Brian Phan, PharmD, BCCCP
Critical Care Clinical Pharmacist
Riverside University Health System Medical Center, United States
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Title: Continuous Infusion of Ketamine in Mechanically Ventilated Patients with SARS-CoV-2
Introduction: Emerging evidence on the potentially advantageous hemodynamic profile and anti-inflammatory properties of ketamine has recently increased its use as a sedative among mechanically ventilated (MV), critically ill patients. There remains a paucity of data specifically evaluating ketamine in patients with severe SARS-CoV-2. This study sought to determine if the use of continuous infusion of ketamine in MV patients with SARS-CoV-2 would lead to a decrease in vasopressor requirements.
METHOD: This was a single-center, retrospective, cohort study comparing MV patients with SARS-CoV-2 who received either a continuous infusion of ketamine or propofol as their main sedative. Study outcomes included vasopressor requirements at 24-, 48-, and 72-hour, incidence of emergence reactions, C-reactive protein (CRP), mean arterial pressures and opioid requirements at specified timepoints. Patients above 18 years of age were eligible for inclusion. The main exclusion criterion included patients receiving less than 72 hours of sedation.
Results: A total of 84 patients (mean age of 61, 68% male) were included, of these 31 and 53 received ketamine and propofol, respectively. Baseline vasopressor doses (in norepinephrine equivalent) for ketamine and propofol groups were 9mcg/min and 4mcg/min (p < 0.005), respectively. Mean vasopressor doses were not significantly different between ketamine and propofol groups at 24-hr (13.54mcg/min vs. 13.49mcg/min, p=0.99), 48-hr (16.80mcg/min vs. 11.61mcg/min, p= 0.27), and 72-hr (14.95mcg/min vs. 14.85mcg/min, p= 0.99). However, ketamine was associated with a significant increase in MAP at 24-hr (79.9mmHg vs. 72mmHg, p< 0.005) and at 96-hr (81.7mmHg vs. 71.4mmHg, p< 0.005). There was also a significant decline in CRP levels among ketamine patients with or without concurrent use of dexmedetomidine. Average opioid requirements (in morphine equivalent) were lower in ketamine patients compared to propofol (3mg/hr vs. 12.5mg/hr, p< 0.0001). Nonetheless, 42% of ketamine patients had a reported event of agitation compared to 21% of propofol, p< 0.05.
Conclusion: In MV patients with SARS-CoV-2, there was no difference in vasopressor requirements among patients receiving ketamine compared to propofol. Nevertheless, the use of ketamine was associated with reductions in CRP and opioid requirements.