Safety and Utility of Continuous Ketamine Infusion for Sedation in Mechanically Ventilated Pediatric Patients

Abstract

OBJECTIVES The selection of sedative medications for mechanically ventilated pediatric patients remains an ongoing clinical challenge. Although continuous ketamine infusion has been used in this population, support for its use remains largely anecdotal. This study describes a single institution's use of ketamine infusions as part of a sedation protocol in the pediatric intensive care unit (PICU). METHODS This was a retrospective study of children who received ketamine infusions as part of a multidrug sedation protocol in a 12-bed PICU at a tertiary children's hospital. Outcomes included effectiveness of ketamine infusion in providing adequate sedation as determined by State Behavioral Scale (SBS) scores and incidence of adverse events. RESULTS A total of 22 children receiving ketamine continuous infusion as part of a multidrug sedation protocol from February 2014 through October 2015 were eligible and enrolled in the study. Ketamine continuous infusion was administered in addition to at least 2 other sedation infusions at an average rate of 1.02 ± 0.50 mg/kg/hr, with a range of 0.07 to 2.0 mg/kg/hr. The duration of ketamine was 65.7 ± 41.01 hours, with a range of 19 to 153 hours. There was no significant change in SBS scores before and after initiation of ketamine infusion. Although not statistically significant, patients with inadequate sedation prior to starting ketamine required fewer bolus sedation doses and had improved sedation after ketamine was started. There were no reported adverse events. CONCLUSIONS The addition of a ketamine infusion as part of a multidrug sedation regimen was at least as effective as patients' regimen prior to ketamine addition in this population of intubated pediatric patients, with no adverse events.

Extended Duration Ketamine Infusions in Critically Ill Children: A Case Report and Review of the Literature

“…14 While it does not have a labeled indication in children, ten published reports describe the use of ketamine infusions in mechanically ventilated children. [3][4][5][6][7][8][9][10][11][12] ►Table 2 provides an overview of dosing, duration, adverse events, and tapering details from these reports. Ketamine's popularity has increased over the last 5 years as it is not associated with the negative hemodynamic effects noted with opioids and benzodiazepines and possesses opioid sparing effects.…”

“…►Table 2 provides a description of published dosing for this indication, with doses ranging from 1.2 to 100 µg/kg/min (►Table 2). [3][4][5][6][7][8][9][10][11][12] However, most of these reports do not describe initial or peak ketamine doses. The duration of use in nine of these reports ranged from 12 to 153 hours.…”

“…The duration of use in nine of these reports ranged from 12 to 153 hours. [3][4][5][6][7][8][9][10][11] However, the most recent study by Park et al 12 noted one patient who received up to 408 hours of ketamine. Another report by Klepstad et al 15 described extremely prolonged use of IV ketamine for 1,608 hours for neuropathic pain in a 12year-old patient with a cervical spinal tumor.…”

“…2 Several reports have described the use of prolonged infusions of ketamine in mechanically-ventilated children as part of their sedation and analgesia regimen. [3][4][5][6][7][8][9][10][11][12] The duration of use in these studies varied from 12 to 408 hours. Common adverse events of ketamine include hypertension, tachycardia, emergence phenomenon, and increased secretions.…”

“…Summary of ketamine dosing, duration, adverse events, and tapering plan in published reports of mechanically ventilated children[3][4][5][6][7][8][9][10][11][12] …”