Ashley Choe, MBA, MD
Critical Care Fellow
Strong Memorial Hospital of the University of Rochester
Rochester, NY
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Title: Ketamine and Buprenorphine Adjunctive Therapies in an Opioid-tolerant Patient with Severe ARDS
Case Report Body:
Introduction: This case presents an opioid-tolerant critically ill patient with acute respiratory distress syndrome from streptococcal pneumonia who required escalation of care for difficult sedation.
Description: A 61 year old woman with history of chronic pain prescribed 1870 morphine milligram equivalents daily (1600mg morphine SR daily, oxycodone 30mg every 4 hours) with additional polypharmacy (alprazolam, bupropion, amitriptyline, valproic acid, and escitalopram). She presented to the intensive care unit with severe acute respiratory distress syndrome from streptococcal pneumonia. Achievement of adequate deep sedation was difficult due to her opioid tolerance even with enteral oxycodone, infusions of up to 10mg/hr of midazolam, 350mcg/min of fentanyl, 1mcg/kg/min of dexmedetomidine, and IV phenobarbital boluses. This difficulty delayed paralysis and proning by around 20 hours with P/F ratios less than 65. She was ultimately transferred to a tertiary care facility for toxicology consultation, ketamine infusion up to 2mg/kg/hr, and micro-induction of buprenorphine. This quickly facilitated weaning of benzodiazepines, opioids, and multiplicity of infusions, as well as oxygenation and eventual ventilator weaning. Months after admission she was discharged home with family on buprenorphine, gabapentin, aripiprazole, and hydroxyzine.
Discussion: With the sale of prescription opioids tripling from 1999 to 2015, the opioid epidemic has long been recognized as a major public health issue. This case highlights how the opioid epidemic affects the care of critically ill patients that require sedation and paralysis for proper oxygenation. It also demonstrates successful use of ketamine infusions and buprenorphine micro-induction adjunctive therapies to overcome high opioid tolerance in chronic users with decreased use of opioids. There is little evidence in literature for specific dosing of these adjuncts, but there is consensus that protocolized multi-modal sedation and analgesia is best for ventilator weaning in prolonged and difficult sedations. This case represents a need for further investigation into non-opioid options for ICU sedation and analgesia protocols in high-tolerance patients.