Ketamine Could Be Useful Alternative for Pain Relief, Sedation in ICU

Christine Groth, PharmD

Results of a new study indicate continuous infusion ketamine could increase time spent in goal pain and sedation score range and decrease the need for opioids, benzodiazepines, and other analgesics—indicating it could be a reliable alternative for intensive care unit (ICU) patients.

Presented at the Society of Critical Care Medicine’s 49^th Annual Critical Care Congress in Orlando, the Effects of Ketamine on Pain, Sedation, and Delirium in the Intensive Care Unit (Ketamine-ICU Study) was designed to address the lack of guidance as to how to use ketamine in the ICU.

“We feel ketamine is a reasonable option especially in those failing traditional sedative and analgesia regimens,” said Christine Groth, PharmD, Clinical Pharmacy Coordinator of the University of Rochester Medical Center.

The Ketamine-ICU study was designed by Groth and the Ketamine-ICU study members as a multicenter, retrospective study evaluating a cohort of 390 adult ICU patients from 25 institutions from 2014-2017. The mean age of the study population was 52 years, median APACHE II score was 21, mean length of stay in ICU was 9 days, and mean length of hospital stay was 15 days.

Investigators hypothesized a continuous infusion of ketamine would lead to an increased proportion of time spent in goal pain and sedation score range, reduced exposure to other sedatives, and variable effects on delirium.

For the purpose of the analysis, pain and sedation scores and delirium screenings in the 24 hours prior to ketamine were compared to scores and screenings in the first 24 hours and 25 to 48 hours following ketamine administration.

Analyses revealed a significant increase in median time spent within goal pain score range after ketamine initiation (24H prior: 68.9% [66.7-72.6%], first 24H: 78.6% [74.3-82.5%], 25-48H: 80.3% [74.6-84.3%]; P< .001). Results also indicated there was a significant increase in median time spent within goal sedation score range after ketamine initiation (24H prior: 57.1% [52.5%-60%], first 24H: 64.1% [60.7-67.2%], 25-48H: 68.9% [65.5-79.5%]; P< .001).

Investigators pointed out there was no difference in median time spent delirious after ketamine initiation (24H prior: 43.0% [17.0-47.0%], first 24H: 39.5% [27.0-43.8%], 25-48H: 0% [0-43.7%]; P = .233). Additionally, results suggest ketamine associated with a significant reduction in opioid, benzodiazepine, propofol and dexmedetomidine requirements.

“Eighty percent of patients were mechanically ventilated and in a fair amount of these patients ketamine was continued through the extubation period, which we thought was interesting,” Groth said.

Of note, 5.7% of participants discontinued participation due to adverse effects. Adverse effects observed in participants included increased secretions, which occurred in 10% of patients, and resulted in increased anticholinergic use. Additionally, psychotropic effects were recorded in just 4.6% of patients—however, this study was retrospective and, because of this, these effects may have been underrepresented.

“We definitely need prospective randomized comparative data to really determine its place in therapy as well as the overall safety of this medication,” Groth added.

This study, “Effects of Ketamine on Pain, Sedation, and Delirium in the Intensive Care Unit (KETAMINE-ICU Study),” was presented at CCC 49 in Orlando, FL.

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Adam Sturts, MSIV, a fourth-year medical student at Rowan University School of Osteopathic Medicine, volunteered to contribute to HCPLive's Notes from Rounds while attending CCC 49 in Orlando, FL. In addition to providing insights and coverage of the meeting, Sturts also presented a study he took part in with colleagues from Inspira Health Network in Vineland, NJ, titled "Predischarge decision tree analysis predicts 30-day congestive heart failure readmission," which examined the use of a predischarge decision tree analysis in nearly 5000 congestive heart failure admissions.