Authors: Mary Taylor, PharmD, PGY-1 Pharmacy Resident, Asra Kidwai, PharmD, BCPS and Jessica Hagy, PharmD, BCPS
Learning Objective: Audience members will be able to explain the efficacy of ketamine for analgesia-based sedation in mechanically ventilated intensive care unit (ICU) patients.
Background: This study aims to evaluate whether ketamine is an effective and safe alternative to fentanyl for analgesia-based sedation in mechanically ventilated ICU patients, given limited evidence despite its potential opioid-sparing and sedative benefits.
Methods: This retrospective, multicenter, medication use evaluation will include adult medical ICU patients who received ketamine or fentanyl for 24 hours or more for analgesia and adjunct sedation while mechanically ventilated. Patients receiving ketamine at Northwest Hospital will be compared to those receiving fentanyl at Sinai Hospital, where ketamine use is rare, to reduce institutional confounding. Exclusions include surgical ICU patients, pregnancy, need for deep sedation (Richmond Agitation Sedation Score (RASS) of -5) or neuromuscular blockade, primary neurological injury, ketamine use for status asthmatics or refractory status epilepticus, or receipt of both agents. The primary outcome is time to extubation; secondary outcomes include Critical-Care Pain Observation Tool (CPOT) scores, RASS goal attainment, adjunct opioid use, Confusion Assessment Method for the ICU (CAM-ICU), hemodynamics and mortality. Data collected from chart reviews will be analyzed using descriptive statistics.
Results: A total of 40 patients were included in the results, 20 patients in the ketamine group and 20 patients in the fentanyl group. Results showed that time to extubation in the ketamine group was about 76 hours and 14 minutes and 81 hours and 46 minutes in the fentanyl group. Secondary outcomes showed average CPOT scores were 0.36 in the ketamine group and 0.33 in the fentanyl group, however, the ketamine group required more adjunct as-needed opioids (11 (55%) vs 5 (25%)). Additionally, CAM-ICU positivity within 12 hours after treatment initiation was also notably higher in the ketamine group compared to the fentanyl group (18 (90%) vs 6 (30%)).
Conclusion(s): Overall, while ketamine may offer a potential alternative to fentanyl for analgesia-based sedation in mechanically ventilated medical ICU adults, these finding suggest possible limitations related to sedation quality and delirium that warrant further investigation with larger prospective studies.
Self-Assessment Question: Based on this study, which of the following best describes a potential advantage of ketamine compared to fentanyl?
- Improved maintenance of RASS goals
- Lower CPOT pain scores
- Reduced time to extubation
- Decreased need for adjunct opioids
