About PANDEM 2022 and “Rationale: Ketamine Appears to Be a Safe...”

Abstract

T he 2022 Society of Critical Care Medicine clinical practice guidelines (CPG) on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill patients with consideration of the ICU Environment and Early Mobility (PANDEM) is a tremendous achievement that starts a new era in our field (1). The CPG provides contemporary understanding of complex issues and provides readers with ideas about future clinical investigations.We would, however, like to ask the PANDEM authors three questions that relate to recommendation 12, and the statement that reads "Rationale: Ketamine appears to be a safe … alternative in patients who are not adequately sedated with other agents …" and in consequence "we suggest... ". Until the PANDEM publication (1), we used to recommend avoiding prolonged continuous infusion of ketamine and, if its use is inevitable, limiting the duration of continuous infusion to 48-72 hours with a maximum of 1 week. Our concern was that preclinical and clinical studies suggest that ketamine, unlike opioids, alpha-adrenergics, and benzodiazepines, poses additional risks to patient neurologic and psychiatric outcomes. The bibliographic underpinnings of our concern are summarized in Table 1. Therefore, can the PANDEM authors address for us:1) What is their opinion about the risk of extended use of ketamine in the PICU?2) The recommended dosing of ketamine by continuous infusion is 0.5-2 mg/kg/hr: is this dosing suitable for prolonged use or should it be time-limited? 3) Are there any studies in children that describe long-term behavioral/cognitive outcomes of extended ketamine use?

The authors reply

“…We appreciate the extensive preclinical and animal studies that the authors included in their correspondence (1) as a foundation for their concern about possible complications associated with long-term ketamine administration. The “Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients with Consideration of the ICU Environment and Early Mobility” (Peds-PANDEM) guidelines did not use preclinical or animal studies in the development of clinical guidelines (2).…”

“…We thank the authors of their interest and correspondence (1) with questions about the use of ketamine for sedation among critically ill pediatric patients in reference to the 2022 Society of Critical Care Medicine (SCCM) Clinical Practice Guidelines, published recently in Pediatric Critical Care Medicine (2). Here, we deal with each of the questions.…”