Analgosedation with Ketamine in the ICU: What is the Evidence?

Ketamine

Ketamine’s success seems unstoppable:
​+++ Anaesthesiologists are opening private clinics for off-label infusions of ketamine for depression http://bit.ly/1IGYTcI +++ Dr. Jim Roberts says #ketamine is an ideal treatment for excited #delirium: http://emn.online/Dec15InFocus +++ Major #ketamine treatment trial to start in 2016 http://m.huffpost.com/au/entry/8501942 +++ More impressed every day with low dose ketamine for pain management! https://www.youtube.com/watch?v=DgckjVVBb48

Intravenous ketamine is also used in critical care units and to my knowledge most clinicians use ketamine as an adjunct to other sedatives. This might be for patients on mechanical ventilation, intubation procedures or simply as an additive to a patient-controlled analgesia pump. I personally think ketamine is one of the essentials in ICU’s, but what does the evidence say.

Asad et al. have performed a systematic review on the usage of ketamine as a continuous infusion (>24h) in intensive care patients. The aim was to find evidence in favour for the utilisation of ketamine in the ICU.

As a result of this review – current evidence suggests that:

– In critically ill postoperative patients ketamine has the potential to reduce the cumulative morphine consumption at 48h compared to morphine only

– Several trials show the potential safety of ketamine in regards of cerebral haemodynamics in patients with traumatic brain injury, improved gastrointestinal motility and decreased vasopressor requirements

– One observational study and case reports suggest that ketamine is safe, effective and may have a role in patients who are refractory to other therapies
​Our conclusion: THUMBS UP for ketamine in the ICU

 

Asad E. et al. J Intensive Care Med December 8, 2015

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What is Better in ARDS: Pressure Controlled or Volume Controlled Ventilation?

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A good question, but do you actually know. Most ICU’s have their standard modes of ventilation and we are busy enough concentrating on the wright PEEP, the perfect tidal volume or prone positioning the patient. But does the mode of ventilation actually have an impact on the outcome? Chacko et al. had a look at exactly this question and performed a systematic review on this topic:

– Early mortality: There is only some moderate-quality evidence suggesting that pressure controlled ventilation might be of benefit, although this was not observed in the long term follow-up!

– Duration of mechanical ventilation: no apparent difference between pressure- and volume-controlled ventilation

– ICU length of stay: no apparent difference between pressure- and volume-controlled ventilation

– incidence of barotrauma: no apparent difference between pressure- and volume-controlled ventilation

– Extrapulmonary organ failure: One underpowered study in favour of pressure controlled ventilation

– Infective complications, Quality of life: To this date no studies available

Conclusion: Current evidence shows no difference between pressure controlled and volume controlled ventilation in ARDS

 

Cochrane, Clinical Answers OPEN ACCESS

Chacko B, Peter JV, Tharyan P, John G, Jeyaseelan L. Cochrane Database of Systematic Reviews 2015, Issue 1. Art. No.: CD008807. OPEN ACCESS