In this episode I’ll:
1. Discuss an article about Cardiac Arrest and Mortality Related to Intubation Procedure in Critically Ill Adult Patients.
2. Answer the drug information question “Is it possible for ketamine to cause apnea?”
3. Share a resource for managing patients for whom blood transfusion is not an option.
Article
Lead author: Audrey De Jong
Published in Critical Care Medicine April 2018
Background
Endotracheal intubation is not a risk-free procedure when performed in critically ill patients. The authors of this study sought to determine the prevalence of and risk factors for cardiac arrest during intubation in ICU. They also sought to determine the association of ICU intubation–related cardiac arrest with 28-day mortality.
Methods
The study was a retrospective analysis of prospectively collected data from 64 ICUs in France. Patients were included if they were critically ill adults that required intubation in the ICU.
Results
A total of 1,847 intubation procedures were included in the analysis. The incidence of intubation-related cardiac arrest was 2.7%. About one-quarter of the patients with cardiac arrest did not achieve return of spontaneous circulation.
In multivariate analysis, the main predictors of intubation-related cardiac arrest were systolic blood pressure < 90 mm Hg prior to intubation (odds ratio = 3.406), hypoxemia prior to intubation (odds ratio = 3.99), absence of pre-oxygenation (odds ratio = 3.584), body mass index > 25 (odds ratio = 2.005), and age more than 75 years old (odds ratio = 2.251).
The 28-day mortality rate was more than doubled in patients who experienced intubation-related cardiac arrest than in noncardiac arrest patients (73.5% vs 30.1%).
Conclusion
The authors concluded:
ICU intubation–related cardiac arrest occurs in one of 40 procedures with high immediate and 28-day mortality. We identified five independent risk factors for cardiac arrest, three of which are modifiable, possibly to decrease intubation-related cardiac arrest prevalence and 28-day ICU mortality.
Discussion
Three of the 5 risk factors are potentially modifiable:
* Systolic BP < 90 mmHg
* Hypoxia
* Absence of pre-oxygenation
Of these, the factor with the most potential for a pharmacist to impact is the systolic blood pressure. I make sure that vasopressors and fluids are being used optimally to establish a systolic above 90 prior to intubation whenever possible. In addition, if patient agitation is preventing adequate pre-oxygenation, a pharmacist can facilitate providing sedation with medications such as dexmedetomidine or ketamine that would allow for pre-oxygenation to take place.
Finally, if multiple risk factors are present, consider preparing in advance by having the code cart in the room so that in the event of an intubation-related cardiac arrest, supplies and medications to treat the patient are readily available.
Drug information question
Q: Is it possible for ketamine to cause apnea?
A: Yes.
Ketamine is commonly thought of as not causing respiratory depression, but it can under certain circumstances.
Rapid IV push doses given in less than 60 seconds are thought to contribute to the risk of apnea with ketamine.
In episode 139 I described an agitated patient that got a low dose of ketamine and developed apnea within 1 minute. One review from 2008 in the American Journal of Emergency Medicine even stated that:
…a brief period of apnea around the time of injection is common.
Apnea from ketamine is transient and of minimal clinical significance if the team is prepared to recognize and deal with it. The biggest risk would be treating ketamine as a medication with zero risk of apnea, and then being caught by surprise and unprepared in the rare instance when it happens.
Resource
Englewood Hospital and Medical Center has managed patients for whom blood transfusion is not an option using a bloodless protocol, which has been in place since 1994. You can download the protocol here. A retrospective study that spanned a 15 year period concluded that the overall risk of mortality in severely anemic critically ill patients managed according to the bloodless protocol appeared to be comparable with transfused patients.
You can get a detailed and referenced pdf on the use of ketamine in critical care in my free download section at pharmacyjoe.com/free (it’s download #13).
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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