Multicenter Retrospective Review of Ketamine Use in the ICU

Abstract

The response of ICU patients to continuously infused ketamine when it is used for analgesia and/or sedation remains poorly established. OBJECTIVES:To describe continuous infusion (CI) ketamine use in critically ill patients, including indications, dose and duration, adverse effects, patient outcomes, time in goal pain/sedation score range, exposure to analgesics/sedatives, and delirium. DESIGN, SETTING, AND PARTICIPANTS:Multicenter, retrospective, observational study from twenty-five diverse institutions in the United States. Patients receiving CI ketamine between January 2014 and December 2017. MAIN OUTCOMES AND MEASURES:Chart review evaluating institutional and patient demographics, ketamine indication, dose, administration, and adverse effects. Pain/sedation scores, cumulative doses of sedatives and analgesics, and delirium screenings in the 24 hours prior to ketamine were compared with those at 0-24 hours and 25-48 hours after. RESULTS:A total of 390 patients were included (median age, 54.5 yr; interquartile range, 39-65 yr; 61% males). Primary ICU types were medical (35.3%), surgical (23.3%), and trauma (17.7%). Most common indications were analgesia/sedation (n = 357, 91.5%). Starting doses were 0.2 mg/kg/hr (0.1-0.5 mg/kg/hr) and continued for 1.6 days (0.6-2.9 d). Hemodynamics in the first 4 hours after ketamine were variable (hypertension 24.0%, hypotension 23.5%, tachycardia 19.5%, bradycardia 2.3%); other adverse effects were minimal. Compared with 24 hours prior, there was a significant increase in proportion of time spent within goal pain score after ketamine initiation (24 hr prior:

Ketamine for Primary Analgosedation in Critically Ill Surgery and Trauma Patients Requiring Mechanical Ventilation

“…Respective to toxicity, chief concerns include dissociative effects, potential for increased delirium, increased airway secretions, and hemodynamic alterations. In our cohort, ketamine was discontinued due to perceived toxicity in 7% of patients which is very similar to the rates of discontinuation due to an adverse effect observed by Groetzinger et al (7.7%) and Groth et al (5.7%) (14, 16). Hallucinations or agitation were documented to occur in 2% and 11%, respectively.…”

“…Similarly, Bucheit et al (15) reported fentanyl discontinuation in over half of patients following ketamine initiation. A recent multicenter observational study including 390 ICU patients receiving ketamine infusions explored a broad range of indications (analgesia/sedation in 92%) and associated outcomes (16). Among those receiving ketamine for analgesia/sedation, the outcomes observed were in alignment with previous retrospective studies of adjunctive ketamine use.…”

Continuous Ketamine Infusion as a Treatment for Refractory Facial Pain

“…Inpatient monitoring during continuous ketamine infusion in the current study allowed the safe delivery of a higher dose of ketamine compared to intermittent ketamine infusion [13]. There are known biological mechanisms consistent with the notion that continuous ketamine infusion may lead to better analgesia in the perioperative period and may be more suited than intermittent boluses in treating conditions related to central sensitization [9,20]. Although continuous ketamine infusion is likely more costly than intermittent infusion, a greater analgesic effect may justify the investment of resources.…”

Prevalence of Delirium After Abdominal Surgery and Association With Ketamine: A Retrospective, Propensity-Matched Cohort Study

“…Previous observational studies (28, 29) and a recent meta-analysis (30) have reported that ketamine used as an adjunctive analgesic was associated with reduced opioid requirements, goal sedation scores, pain scale, CPOT scores, and minimal to no adverse events. In contrast, our present study failed to identify an association between ketamine use and opioid consumption but a higher pain score.…”