Lee Jan Hau, MBBS, MRCPCH, MCI (he/him/his)
KK Women's and Children's Hospital, Singapore
Singapore, Slovenia
Disclosure information not submitted.
Jimmy Huh, MD
Associate Professor of Anesthesia, Critical Care and Pediatrics
Children's Hospital of Philadelphia, United States
Disclosure information not submitted.
Palen Mallory, MD
Assistant Professor in Pediatrics
Duke University, United States
Disclosure information not submitted.
Natalie Napolitano, MPH, MPH, RRT-NPS (she/her/hers)
Research Clinical Specialist
The Children's Hospital of Philadelphia
Philadelphia, Pennsylvania, United States
Disclosure information not submitted.
Justine Shults, PhD
Professor of Biostatistics
Perelman School of Medicine, United States
Disclosure information not submitted.
.jpg "Vinay Nadkarni, MD, MS, FCCM (he/him/his) photo")
Vinay Nadkarni, MD, MS, FCCM (he/him/his)
Professor, Anesthesiology, Critical Care and Pediatrics
University of Pennsylvania Perelman School of Medicine, CHOP
Media, Pennsylvania, United States
Disclosure information not submitted.
Akira Nishisaki, MD, MSCE
Associate Professor of Anesthesia and Critical Care Medicine
The Children's Hospital of Philadelphia, United States
Disclosure information not submitted.
Title: Ketamine Use for Intubation of Critically Ill Children with Neurological Conditions
Introduction/Hypothesis: Ketamine has been traditionally avoided for intubations in respiratory failure for neurological reasons due to concerns of ICP elevation; recent evidence suggests possible beneficial effects including reduced hypoxemia and hemodynamic instability. We hypothesize increasing ketamine use in children with neurological conditions, with reduced peri-intubation hypoxemia and hemodynamic adverse events.
Methods: Multicenter NEAR4KIDS pediatric tracheal intubation (TI) 2014-2020 registry data were analysed. Inclusion criteria: children ( < 18yr) intubated for neurological reasons. Secular trend for ketamine use was evaluated using non-parametric trend. Multivariable logistic regression was performed to evaluate the association between ketamine use and composite adverse outcomes (hypoxemia < 80%, hypo/hypertension, cardiac arrests, dysrhythmia). Dose effect was assessed based on ketamine per-kg dose quartiles.
Results: Of 21,562 TIs, 2,073 were for neurological indications, including 290 for TBI/trauma. 495 (23.9%) received ketamine, which increased from 10% in 2014 to 41% in 2020 (p < 0.001). Ketamine use was associated with: respiratory failure, difficult airway history, vagolytic use, apneic oxygenation, and video laryngoscope. Composite adverse outcomes were reported in 289 (13.9%) TIs: more common in ketamine vs. non-ketamine group (17.0% vs. 13.0%, p=0.026). After adjusting for location, patient age/category, respiratory failure, shock, difficult airway history, provider, apneic oxygenation, device, vagolytic and neuromuscular blockade use, ketamine use was not significantly associated with composite adverse outcomes (aOR 1.34, 95% CI 0.99-1.81, p=0.057). Infant age, respiratory failure, and difficult airway history were independently associated with increased adverse outcomes (p < 0.05). Among TIs with ketamine, the dose was not associated with adverse outcomes (p=0.91). In subgroup analysis with TBI/trauma (n=190), ketamine use was not associated with composite adverse outcomes (10.6% vs. 7.7%, p=0.528).
Conclusions: This retrospective cohort study suggests a potential association between the use of ketamine and increased risk of peri-intubation hypoxemia and hemodynamic instability in patients with neurological conditions. Selection bias needs to be addressed by a prospective multicenter trial.