Angad Sodhi
The Ohio State University Wexner Medical Center
Blacklick, Ohio
Disclosure information not submitted.
Joshua Arnold, PharmD, BCPS, BCCCP
Critical Care Pharmacy Specialist
The Ohio State University Wexner Medical Center, United States
Disclosure information not submitted.
Bruce Doepker, PharmD
Pharmacy Specialist
The Ohio State University Medical Center, United States
Disclosure information not submitted.
Jessica Elefritz, PharmD, BCCCP
PGY2 Critical Care Residency Program Director Critical Care Pharmacist
The Ohio State University Medical Center
Blacklick, Ohio
Disclosure information not submitted.
Gregory Eisinger, BA, MD, MSW
fellow
Ohio State University Hospital
Columbus, Ohio
Disclosure information not submitted.
Eric McLaughlin
Biostatistician
The Ohio State University Wexner Medical Center, United States
Disclosure information not submitted.
Kaeli Parcel
PharmD Candidate
The Ohio State College of Pharmacy, United States
Disclosure information not submitted.
Title: Comparison of nurse-titrated versus provider-titrated continuous infusion ketamine for ICU sedation
INTRODUCTION: Ketamine has seen an increase in utilization for sedation in mechanically ventilated patients due to a favorable pharmacodynamic profile. However, limited data exists evaluating the optimal dosing strategy of continuous infusion ketamine for intensive care unit (ICU) sedation. The objective of this study was to determine if patients receiving ketamine for continuous infusion ICU sedation are maintained within goal sedation range as effectively using a nurse-titrated (NT) protocol compared to a provider-titrated (PT) protocol.
Methods: A single-center, retrospective, study was completed evaluating a NT versus a PT protocol of continuous infusion ketamine for sedation in mechanically ventilated patients admitted to a medical ICU. The primary outcome was the percentage of Richmond Agitation and Sedation Scale (RASS) scores within goal range during the first 72 hours. Secondary outcomes included time to target RASS goal, percentage of RASS scores above and below goal, incidence of delirium, ICU and hospital length of stay (LOS), in-hospital mortality, and duration of mechanical ventilation.
Results: There were 94 patients included in this study, with 41 patients in the PT group and 53 patients in the NT group. Percentage of RASS scores in goal was significantly higher in the NT group compared to the PT group (47.8% [15.4%-63.3%] vs. 22.2% [8%-44.8%], P = 0.02), with multivariable regression analysis demonstrating significantly higher odds of time at RASS goal in the NT group (OR 18.13; 95% CI 5.46-30.81). Non-inferiority testing was significant (P = 0.001), indicating patients in the NT group did not perform worse than patients in the PT group. Patients in the PT group had higher median percentage of RASS scores below goal compared to patients in the NT group (57.1% [23.5%-79.6%] vs. 25% [5.9%-50%] P = 0.004). There were no differences in any other secondary outcomes or adverse effects between the groups.
Conclusions: Patients receiving continuous infusion ketamine via the NT protocol were maintained within goal sedation range at a significantly higher percentage than patients in the PT protocol and experienced less over sedation. Ketamine was well tolerated with no increase in adverse effects and no difference in the reasons for discontinuation.