The Future of Intensive Care Unit Sedation: A Report of Continuous Infusion Ketamine as an Alternative Sedative Agent

2016 ◽  
Vol 30 (5) ◽  
pp. 576-581 ◽  
Author(s):  
Scott T. Benken ◽  
Alexandra Goncharenko
Keyword(s):  
Intensive Care Unit ◽  
Mechanical Ventilation ◽  
Intensive Care ◽  
Continuous Infusion ◽  
Ventilator Weaning ◽  
Long Term Effects ◽  
Alternative Agent ◽  
Epidural Hemorrhage ◽  
Icu Sedation

This report describes a patient case utilizing a nontraditional sedative, continuous infusion ketamine, as an alternative agent for intensive care unit (ICU) sedation. A 27-year-old female presented for neurosurgical management of a coup contrecoup injury, left temporal fracture, epidural hemorrhage (EDH), and temporal contusion leading to sustained mechanical ventilation. The patient experienced profound agitation during mechanical ventilation and developed adverse effects with all traditional sedatives: benzodiazepines, dexmedetomidine, opioids, and propofol. Ketamine was titrated to effect and eliminated the need for other agents. This led to successful ventilator weaning, extubation, and transition of care. Given the unique side effect profile of ketamine, it is imperative that information is disseminated on potential utilization of this agent. More information is needed regarding dosing, monitoring, and long-term effects of utilizing ketamine as a continuous ICU sedative, but given the analgesia, anesthesia, and cardiopulmonary stability, future utilization of this medication for this indication seems promising.

Using a Collaborative Weaning Plan to Decrease Duration of Mechanical Ventilation and Length of Stay in the Intensive Care Unit for Patients Receiving Long-Term Ventilation

2002 ◽  
Vol 11 (2) ◽  
pp. 132-140 ◽  
Author(s):  
Elizabeth Henneman ◽  
Kathleen Dracup ◽  
Tomas Ganz ◽  
Orna Molayeme ◽  
Christopher B. Cooper
Keyword(s):  
Intensive Care Unit ◽  
Mechanical Ventilation ◽  
Intensive Care ◽  
Length Of Stay ◽  
Unit Cost ◽  
Outcome Variable ◽  
Collaborative Management ◽  
Flow Sheet ◽  
Long Term Ventilation

• Background Patients requiring mechanical ventilation for prolonged periods typically are sicker and have more comorbid illnesses than do patients who can be weaned more rapidly. As a result, the weaning process is often complex, requiring shared decision making by a skilled, multidisciplinary team. Unfortunately, many of the structures used in critical care units to plan and evaluate care do not lend themselves to collaborative management of patients. • Objective To evaluate the effect of a collaborative weaning plan on outcomes, including duration of mechanical ventilation, for patients treated with mechanical ventilation for 7 days or more. • Methods A collaborative weaning plan (weaning board and flow sheet) was introduced into the medical intensive care unit at the University of California Los Angeles, Medical Center. A historical design was used to compare outcomes before and after the plan was used. The primary outcome variable was duration of mechanical ventilation. Other outcomes studied included length of stay in the unit, cost, prevalence of complications (ie, reventilation, readmission to the intensive care unit), and mortality rate. • Results The collaborative weaning plan decreased duration of ventilation by 4.9 days (P = .02) and decreased median length of stay in the unit by 4.5 days (P = .004). The median cost per stay in the unit decreased from $50 462 to $37 330 (P = .004). The prevalence of complications did not differ significantly between groups. • Conclusions Collaborative structures (eg, weaning boards, flow sheets) are useful in decreasing duration of mechanical ventilation for patients receiving long-term ventilation.

scholarly journals Effects of Early Vocal Contact in the Neonatal Intensive Care Unit: Study Protocol for a Multi-Centre, Randomised Clinical Trial

2021 ◽  
Vol 18 (8) ◽  
pp. 3915
Author(s):  
Manuela Filippa ◽  
Elisa Della Casa ◽  
Roberto D’amico ◽  
Odoardo Picciolini ◽  
Clara Lunardi ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Neonatal Intensive Care Unit ◽  
Preterm Infants ◽  
Neonatal Intensive Care ◽  
Sensitive Period ◽  
Control Group ◽  
Long Term Effects ◽  
Infant Neurodevelopment

Preterm infants are at risk for developing altered trajectories of cognitive, social, and linguistic competences compared to a term population. This is mainly due to medical and environmental factors, as they are exposed to an atypical auditory environment and simultaneously, long periods of early separation from their parents. The short-term effects of early vocal contact (EVC) on an infant’s early stability have been investigated. However, there is limited evidence of its impact on the infant’s autonomic nervous system maturation, as indexed by heart rate variability, and its long-term impact on infant neurodevelopment. Our multi-centric study aims to investigate the effects of EVC on a preterm infant’s physiology, neurobehaviour, and development. Eighty stable preterm infants, born at 25–32 weeks and 6 days gestational age, without specific abnormalities, will be enrolled and randomised to either an intervention or control group. The intervention group will receive EVC, where mothers will talk and sing to their infants for 10 min three times per week for 2 weeks. Mothers in the control group will be encouraged to spend the same amount of time next to the incubator and observe the infant’s behaviour through a standard cluster of indicators. Infants will be assessed at baseline; the end of the intervention; term equivalent age; and 3, 6, 12, and 24 months corrected age, with a battery of physiological, neurobehavioral, and developmental measures. Early interventions in the neonatal intensive care unit have demonstrated effects on the neurodevelopment of preterm infants, thereby lowering the negative long-term effects of an atypical auditory and interactional environment. Our proposed study will provide new insight into mother–infant early contact as a protective intervention against the sequelae of prematurity during this sensitive period of development. Early intervention, such as EVC, is intuitive and easy to implement in the daily care of preterm infants. However, its long-term effects on infant neurodevelopment and maternal sensitivity and stress are still unclear. Trial Registration: NCT04759573, retrospectively registered, 17 February 2021.

scholarly journals Bichat guidelines for the clinical management of botulism and bioterrorism-related botulism

2004 ◽  
Vol 9 (12) ◽  
pp. 31-32 ◽  
Author(s):  
P Bossi ◽  
A Tegnell ◽  
A Baka ◽  
A Werner ◽  
F van Loock ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Mechanical Ventilation ◽  
Body Weight ◽  
Intensive Care ◽  
Botulinum Toxin ◽  
Respiratory Failure ◽  
Clinical Management ◽  
Clostridium Botulinum ◽  
Deliberate Release

Botulism is a rare but serious paralytic illness caused by botulinum toxin, which is produced by the Clostridium botulinum. This toxin is the most poisonous substance known. It 100 000 times more toxic than sarin gas. Eating or breathing this toxin causes illness in humans. Four distinct clinical forms are described: foodborne, wound, infant and intestinal botulism. The fifth form, inhalational botulism, is caused by aerosolised botulinum toxin that could be used as a biological weapon. A deliberate release may also involve contamination of food or water supplies with toxin or C. botulinum bacteria. By inhalation, the dose that would kill 50% of exposed persons (LD50) is 0.003 microgrammes/kg of body weight. Patients with respiratory failure must be admitted to an intensive care unit and require long-term mechanical ventilation. Trivalent equine antitoxins (A,B,E) must be given to patients as soon as possible after clinical diagnosis. Heptavalent human antitoxins (A-G) are available in certain countries.

Weaning Older Patients From Long-term Mechanical Ventilation: A Pilot Study

2002 ◽  
Vol 11 (4) ◽  
pp. 369-377 ◽  
Author(s):  
Carol Diane Epstein ◽  
Naglaa El-Mokadem ◽  
Joel R. Peerless
Keyword(s):  
Older Adults ◽  
Intensive Care Unit ◽  
Mechanical Ventilation ◽  
Intensive Care ◽  
Venous Pressure ◽  
Ventilatory Support ◽  
Oxygen Cost ◽  
Fraction Of Inspired Oxygen ◽  
Weaning Outcome

• Background As older persons in the intensive care unit increasingly require long-term mechanical ventilation, accurate indications of readiness for weaning from ventilatory support are needed to avoid premature extubation. • Objective To describe temporal changes in pulmonary and systemic variables in older adults receiving long-term mechanical ventilation. • Methods After 3 days of unsuccessful attempts at weaning from ventilatory support, 10 trauma and surgical patients more than 60 years old were monitored daily. Previously reported predictors of the duration of mechanical ventilation and weaning outcome were measured, including hemodynamic and gas exchange variables, oxygen cost of breathing, and the score on the Burns Weaning Assessment Program. • Results The 6 patients who could be weaned from ventilatory support were younger (median age, 71.5 years) than the 4 patients who could not be weaned (median age, 80 years). Patients who could be weaned were ready for weaning by day 11 of their stay in the intensive care unit and required an additional 5.5 days of mechanical ventilation; those who could not be weaned were not ready for weaning until day 17. All patients initially had increases in oxygen consumption during weaning; those who were successfully weaned had decreases before extubation. Respiratory rate, maximal inspiratory pressure, the ratio of Pao2 to fraction of inspired oxygen, and mean arterial pressure were higher in patients who could be weaned, and oxygen cost of breathing and central venous pressure were lower. • Conclusion Further study of weaning in older adults is warranted.

Veno-venous extracorporeal life support for blastomycosis-associated acute respiratory distress syndrome

Perfusion ◽  
2019 ◽  
Vol 34 (8) ◽  
pp. 660-670
Author(s):  
Abdulrahman Al-Fares ◽  
Eddy Fan ◽  
Shahid Husain ◽  
Matteo Di Nardo ◽  
Marcelo Cypel ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Mechanical Ventilation ◽  
Acute Respiratory Distress Syndrome ◽  
Intensive Care ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Distress Syndrome ◽  
Life Support ◽  
Extracorporeal Life Support

Background: Blastomyces is a dimorphic fungus endemic to regions of North America, which can lead to pneumonia and fatal severe acute respiratory diseases syndrome in up to 89% of patients. Extracorporeal life support can provide adequate oxygenation while allowing the lungs to rest and heal, which might be an ideal therapy in this patient group, although long-term clinical and radiological outcomes are not known. Clinical features: We report on five consecutive patients admitted to Toronto General Hospital intensive care unit between January 2012 and September 2016, with progressive respiratory failure requiring veno-venous extracorporeal life support within 24-96 hours following mechanical ventilation. Ultra-lung protective mechanical ventilation was achieved within 24 hours. Recovery was the initial goal in all patients. Extracorporeal life support was provided for a prolonged period (up to 49 days), and four patients were successfully discharged from the intensive care unit. Long-term radiological assessment in three patients showed major improvement within 2 years of follow-up with some persistent disease-related changes (bronchiectasis, fibrosis, and cystic changes). In two patients, long-term functional and neuropsychological outcomes showed similar limitations to what is seen in acute respiratory distress syndrome patients who are not supported with extracorporeal life support and in acute respiratory distress syndrome patients without blastomycosis, but worse pulmonary function outcomes in the form of obstructive and restrictive changes that correlated with the radiological imaging. Conclusion: Veno-venous extracorporeal life support can effectively provide prolonged support for patients with blastomycosis-associated acute respiratory distress syndrome that is safe and associated with favorable long-term outcomes.

scholarly journals Analgosedation: The use of Fentanyl Compared to Hydromorphone

2021 ◽  
Vol 7 (3) ◽  
pp. 192-198
Author(s):  
Hahnl Choi ◽  
Sara Radparvar ◽  
Samuel L. Aitken ◽  
Jerry Altshuler
Keyword(s):  
Intensive Care Unit ◽  
Mechanical Ventilation ◽  
Critical Care ◽  
Intensive Care ◽  
Length Of Stay ◽  
Continuous Infusion ◽  
Surgical Intensive Care Unit ◽  
Icu Length Of Stay ◽  
Primary Endpoints ◽  
Fentanyl Group

Abstract Background: The 2018 Society of Critical Care Medicine guidelines on the “Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU” advocate for protocol-based analgosedation practices. There are limited data available to guide which analgesic to use. This study compares outcomes in patients who received continuous infusions of fentanyl or hydromorphone as sedative agents in the intensive care setting. Methods: This retrospective cohort study evaluated patients admitted into the medical intensive care unit, the surgical intensive care unit, and the cardiac intensive care unit from April 1, 2017, to August 1, 2018, who were placed on continuous analgesics. Patients were divided according to receipt of fentanyl or hydromorphone as a continuous infusion as a sedative agent. The primary endpoints were ICU length of stay and time on mechanical ventilation. Results: A total of 177 patients were included in the study; 103 received fentanyl as a continuous infusion, and 74 received hydromorphone as a continuous infusion. Baseline characteristics were similar between groups. Patients in the hydromorphone group had deeper sedation targets. Median ICU length of stay was eight days in the fentanyl group compared to seven days in the hydromorphone group (p = 0.11) and median time on mechanical ventilation was 146.47 hours in the fentanyl group and 122.33 hours in the hydromorphone group (p = 0.31). There were no statistically significant differences in the primary endpoints of ICU length of stay and time on mechanical ventilation between fentanyl and hydromorphone for analgosedation purposes. Conclusion: No statistically significant differences were found in the primary endpoints studied. Patients in the hydromorphone group required more tracheostomies, restraints, and were more likely to have a higher proportion of Critical Care Pain Observation Tool (CPOT) scores > 2.

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