Ketamine infusion for patients receiving extracorporeal membrane oxygenation support: a case series

Abstract

The use of ketamine infusion for sedation/analgesia in patients receiving extracorporeal membrane oxygenation (ECMO) therapy has not been described. The aims of this retrospective cohort study were to explore whether ketamine infusion for patients requiring ECMO therapy was associated with altered RASS scores, decreased concurrent sedative or opioid use, or with changes in vasopressor requirements. All patients on ECMO who received ketamine infusions in addition to sedative and/or opioid infusions between December 2013 and October 2014 at Barnes-Jewish Hospital in St. Louis were retrospectively identified. Patient characteristics and process of care data were collected.A total of 26 ECMO patients receiving ketamine infusion were identified. The median (inter quartile range [range]) age was 40 years (30-52 [25-66]) with 62% male. The median starting infusion rate of ketamine was 50 mg/hr (30-50 [6-150]) and it was continued for a median duration of 9 days (4-14 [0.2-21]). Prior to ketamine, 14/26 patients were receiving vasopressor infusions to maintain hemodynamic stability. Ketamine initiation was associated with a decrease in vasopressor requirement in 11/26 patients within two hours, and 0/26 required an increase (p<0.001). All patients were receiving sedative and/or opioid infusions at the time of ketamine initiation; 9/26 had a decrease in these infusions within two hours of ketamine initiation, and 1/26 had an increase (p=0.02; odds ratio for decrease to increase = 9; 95% CI, 1.14 to 71.04). The median (IQR[range]) RASS score 24 hours before ketamine initiation was -4 (-3 to -5, [0 to -5]) and after ketamine was -4 (-3 to -4 [-1 to -5]) ( P = 0.614).Ketamine infusion can be used as an adjunctive sedative agent in patients receiving ECMO and may decrease concurrent sedative and/or opioid infusions without altering RASS scores. The hemodynamic effects of ketamine may provide the benefit of decreasing vasopressor requirements.

Evaluation of Altered Drug Pharmacokinetics in Critically Ill Adults Receiving Extracorporeal Membrane Oxygenation

“…56 A case series evaluated ketamine use in 26 patients to determine the resulting effect on Richmond Agitation-Sedation Scale scores, decreased concurrent sedative or opioid use, or changes in vasopressor requirements. 46 The authors noted decreases in vasopressor (11 of 26 patients) and sedation-analgesia (9 of 26 patients) requirements within 2 hours of ketamine initiation. Another case report demonstrated similar findings with reduction in opioids and/or sedative dosing following initiation of ketamine infusion.…”

“…Current experience with ketamine use exists as a case series and case report; however, an international survey demonstrated that 28% of responders used ketamine as a co‐sedative in ECMO management . A case series evaluated ketamine use in 26 patients to determine the resulting effect on Richmond Agitation‐Sedation Scale scores, decreased concurrent sedative or opioid use, or changes in vasopressor requirements . The authors noted decreases in vasopressor (11 of 26 patients) and sedation‐analgesia (9 of 26 patients) requirements within 2 hours of ketamine initiation.…”

Overview of Pharmacological Considerations in Extracorporeal Membrane Oxygenation

“…The investigators found that of 26 patients, 42% had a meaningful dose decrease in vasopressors and 35% had decreased opioid and sedative requirements after receiving 2 hours of ketamine infusion. 24 The lipophilic nature of ketamine leads to a high propensity for sequestration, necessitating potentially higher doses than those studied for general analgesia. 24 Despite the potential benefits for both respiratory and cardiovascular status, its use must be evaluated on an individual patient basis because it can be harmful in certain subsets of patients.…”

“…24 The lipophilic nature of ketamine leads to a high propensity for sequestration, necessitating potentially higher doses than those studied for general analgesia. 24 Despite the potential benefits for both respiratory and cardiovascular status, its use must be evaluated on an individual patient basis because it can be harmful in certain subsets of patients. 24 With the push toward reducing opioid use to limit the development of chemical dependency, the use of alternative (nonopioid) medications has increased.…”

“…24 Despite the potential benefits for both respiratory and cardiovascular status, its use must be evaluated on an individual patient basis because it can be harmful in certain subsets of patients. 24 With the push toward reducing opioid use to limit the development of chemical dependency, the use of alternative (nonopioid) medications has increased. We are aware of only 1 in vitro analysis evaluating intravenous acetaminophen in patients receiving ECMO.…”