Intravenous Ketamine as an Adjunct to Procedural Sedation During Burn Wound Care and Dressing Changes

Abstract

Little has been published regarding intravenous (IV) ketamine for burn wound care in adult patients. Ketamine may serve as a safe alternative to provide conscious sedation and limit opioid administration to patients. The purpose of this study was to characterize IV ketamine use during burn wound care and establish its potential role as a safe adjunct to opioid and benzodiazepine medications. This is a retrospective review of adult patients admitted to a regional burn center who received IV ketamine for burn wound care. Patient demographics, medications, and ketamine-related side effects including hypertension and dysphoric reactions were recorded. Cardiopulmonary complications were also tracked. Thirty-six patients met inclusion criteria; 50 total cases were performed. The median patient age was 37 [IQR 28 - 55] years with a median burn size of 9.5 [IQR 4.0 - 52] %TBSA. The median ketamine dose administered was 1.2 [IQR 0.8 - 2.1] mg/kg. IV midazolam was administered in almost all cases (98%) at a median dose of 3.0 [IQR 2.0 - 5.0] mg. Opioids were administered in 13 of 50 cases (26%) at a median morphine equivalent dose of 10 [IQR 5.0 - 18] mg. In 46 cases (92%), patients denied unpleasant recall of medication. Dysphoric reactions were observed in 3 cases (6%). Ketamine-induced hypertension occurred in 3 cases (6%) and all immediately responded to IV labetalol. There were no cardiopulmonary complications. These findings suggest IV ketamine provides a safe analgesia and sedative option for burn wound care. Given these findings, IV ketamine for burn wound care warrants further study.

Reply to: Ketamine-based analgosedation for dressing changes in burn patients

“…A recent retrospective analysis of ketamine use in the burn patient population utilised a larger dose (1.2 mg kg À1 ) along with midazolam and, other than reports of hypertension with a few dysphoric symptoms, minimal complications were noted. 3 Furthermore, a prospective randomised study, utilising a 1 mg kg À1 bolus dose of ketamine as an analgesic in spinal surgery, found no particular side effects, including SSC. 4 In a larger study of 90 patients receiving 1 mg kg À1 boluses of ketamine for burn dressing changes along with three other sedatives, other than hypotension in one of the burn groups, ketamine was safe.…”

“…We did not specifically explore the side effect profile relating to SSC since, to the best of our knowledge, there is currently minimal evidence in the literature suggesting that intermittent procedural sedation with ketamine can lead to SSC. A recent retrospective analysis of ketamine use in the burn patient population utilised a larger dose (1.2 mg kg −1 ) along with midazolam and, other than reports of hypertension with a few dysphoric symptoms, minimal complications were noted 3 . Furthermore, a prospective randomised study, utilising a 1 mg kg −1 bolus dose of ketamine as an analgesic in spinal surgery, found no particular side effects, including SSC 4 .…”

Reply to: “Potential role of ketamine in burn-associated cholestasis”

“…We thank Dr Meunier and colleagues 1 for their letter pointing out a potential relationship between cholestasis and ketamine infusion, which can be used to maintain sedation and analgesia in critically ill patients with severe burn injury, limiting the need for opioid administration. 2 Nasal, oral and intravenous use of ketamine, especially in drug-abuse patients from Asia, was associated with drug-induced liver injury (DILI), including cholangiopathy, bile duct dilatation and sclerosing cholangitis. 3,4 On June 20, 2017, the French National Agency for the Safety of Medicines and Health Products (Agence nationale de sécurité du médicament) reported cases of DILI associated with repeated and/or prolonged use of ketamine at high doses in patients with burn injury.…”

Ketamine restriction correlates with reduced cholestatic liver injury and improved outcomes in critically ill patients with burn injury

“…Ketamine is an intravenous hypnotic agent used in critically ill patients for rapid sequence induction 1 ; for the management of acute and chronic pain, 2 , 3 including patients with severe burn injury 4 ; and for maintenance sedation of patients with acute respiratory distress syndrome. 5 …”