Ketamine sedation in the intensive care unit: a survey of Canadian intensivists

Sharif, Sameer; Munshi, Laveena; Burry, Lisa; Mehta, Sangeeta; Gray, Sara; Chaudhuri, Dipayan; Duffett, Mark; Siemieniuk, Reed A.; Rochwerg, Bram

doi:10.1007/s12630-023-02608-x

Cited by 4 publications

(1 citation statement)

References 36 publications

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“…A systematic review of seven prospective studies (including two paediatric studies) concluded that there was no clear benefit from the administration of IV ketamine in patients with refractory asthma, and further multi-centre randomised controlled trials are required to conclusively evaluate this finding [83]. However, ketamine is commonly used as an induction and maintenance of sedation agent in patients with severe asthma [89,90]. In summary, it appears that although there is a potentially physiological argument for the use of ketamine as an adjunct to improve bronchoconstriction, and anecdotal data appear to suggest some benefit, the literature thus far does not support its use.…”

Section: Anaesthetic Agents 451 Ketaminementioning

confidence: 99%

Management of Acute Life-Threatening Asthma Exacerbations in the Intensive Care Unit

Talbot,

Roe,

Dushianthan

2024

Applied Sciences

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Managing acute asthma exacerbations in critical care can be challenging and may lead to adverse outcomes. While standard management of an acute asthma exacerbation is well established in outpatient and emergency department settings, the management pathway for patients with life-threatening and near-fatal asthma still needs to be fully defined. The use of specific interventions such as intravenous ketamine, intravenous salbutamol, and intravenous methylxanthines, which are often used in combination to improve bronchodilation, remains a contentious issue. Additionally, although it is common in the intensive care unit setting, the use of non-invasive ventilation to avoid invasive mechanical ventilation needs further exploration. In this review, we aim to provide a comprehensive overview of the available treatments and the evidence for their use in intensive care. We highlight the ongoing need for multicentre trials to address clinical knowledge gaps and the development of intensive-care-based guidelines to provide an evidence-based approach to patient management.

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Section: Anaesthetic Agents 451 Ketaminementioning

confidence: 99%

Management of Acute Life-Threatening Asthma Exacerbations in the Intensive Care Unit

Talbot,

Roe,

Dushianthan

2024

Applied Sciences

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Ketamine analgo‐sedation for mechanically ventilated critically ill adults: A rapid practice guideline from the Saudi Critical Care Society and the Scandinavian Society of Anesthesiology and Intensive Care Medicine

Amer,

Møller,

Alshahrani

et al. 2024

Acta Anaesthesiol Scand

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BackgroundThis Rapid Practice Guideline (RPG) aimed to provide evidence‐based recommendations for ketamine analgo‐sedation (monotherapy and adjunct) versus non‐ketamine sedatives or usual care in adult intensive care unit (ICU) patients on invasive mechanical ventilation (iMV) and to identify knowledge gaps for future research.MethodsThe RPG panel comprised 23 multinational multidisciplinary panelists, including a patient representative. An up‐to‐date systematic review and meta‐analysis constituted the evidence base. The Grading Recommendations, Assessment, Development, and Evaluation approach, and the evidence‐to‐decision framework were used to assess the certainty of evidence and to move from evidence to decision/recommendation. The panel provided input on the balance of the desirable and undesirable effects, certainty of evidence, patients' values and preferences, costs, resources, equity, feasibility, acceptability, and research priorities.ResultsData from 17 randomized clinical trials (n = 898) and nine observational studies (n = 1934) were included. There was considerable uncertainty about the desirable and undesirable effects of ketamine monotherapy for analgo‐sedation. The evidence was very low certainty and downgraded for risk of bias, indirectness, and inconsistency. Uncertainty or variability in values and preferences were identified. Costs, resources, equity, and acceptability were considered varied. Adjunctive ketamine therapy had no effect on mortality (within 28 days) (relative risk [RR] 0.99; 95% confidence interval [CI] 0.76 to 1.27; low certainty), and may slightly reduce iMV duration (days) (mean difference [MD] −0.05 days; 95% CI −0.07 to −0.03; low certainty), and uncertain effect on the cumulative dose of opioids (mcg/kg/h morphine equivalent) (MD −11.6; 95% CI −20.4 to −2.7; very low certainty). Uncertain desirable effects (cumulative dose of sedatives and vasopressors) and undesirable effects (adverse event rate, delirium, arrhythmia, hepatotoxicity, hypersalivation, use of physical restraints) were also identified. A possibility of important uncertainty or variability in patient‐important outcomes led to a balanced effect that favored neither the intervention nor the comparison. Cost, resources, and equity were considered varied.ConclusionThe RPG panel provided two conditional recommendations and suggested (1) against using ketamine as monotherapy analgo‐sedation in critically ill adults on iMV when other analgo‐sedatives are available; and (2) using ketamine as an adjunct to non‐ketamine usual care sedatives (e.g., opioids, propofol, dexmedetomidine) or continuing with non‐ketamine usual care sedatives alone. Large‐scale trials should provide additional evidence.

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Ketamine Analgo-sedation for Mechanically Ventilated Critically Ill Adults: A Rapid Practice Guideline from the Saudi Critical Care Society and the Scandinavian Society of Anesthesiology and Intensive Care Medicine

Amer,

Hylander Møller,

Alshahrani

et al. 2024

Anesthesia &Amp; Analgesia

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Background: This Rapid Practice Guideline (RPG) aimed to provide evidence‑based recommendations for ketamine analgo-sedation (monotherapy and adjunct) versus non-ketamine sedatives or usual care in adult intensive care unit (ICU) patients on invasive mechanical ventilation (iMV) and to identify knowledge gaps for future research. Methods: The RPG panel comprised 23 multinational multidisciplinary panelists, including a patient representative. An up-to-date systematic review and meta-analysis constituted the evidence base. The Grading Recommendations, Assessment, Development, and Evaluation approach, and the evidence-to-decision framework were used to assess the certainty of evidence and to move from evidence to decision/recommendation. The panel provided input on the balance of the desirable and undesirable effects, certainty of evidence, patients’ values and preferences, costs, resources, equity, feasibility, acceptability, and research priorities. Results: Data from 17 randomized clinical trials (n=898) and 9 observational studies (n=1934) were included. There was considerable uncertainty about the desirable and undesirable effects of ketamine monotherapy for analgo-sedation. The evidence was very low certainty and downgraded for risk of bias, indirectness, and inconsistency. Uncertainty or variability in values and preferences were identified. Costs, resources, equity, and acceptability were considered varied. Adjunctive ketamine therapy had no effect on mortality (within 28 days) (relative risk [RR] 0.99; 95% confidence interval [CI] 0.76 to 1.27; low certainty), and may slightly reduce iMV duration (days) (mean difference [MD] -0.05 days; 95% CI -0.07 to -0.03; low certainty), and uncertain effect on the cumulative dose of opioids (mcg/kg/h morphine equivalent) (MD -11.6; 95% CI -20.4 to -2.7; very low certainty). Uncertain desirable effects (cumulative dose of sedatives and vasopressors) and undesirable effects (adverse event rate, delirium, arrhythmia, hepatotoxicity, hypersalivation, use of physical restraints) were also identified. A possibility of important uncertainty or variability in patient-important outcomes led to a balanced effect that favored neither the intervention nor the comparison. Cost, resources, and equity were considered varied. Conclusion: The RPG panel provided two conditional recommendations and suggested (1) against using ketamine as monotherapy analgo-sedation in critically ill adults on iMV when other analgo-sedatives are available; and (2) using ketamine as an adjunct to non-ketamine usual care sedatives (e.g., opioids, propofol, dexmedetomidine) or continuing with non-ketamine usual care sedatives alone. Large-scale trials should provide additional evidence.

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Ketamine sedation in the intensive care unit: a survey of Canadian intensivists

Cited by 4 publications

References 36 publications

Management of Acute Life-Threatening Asthma Exacerbations in the Intensive Care Unit

Management of Acute Life-Threatening Asthma Exacerbations in the Intensive Care Unit

Ketamine analgo‐sedation for mechanically ventilated critically ill adults: A rapid practice guideline from the Saudi Critical Care Society and the Scandinavian Society of Anesthesiology and Intensive Care Medicine

Ketamine Analgo-sedation for Mechanically Ventilated Critically Ill Adults: A Rapid Practice Guideline from the Saudi Critical Care Society and the Scandinavian Society of Anesthesiology and Intensive Care Medicine

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