in the KXB group than in the AVB group (1.66±0.28 vs. 1.16±0.34 ng/ml, P<0.01). The highest lung wet/dry weight ratio was observed in the KXB group. However, no evident heart tissue pathological changes were observed in these groups. The apoptotic index of myocardial cells and caspase 3 expression level were highest in the KXB group (P<0.01). In conclusion, K/X exacerbated cardiac inhibition in severely scalded rats during the shock stage by a mechanism which may involve mitochondrial apoptosis.

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Section: Discussionmentioning

confidence: 99%

Combination of ketamine and xylazine exacerbates cardiac dysfunction in severely scalded rats during the shock stage

Feng

Chai

Chu

et al. 2013

Experimental and Therapeutic Medicine

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“…31,32 In contrast, one study reported on a decrease in cardiac index in patients with catecholamine-dependent heart failure when sufentanil was replaced by ketamine. 33 As left ventricular dysfunction and electrocardiographic abnormalities occur frequently after SAH, 34,35 ketamine might be contraindicated in patients presenting with left ventricular failure. In our study patient population, we could not observe clinical relevant cardial abnormalities.…”

Section: Discussionmentioning

confidence: 99%

Effects of Fentanyl and S(+)-ketamine on Cerebral Hemodynamics, Gastrointestinal Motility, and Need of Vasopressors in Patients With Intracranial Pathologies

Schmittner¹,

Vajkoczy²,

Horn

et al. 2007

Journal of Neurosurgical Anesthesiology

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In neurosurgical patients, opioids are administered to prevent secondary cerebral damage. Complications often related to the administration of opioids are a decrease in blood pressure affording the use of vasopressors and intestinal atonia. One alternative approach to opioids is the application of S(+)-ketamine. However, owing to a suspected elevation of intracranial pressure (ICP), the administration of S(+)-ketamine has questioned for a long time. The aim of the present study was to evaluate ICP, gastrointestinal motility, and catecholamine consumption in neurosurgical patients undergoing 2 different protocols of anesthesia using fentanyl or S(+)-ketamine. Twenty-four patients sustaining traumatic brain injury or aneurysmal subarachnoid hemorrhage received methohexitone plus either fentanyl or S(+)-ketamine to establish a comparable level of sedation. To reach an adequate cerebral perfusion pressure (CPP), the norepinephrine dosage was adapted successively. Enteral nutrition and gastrointestinal stimulation were started directly after admission on the critical care unit. ICP, CPP, and norepinephrine dosage were recorded over 5 days and also the time intervals to full enteral nutrition and first defecation. There was no difference regarding ICP, CPP, and the time period until full enteral nutrition or first defecation between both groups. Patients who underwent analgesia with S(+)-ketamine showed a trend to a lower demand of norepinephrine compared with the fentanyl group. Our results indicate that S(+)-ketamine does not increase ICP and that its use in neurosurgical patients should not be discouraged on the basis of ICP-related concerns.

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“…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.…”

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confidence: 99%

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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Adverse Cardiovascular Effects of Ketamine Infusion in Patients with Catecholamine-Dependent Heart Failure

Cited by 59 publications

References 9 publications

Combination of ketamine and xylazine exacerbates cardiac dysfunction in severely scalded rats during the shock stage

Combination of ketamine and xylazine exacerbates cardiac dysfunction in severely scalded rats during the shock stage

Effects of Fentanyl and S(+)-ketamine on Cerebral Hemodynamics, Gastrointestinal Motility, and Need of Vasopressors in Patients With Intracranial Pathologies

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

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