Ketamine infusions as an adjunct for sedation in critically ill children
DOI:
https://doi.org/10.5055/jom.2022.0695Keywords:
ketamine, sedation, pediAbstract
Objective: Limited reports have described ketamine’s role as an adjunct sedative. The purpose was to describe ketamine’s role as an adjunct to achieve goal sedation in mechanically ventilated children.
Design: Retrospective, descriptive study.
Setting: Thirteen-bed pediatric intensive care unit (ICU) and 12-bed pediatric cardiovascular ICU.
Participants: Seventy-three ketamine courses were included, representing 62 mechanically ventilated children <18 years receiving ketamine for ≥12 hours.
Main outcome measure(s): The primary outcome was to determine the median dose and time to achieve goal sedation (80 percent of State Behavioral Scale scores between 0 and –1) based on ketamine’s place in therapy as an adjunct in the sedation regimen. Secondary outcomes included a comparison of sedative dosing pre- and post-ketamine initiation between place in therapy groups and paralyzed/nonparalyzed patients, and identification of ketamine-attributed adverse drug event (ADEs) or iatrogenic withdrawal syndrome (IWS).
Results: The median age was 1.0 years (interquartile range: 0.4-4.9). Ketamine was initiated as first-line (n = 7; 9.6 percent), second-line (n = 39; 53.4 percent), third-line (n = 26; 35.6 percent), or fourth-line (n = 1; 1.4 percent) sedation. The median initial and peak doses were 0.6 mg/kg/h (0.3-0.6) and 0.9 mg/kg/h (0.9-1.2), respectively. The median dose and time to achieve goal sedation was 0.8 mg/kg/h (0.6-1.1) and 2 hours (1-7), respectively. ADEs were noted during three courses (4.1 percent) and IWS after discontinuation of one course (1.4 percent).
Conclusions: The majority were initiated on ketamine as a second- or third-line adjunct sedative. The median initial dose was 0.6 and dose to achieve goal sedation was 0.8 mg/kg/h. Ketamine-attributed ADEs and IWS episodes were rare.
References
Anand KJS, Clark AE, Willson DF, et al.: Opioid analgesia in mechanically ventilated children: Results from the multicenter Measuring Opioid Tolerance Induced by Fentanyl Study. Pediatr Crit Care Med. 2013; 14: 27-36.
Twite MD, Rashid A, Zuk J, et al.: Sedation, analgesia, and neuromuscular blockade in the pediatric intensive care unit: Survey of fellowship training programs. Pediatr Crit Care Med. 2004; 5: 521-532.
Mody K, Kaur S, Mauer EA, et al.: Benzodiazepines and development delirium in critically ill children: Estimating the causal effect. Crit Care. 2018; 46: 1486-1491.
Heiberger AL, Ngorsuraches S, Olgun G, et al.: Safety and utility of continuous ketamine infusion for sedation in mechanically ventilated pediatric patients. J Pediatr Pharmacol Ther. 2018; 23: 447-454.
Neunhoeffer F, Hanser A, Esslinger M, et al.: Ketamine infusion as a counter measure for opioid tolerance in mechanically ventilated children: A pilot study. Pediatr Drugs. 2017; 19: 259-265.
Tobias JD, Martin LD, Wetzel RC: Ketamine by continuous infusion for sedation in the pediatric intensive care unit. Crit Care Med. 1990; 18: 819-821.
Barbi E, Rizzello E, Taddio A: Use of ketamine continuous infusion for pediatric sedation in septic shock. Pediatr Emerg Care. 2010; 26: 689-690.
Ito H, Sobue K, Hirate H: Use of ketamine to facilitate opioid withdrawal in a child. Anesthesiology. 2006; 104: 1113.
Strube PJ, Hallam PL: Ketamine by continuous infusion in status asthmaticus. Anaesthesia. 1986; 41: 1017-1019.
Denmark TK, Crane HA, Brown L: Ketamine to avoid mechanical ventilation in severe pediatric asthma. J Emerg Med. 2006; 30: 163-166.
Allen JY, Marcias CG: The efficacy of ketamine in pediatric emergency department patients who present with acute severe asthma. Ann Emerg Med. 2005; 46: 43-50.
Petrillo TM, Fortenberry JD, Linzer JF, et al.: Emergency department use of ketamine in pediatric status asthmaticus. J Asthma. 2001; 38: 657-664.
Rock MJ, Reyes De La Rocha S, L’Hommedieu CS, et al.: Use of ketamine in asthmatic children to treat respiratory failure refractory to conventional therapy. Crit Care Med. 1986; 14: 514-516.
Nehama J, Pass R, Bechtler-Karsch A, et al.: Continuous ketamine infusion for the treatment of refractory asthma in a mechanically ventilated infant: Case report and review of the pediatric literature. Pediatr Emerg Care. 1996; 12: 294-297.
Agrawal A, Shrivastava J: Intravenous ketamine for refractory bronchospasm precipitated by H1N1 infection. Front Pediatr. 2014; 2: 24.
Youssef-Ahmed MZ, Silver P, Nimkoff L, et al.: Continuous infusion of ketamine in mechanically ventilated children with refractory bronchospasm. Intensive Care Med. 1996; 22: 972-976.
Park S, Choi AY, Park E, et al.: Effects of continuous ketamine infusion on hemodynamics and mortality in critically ill children. PLoS One. 2019; 14: e0224035.
Moore E, Mayes R, Harkin M, et al.: Extended duration ketamine infusions in critically ill children: A case report and review of the literature. J Pediatr Intensive Care. 2020; 1-8. DOI:10.1055/s-0040-1713144.
Golding CL, Miller JL, Gessouroun MR, et al.: Ketamine continuous infusions in critically ill infants and children. Ann Pharmacother. 2016; 50: 234-241.
Flint RB, Brouwer CNM, Kranzlin ASC, et al.: Pharmacokinetics of S-ketamine during prolonged sedation at the pediatric intensive care unit. Paediatr Anaesth. 2017; 27: 1098-1107.
Kinder KL, Lehman-Huskamp KL, Gerard JM: Do children with high body mass indices have a higher incidence of emesis when undergoing ketamine sedation? Pediatr Emerg Care. 2012; 28: 1203-1205.
WHO Multicentre Growth Reference Study Group: WHO Child Growth Standards: Length/Height-for-Age, Weight-for-Age, Weight-for-Length, Weight-for-Height and Body Mass Index-for-Age: Methods and Development. Geneva, Switzerland: World Health Organization, 2006. Available at https://www.who.int/childgrowth/standards/technical_report/en/. Accessed July 22, 2020.
Centers for Disease Control and Prevention: Children’s BMI tool for schools. 2011. Available at https://www.cdc.gov/healthyweight/bmi/calculator.html. Accessed July 22, 2020.
Ibach BW, Miller JL, Woo S, et al.: Characterization of tolerance in children during fentanyl continuous infusions. J Pediatr Intensive Care. 2017: 6; 83-90.
Flynn JT, Kaelber DC, Baker-Smith CM, et al.: Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017; 140: e20171904.
Curley MA, Harris SK, Fraser KA, et al.: State Behavioral Scale: A sedation assessment instrument for infants and young children supported on mechanical ventilation. Pediatr Crit Care Med. 2006; 7: 107-114.
Johnson PN, Skrepnek G, Golding CL, et al.: Relationship between rate of fentanyl infusion and time to achieve sedation in nonobese and obese critically ill children. Am J Health Syst Pharm. 2017; 74: 1174-1183.
Franck LS, Scoppettuolo LA, Wypij D, et al.: Validity and generalizability of the Withdrawal Assessment Tool-1 (WAT-1) for monitoring iatrogenic withdrawal syndrome in pediatric patients. Pain. 2012; 153: 142-148.
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