Ketamine sedation in mechanically ventilated patients: A systematic review and meta-analysis

Manasco, A. Travis; Stephens, Robert J.; Yaeger, Lauren; Roberts, Brian W.; Fuller, Brian M.

doi:10.1016/j.jcrc.2019.12.004

Cited by 33 publications

(48 citation statements)

References 32 publications

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“…The required dosages of esketamine (mean 0.86 (±0.75) mg�kg -1 �h -1 ) observed in our study were unusually high compared to the dosages referred to in the literature (mean approximately 0.4 mg�kg -1 �h -1 ) [29,30]. This observation is especially meaningful when taking into account that esketamine was only administered in combination with a sedative that had already been used at its optimum dose.…”

Section: Plos Onesupporting

confidence: 42%

High sedation needs of critically ill COVID-19 ARDS patients—A monocentric observational study

et al. 2021

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Background Therapy of severely affected coronavirus patient, requiring intubation and sedation is still challenging. Recently, difficulties in sedating these patients have been discussed. This study aims to describe sedation practices in patients with 2019 coronavirus disease (COVID-19)-induced acute respiratory distress syndrome (ARDS). Methods We performed a retrospective monocentric analysis of sedation regimens in critically ill intubated patients with respiratory failure who required sedation in our mixed 32-bed university intensive care unit. All mechanically ventilated adults with COVID-19-induced ARDS requiring continuously infused sedative therapy admitted between April 4, 2020, and June 30, 2020 were included. We recorded demographic data, sedative dosages, prone positioning, sedation levels and duration. Descriptive data analysis was performed; for additional analysis, a logistic regression with mixed effect was used. Results In total, 56 patients (mean age 67 (±14) years) were included. The mean observed sedation period was 224 (±139) hours. To achieve the prescribed sedation level, we observed the need for two or three sedatives in 48.7% and 12.8% of the cases, respectively. In cases with a triple sedation regimen, the combination of clonidine, esketamine and midazolam was observed in most cases (75.7%). Analgesia was achieved using sufentanil in 98.6% of the cases. The analysis showed that the majority of COVID-19 patients required an unusually high sedation dose compared to those available in the literature. Conclusion The global pandemic continues to affect patients severely requiring ventilation and sedation, but optimal sedation strategies are still lacking. The findings of our observation suggest unusual high dosages of sedatives in mechanically ventilated patients with COVID-19. Prescribed sedation levels appear to be achievable only with several combinations of sedatives in most critically ill patients suffering from COVID-19-induced ARDS and a potential association to the often required sophisticated critical care including prone positioning and ECMO treatment seems conceivable.

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Section: Plos Onesupporting

confidence: 42%

High sedation needs of critically ill COVID-19 ARDS patients—A monocentric observational study

et al. 2021

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“…Robust clinical outcome data and comprehensive assessments of adverse events (AEs) associated with ketamine use in mechanically ventilated patients are limited, leaving a significant knowledge gap, which has been reflected in the wide variation in the use of ketamine as a sedative agent in ICUs. This is also highlighted in a recent systematic review and meta-analysis by Manasco et al [22]. Therefore, we propose a prospective, randomized, active controlled, open-label, pilot, feasibility study to assess the effect and safety of Analgo-sedative ad-juncT keTAmine Infusion iN Mechanically vENTilated ICU patients (the ATTAINMENT trial) compared to standard of care alone.…”

Section: Introductionmentioning

confidence: 94%

Adjunct low-dose ketamine infusion vs standard of care in mechanically ventilated critically ill patients at a Tertiary Saudi Hospital (ATTAINMENT Trial): study protocol for a randomized, prospective, pilot, feasibility trial

Bawazeer

Amer

Maghrabi

et al. 2020

Trials

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Background: A noticeable interest in ketamine infusion for sedation management has developed among critical care physicians for critically ill patients. The 2018 Pain, Agitation/sedation, Delirium, Immobility, and Sleep disruption guideline suggested low-dose ketamine infusion as an adjunct to opioid therapy to reduce opioid requirements in post-surgical patients in the intensive care unit (ICU). This was, however, rated as conditional due to the very low quality of evidence. Ketamine has favorable characteristics, making it an especially viable alternative for patients with respiratory and hemodynamic instability. The Analgo-sedative adjuncT keTAmine Infusion iN Mechanically vENTilated ICU patients (ATTAINMENT) trial aims to assess the effect and safety of adjunct low-dose continuous infusion of ketamine as an analgo-sedative compared to standard of care in critically ill patients on mechanical ventilation (MV) for ≥ 24 h.Methods/design: This trial is a prospective, randomized, active controlled, open-label, pilot, feasibility study of adult ICU patients (> 14 years old) on MV. The study will take place in the adult ICUs in the King Faisal Specialist Hospital and Research Center (KFSH&RC), Riyadh, Saudi Arabia, and will enroll 80 patients. Patients will be randomized postintubation into two groups: the intervention group will receive an adjunct low-dose continuous infusion of ketamine plus standard of care. Ketamine will be administered over a period of 48 h at a fixed infusion rate of 2 μg/ kg/min (0.12 mg/kg/h) in the first 24 h followed by 1 μg/kg/min (0.06 mg/kg/h) in the second 24 h. The control group will receive standard of care in the ICU (propofol and/or fentanyl and/or midazolam) according to the KFSH&RC sedation and analgesia protocol as clinically appropriate. The primary outcome is MV duration until ICU discharge, death, extubation, or 28 days post-randomization, whichever comes first.

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“…Hence, ketamine can be used as an adjunct to other sedatives to limit their dose and duration and may be considered as an alternative agent in specific COVID-19 patients, including asthmatics, or when other sedatives are unavailable or cannot be used. None the less, a thorough risk-benefit analysis should be considered prior to initiation [68]. Figure 2 provides a brief overview of sedation management in a critically ill mechanically ventilated patient with COVID-19.…”

Section: Ketaminementioning

confidence: 99%

Challenges in Sedation Management in Critically Ill Patients with COVID-19: a Brief Review

Karamchandani

Dalal

Patel

et al. 2021

Curr Anesthesiol Rep

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Purpose of Review To highlight the challenges associated with providing sedation and analgesia to critically ill patients with coronavirus disease 2019 (COVID-19) and also understand the pathophysiological alterations induced by the disease process as well as the logistical difficulties encountered by providers caring for these patients. We also discuss the rationale and risks associated with the use of common sedative agents specifically within the context of COVID-19 and provide evidence-based management strategies to help manage sedation and analgesia in such patients. Recent Findings A significant proportion of patients with COVID-19 require intensive care and mechanical ventilation, thus requiring sedation and analgesia. These patients tend to require higher doses of sedative medications and often for long periods of time. Most of the commonly used sedative and analgesic agents carry unique risks that should be considered within the context of the unique pathophysiology of COVID-19, the logistical issues the disease poses, and the ongoing drug shortages. Summary With little attention being paid to sedation practices specific to patients with COVID-19 in critical care literature and minimal mention in national guidelines, there is a significant gap in knowledge. We review the existing literature to discuss the unique challenges that providers face while providing sedation and analgesia to critically ill patients with COVID-19 and propose evidence-based management strategies.

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Ketamine sedation in mechanically ventilated patients: A systematic review and meta-analysis

Cited by 33 publications

References 32 publications

High sedation needs of critically ill COVID-19 ARDS patients—A monocentric observational study

High sedation needs of critically ill COVID-19 ARDS patients—A monocentric observational study

Adjunct low-dose ketamine infusion vs standard of care in mechanically ventilated critically ill patients at a Tertiary Saudi Hospital (ATTAINMENT Trial): study protocol for a randomized, prospective, pilot, feasibility trial

Challenges in Sedation Management in Critically Ill Patients with COVID-19: a Brief Review

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