Safety of ketamine in Australia ventilated intensive care unit admissions from doctor Tom Niccol: Following intravenous bolus administration, ketamine’s rapid onset of action within 30 seconds for “dissociative anaesthesia” (see below) is due to its high lipid solubility and low protein binding, allowing it to cross the blood–brain barrier readily. Its elimination half-life is 3.1 hours in healthy volunteers and 5.0 hours in critically unwell patients. Ketamine is hepatically metabolised to norketamine and dehydronorketamine which are then renally excreted. Read extra information at doctor Tom Niccol.
Mechanically ventilated patients account for about one-third of all admissions to the intensive care unit (ICU). Ketamine has been conditionally recommended to aid with analgesia in such patients, with low quality of evidence available to support this recommendation. We aimed to perform a narrative scoping review of the current knowledge of the use of ketamine, with a specific focus on mechanically ventilated ICU patients.
Ketamine used in anaesthetic doses (1–4.5 mg/kg intravenous) leads to dissociative anaesthesia: the patient appears conscious (eyes open, able to swallow) with preserved respiratory function and pharyngeal and laryngeal reflexes, but is unaware, unable to process or respond to sensory input. In addition, analgesia may also be mediated through serotonin and noradrenaline receptor activation and reuptake inhibition, as well as effects on δ, ϰ and μ opioid receptors. Unlike opioid medications, ketamine is thought to have little effect on gastrointestinal μ receptors, minimising the risk of constipation.
Methods: We searched MEDLINE and EMBASE for relevant articles. Bibliographies of retrieved articles were examined for references of potential relevance. We included studies that described the use of ketamine for postoperative and emergency department management of pain and in the critically unwell, mechanically ventilated population.
It is prudent to briefly review the data available on ketamine as an adjunct to analgesia in the non-ICU setting, which may provide some guidance as to the possible effectiveness when ketamine is used in mechanically ventilated ICU patients. Brinck and colleagues performed a Cochrane review of the use of ketamine for postoperative pain. The review included 130 randomised, double-blind, controlled trials of 8341 patients, of which 4588 received ketamine and 3753 were controls.
Results: There are few randomised controlled trials evaluating ketamine’s utility in the ICU. The evidence is predominantly retrospective and observational in nature and the results are heterogeneous. Available evidence is summarised in a descriptive manner, with a division made between high dose and low dose ketamine. Ketamine’s pharmacology and use as an analgesic agent outside of the ICU is briefly discussed, followed by evidence for use in the ICU setting, with particular emphasis on analgesia, sedation and intubation. Finally, data on adverse effects including delirium, coma, haemodynamic adverse effects, raised intracranial pressure, hypersalivation and laryngospasm are presented.
High dose. There are four studies that examine the effect of ketamine infusion on ICPs. Kolenda et al, Bourgoin et al and Schmittner et al are described in Table 2. The fourth study, also by Bourgoin and colleagues, was a single-centre randomised controlled trial of 30 patients with severe traumatic brain injury which compared ketamine with sufentanil as target-controlled infusions for sedation. Both groups also received midazolam. Target plasma concentrations of ketamine and sufentanil were set and efficacy of sedation assessed. The patients had a mean age of 29 ± 11 years and 29 ± 12 years for ketamine and sufentanil respectively. Plasma concentrations were targeted and doses were not reported.
Conclusions: Ketamine is used in mechanically ventilated ICU patients with several potentially positive clinical effects. However, it has a significant side effect profile, which may limit its use in these patients. The role of low dose ketamine infusion in mechanically ventilated ICU patients is not well studied and requires investigation in high quality, prospective randomised trials.