Episode 238: Ketamine as an analgesic adjunct in critically ill patients, at what MIC should an alternative to vancomycin be used to treat meningitis, and a resource for those interested in pharmacy compounding

In this episode I’ll:
1. Discuss an article about using ketamine as an analgesic adjunct in critically ill patients.
2. Answer the drug information question “At what MIC should an alternative to vancomycin be used to treat meningitis?
3. Share a resource for those interested in pharmacy compounding.

Members of my Critical Care Pharmacy Academy will have access to my new Masterclass on severe alcohol withdrawal starting Thursday, November 2, 2017. To learn more about becoming a member of the Academy go to pharmacyjoe.com/academy.

Article

Impact of Ketamine Use on Adjunctive Analgesic and Sedative Medications in Critically Ill Trauma Patients

Lead author: Kaitlin A. Pruskowski

Published in Pharmacotherapy October 2017

Background

Ketamine is a uniquely useful drug. I discussed the use of ketamine in critical care in episode 16.

Ketamine checks a lot of boxes and fills a lot of niches. Analgesia? Check. Sedation? Check. Respiratory drive maintained? Check. Neutral to positive cardiovascular effect? Check.

While it is often stated that ketamine may be used to manage pain and agitation that is refractory to “traditional” agents, supporting literature for ketamine continuous infusions in critically ill trauma patients is limited.

The authors of this study sought to determine the impact of the initiation of a ketamine continuous infusion on sedative and analgesic use in critically ill trauma patients.

Methods

The study was a single-center, retrospective chart review that included only critically ill, mechanically ventilated, adult trauma patients in whom a ketamine continuous infusion was initiated for management of sedation and agitation.

Results

The authors found thirty-six patients that met study inclusion criteria. Many patients reviewed were caucasian males with blunt trauma. In patients who received ketamine by continuous infusion, lower doses of opioids and propofol were required to achieve target sedation levels. However the need for ziprasidone and dexmedetomidine was increased. The proportion of patients who achieved their sedation goal was no different when compared to before and after ketamine administration.

Conclusion

The authors concluded:

Although the use of ketamine in critically ill, mechanically ventilated, adult trauma patients was associated with decreased opioid use, it was also associated with increased use of dexmedetomidine and ziprasidone to achieve and maintain sedation. Further examination of clinical outcomes associated with these differences in drug use in a larger population of trauma patients is warranted before routine use of ketamine for analgesia and sedation can be recommended.

 

Discussion

What I take from this small retrospective study is that ketamine has no role in first-line sedation for critically ill trauma patients. There are many unique scenarios were ketamine will greatly help manage a patient who is refractory to traditional agents. However I do not consider that ketamine is a drug for routine, continuous use in the sedation of critically ill patients at this time.

Drug information question

Q: At what MIC should an alternative to vancomycin be used to treat healthcare associated meningitis?
A: The answer is not as clear cut as guidelines may suggest.

The latest healthcare associated meningitis guidelines from IDSA advocate for considering alternate MRSA therapies if the minimum inhibitory concentration (MIC) of staphylococcal pathogens is 1 or greater. While each local antibiogram is different, chances are the majority of MRSA strains have an MIC of at least 1.

A recent letter to the editor in Clinical Infectious Disease took issue with this guideline statement. The authors of the letter point out this is a very low MIC threshold, and claim it glosses over the problem that other agents may be less effective than vancomycin. The authors recommend that patient specific factors also be taken into account when deciding to move away from vancomycin for MRSA meningitis, not just the MIC level.

Resource

The resource for this episode is The Pharmacy Inspection Podcast. This new podcast is hosted by a PharmD and an MBA.  It is dedicated to helping others increase compliance and improve the quality of their pharmacy compounding laboratory and environment. Each host brings a unique perspective to the table, and guests are planned for future episodes. The world of compounding pharmacy is closely intertwined with hospital pharmacy, especially with the large amount of drug shortages in critical care related medications. You can listen to the first episode here.

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If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.

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