In this episode, I’ll discuss a recent practice guideline on ketamine use for analgosedation in critically ill patients.
The 2018 PADIS Guidelines published by the Society of Critical Care Medicine gave a positive recommendation for the use of ketamine saying:
We suggest using low-dose ketamine (0.5 mg/kg IVP x 1 followed by 1-2 μg/kg/min infusion) as an adjunct to opioid therapy when seeking to reduce opioid consumption in postsurgical adults admitted to the ICU.
This was a conditional recommendation based on very low levels of evidence, but its presence in the guidelines raised the likelihood that clinicians might choose to add ketamine for the purposes of analgosedation to the regimen of critically ill patients.
Looking deeper into the rationale of the PADIS Guideline authors, the suggestion to use ketamine was based on some systematic reviews in non-ICU patients and a single randomized controlled trial of 93 surgical ICU patients that the panel described as “generally positive”.
Recently A Rapid Practice Guideline on Ketamine Analgo-sedation for Mechanically Ventilated Critically Ill Adults from the Saudi Critical Care Society and the Scandinavian Society of Anesthesiology and Intensive Care Medicine was published in the journal anesthesia and analgesia.
This expert panel has the benefit of several additional studies that have been published using ketamine in ICU patients for analgosedation since the 2018 PADIS Guidelines were released.
This panel reviewed 17 RCTs and 9 observational studies leading to them to issue two conditional recommendations.
1. For critically ill adults undergoing iMV, the panel suggests not using ketamine monotherapy for analgo-sedation
2. For critically ill adults undergoing iMV, the panel suggests 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
The authors also note that ketamine dosing based on IBW can help minimize adverse events, especially in patients with obesity. If used for analgosedation they suggest a median dose of 0.9 mg/kg/hr based on IBW be considered.
The authors do acknowledge that in limited resource settings such as countries that do not have access to more expensive and well-researched options, ketamine use is still acceptable in their opinion.
These recommendations were based on the panel’s assessment of the balance between desirable and undesirable effects, available resources, and clinical context.
Members of my Hospital Pharmacy Academy have access to practical training on analgosedation and the use of ketamine in critical care from a pharmacist’s point of view, along with many other resources to help in your practice. To get immediate access, go to pharmacyjoe.com/academy.
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