Impact of Ketamine Use on Adjunctive Analgesic and Sedative Medications in Critically Ill Trauma Patients

Pruskowski, Kaitlin A; Harbourt, Kelly; Pajoumand, Mehrnaz; Chui, Sai-Ho Jason; Reynolds, H. Neal

doi:10.1002/phar.2042

Cited by 46 publications

(67 citation statements)

References 19 publications

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“…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%

“…This would provide 80% power with an α of 0.05. The threshold for change in concomitant analgosedatives was extracted from previously published findings of an average 30% reduction in dosing requirements of opioids and propofol after initiation of adjunctive continuous infusion ketamine in trauma patients …”

Section: Methodsmentioning

confidence: 99%

“…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: Discussionmentioning

confidence: 96%

Section: Methodsmentioning

confidence: 99%

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

et al. 2019

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Pain Management Considerations in Patients With Opioid Use Disorder Requiring Critical Care

Smith

Wang

Abdukalikov

et al. 2022

The Journal of Clinical Pharma

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The opioid epidemic has resulted in increased opioid‐related critical care admissions, presenting challenges in acute pain management. Limited guidance exists in the management of critically ill patients with opioid use disorder (OUD). This narrative review provides the intensive care unit clinician with guidance and treatment options, including nonopioid analgesia, for patients receiving medications for OUD and for patients actively misusing opioids. Verification and continuation of the patient's outpatient medications for OUD regimen, specifically buprenorphine and methadone formulations; assessment of pain and opioid withdrawal; and treatment of acute pain with nonopioid analgesia, nonpharmacologic strategies, and short‐acting opioids as needed, are all essential to adequate management of acute pain in patients with OUD. A multidisciplinary approach to treatment and discharge planning in patients with OUD may be beneficial to engage patients with OUD early in their hospital stay to prevent withdrawal, stabilize their OUD, and reduce the risk of unplanned discharge and other associated morbidity.

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Intubated Patient in the Intensive Care Unit (ICU)

Schroeder

Kim

2020

Guide to the Inpatient Pain Consult

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Impact of Ketamine Use on Adjunctive Analgesic and Sedative Medications in Critically Ill Trauma Patients

Cited by 46 publications

References 19 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

Pain Management Considerations in Patients With Opioid Use Disorder Requiring Critical Care

Intubated Patient in the Intensive Care Unit (ICU)

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