Hemodynamic Effects of Ketamine Compared With Propofol or Dexmedetomidine as Continuous ICU Sedation

2021 ◽  
pp. 106002802110510
Author(s):  
Evan Atchley ◽  
Eljim Tesoro ◽  
Robert Meyer ◽  
Alexia Bauer ◽  
Mark Pulver ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Medical Center ◽  
Academic Medical Center ◽  
Academic Medical ◽  
Clinically Significant ◽  
Critically Ill Adults ◽  
Icu Sedation ◽  
Ill Adults ◽  
Positive Effect

Background Ketamine has seen increased use for sedation in the intensive care unit. In contrast to propofol or dexmedetomidine, ketamine may provide a positive effect on hemodynamics. Objective The objective of this study was to compare the development of clinically significant hypotension or bradycardia (ie, negative hemodynamic event) between critically ill adults receiving sedation with ketamine and either propofol or dexmedetomidine. Methods This was a retrospective cohort study of adults admitted to an intensive care unit at an academic medical center between January 2016 and January 2021. Results Patients in the ketamine group (n = 78) had significantly less clinically significant hypotension or bradycardia compared with those receiving propofol or dexmedetomidine (n = 156) (34.6% vs 63.5%; P < 0.001). Patients receiving ketamine also experienced smaller degree of hypotension observed by percent decrease in mean arterial pressure (25.3% [17.4] vs 33.8% [14.5]; P < 0.001) and absolute reduction in systolic blood pressure (26.5 [23.8] vs 42.0 [37.8] mm Hg; P < 0.001) and bradycardia (15.5 [24.3] vs 32.0 [23.0] reduction in beats per minute; P < 0.001). In multivariate logistic regression modeling, receipt of propofol or dexmedetomidine was the only independent predictor of a negative hemodynamic event (odds ratio [OR]: 3.3, 95% confidence interval [CI], 1.7 to 6.1; P < 0.001). Conclusion and Relevance Ketamine was associated with less clinically relevant hypotension or bradycardia when compared with propofol or dexmedetomidine, in addition to a smaller absolute decrease in hemodynamic parameters. The clinical significance of these findings requires further investigation.

Intravenous Chlorothiazide Versus Enteral Metolazone to Augment Loop Diuretic Therapy in the Intensive Care Unit

2016 ◽  
Vol 51 (4) ◽  
pp. 286-292 ◽  
Author(s):  
Christopher J. Michaud ◽  
Kendall C. Mintus
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Loop Diuretic ◽  
Medical Center ◽  
Diuretic Therapy ◽  
Rapid Change ◽  
Icu Length Of Stay ◽  
Potassium Replacement ◽  
Critically Ill Adults ◽  
Ill Adults

Background: In cases of loop diuretic resistance in the intensive care unit (ICU), recommendations for a specific second-line thiazide agent are lacking. Objective: To compare the effects of intravenous chlorothiazide (CTZ) and enteral metolazone (MET) on urine output (UOP) when added to furosemide monotherapy therapy in critically ill adults. Methods: This was a retrospective cohort study conducted in the medical, surgical, and cardiothoracic ICUs of a quaternary medical center. The primary outcome was change in UOP induced by the study interventions compared with furosemide alone. Secondary outcomes included onset of diuresis, eventual need for hemodialysis, and incidence of adverse events. Results: A total of 122 patients (58 in CTZ, 64 in MET) were included. When added to furosemide monotherapy, CTZ induced a greater change in UOP at 24 hours compared with MET (2405 vs 1646 mL, respectively; P = 0.01). CTZ also caused a more rapid dieresis: 1463 mL total UOP in the first 6 hours compared with 796 mL in the MET group ( P < 0.01). There were no differences found regarding ICU length of stay, need for renal replacement therapy, or survival to discharge. The CTZ arm required more potassium supplementation to maintain normokalemia (median 100 vs 57 mEq in MET; P = 0.02) and carried a higher cost (mean $97 vs $8, P < 0.01). Conclusion: Both CTZ and MET induced significant increases in UOP. CTZ induced a greater and more rapid change and was associated with higher cost and greater need for potassium replacement. Randomized controlled trials are needed to establish whether a preferable thiazide diuretic exists in this setting.

Double Trouble: Patients With Both True and False Arrhythmia Alarms

2020 ◽  
Vol 40 (2) ◽  
pp. 14-23
Author(s):  
Stella Chiu Nguyen ◽  
Sukardi Suba ◽  
Xiao Hu ◽  
Michele M. Pelter
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Medical Center ◽  
Academic Medical Center ◽  
Secondary Analysis ◽  
Altered Mental Status ◽  
False Alarms ◽  
Number Of False Alarms ◽  
Academic Medical ◽  
Using Data

Background Patients with both true and false arrhythmia alarms pose a challenge because true alarms might be buried among a large number of false alarms, leading to missed true events. Objective To determine (1) the frequency of patients with both true and false arrhythmia alarms; (2) patient, clinical, and electrocardiographic characteristics associated with both true and false alarms; and (3) the frequency and types of true and false arrhythmia alarms. Methods This was a secondary analysis using data from an alarm study conducted at a tertiary academic medical center. Results Of 461 intensive care unit patients, 211 (46%) had no arrhythmia alarms, 12 (3%) had only true alarms, 167 (36%) had only false alarms, and 71 (15%) had both true and false alarms. Ventricular pacemaker, altered mental status, mechanical ventilation, and cardiac intensive care unit admission were present more often in patients with both true and false alarms than among other patients (P &lt; .001). Intensive care unit stays were longer in patients with only false alarms (mean [SD], 106 [162] hours) and those with both true and false alarms (mean [SD], 208 [333] hours) than in other patients. Accelerated ventricular rhythm was the most common alarm type (37%). Conclusions An awareness of factors associated with arrhythmia alarms might aid in developing solutions to decrease alarm fatigue. To improve detection of true alarms, further research is needed to build and test electrocardiographic algorithms that adjust for clinical and electrocardiographic characteristics associated with false alarms.

scholarly journals Determining Inappropriate Medication Alerts from “Inaccurate Warning” Overrides in the Intensive Care Unit

2018 ◽  
Vol 09 (02) ◽  
pp. 268-274 ◽  
Author(s):  
Christine Rehr ◽  
Adrian Wong ◽  
Diane Seger ◽  
David Bates
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Drug Allergy ◽  
Medical Center ◽  
Inappropriate Medication ◽  
Academic Medical Center ◽  
Patient Characteristics ◽  
Valuable Resource ◽  
Provider Behavior ◽  
Academic Medical

Objective This article aims to understand provider behavior around the use of the override reason “Inaccurate warning,” specifically whether it is an effective way of identifying unhelpful medication alerts. Materials and Methods We analyzed alert overrides that occurred in the intensive care units (ICUs) of a major academic medical center between June and November 2016, focused on the following high-significance alert types: dose, drug-allergy alerts, and drug–drug interactions (DDI). Override appropriateness was analyzed by two independent reviewers using predetermined criteria. Results A total of 268 of 26,501 ICU overrides (1.0%) used the reason “Inaccurate warning,” with 93 of these overrides associated with our included alert types. Sixty-one of these overrides (66%) were identified to be appropriate. Twenty-one of 30 (70%) dose alert overrides were appropriate. Forty of 48 drug-allergy alert overrides (83%) were appropriate, for reasons ranging from prior tolerance (n = 30) to inaccurate ingredient matches (n = 5). None of the 15 DDI overrides were appropriate. Conclusion The “Inaccurate warning” reason was selectively used by a small proportion of providers and overrides using this reason identified important opportunities to reduce excess alerts. Potential opportunities include improved evaluation of dosing mechanisms based on patient characteristics, inclusion of institutional dosing protocols to alert logic, and evaluation of a patient's prior tolerance to a medication that they have a documented allergy for. This resource is not yet routinely used for alert tailoring at our institution but may prove to be a valuable resource to evaluate available alerts.

scholarly journals The impact of patient delirium in the intensive care unit: patterns of anxiety symptoms in family caregivers

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Therese G. Poulin ◽  
Karla D. Krewulak ◽  
Brianna K. Rosgen ◽  
Henry T. Stelfox ◽  
Kirsten M. Fiest ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Family Caregivers ◽  
Critically Ill ◽  
Clinical Assessment ◽  
Anxiety Symptoms ◽  
Clinically Significant ◽  
Critically Ill Adults ◽  
The Impact ◽  
Ill Adults

Abstract Background The purpose of this study was to examine the association of patient delirium in the intensive care unit (ICU) with patterns of anxiety symptoms in family caregivers when delirium was determined by clinical assessment and family-administered delirium detection. Methods In this cross-sectional study, consecutive adult patients anticipated to remain in the ICU for longer than 24 h were eligible for participation given at least one present family caregiver (e.g., spouse, friend) provided informed consent (to be enrolled as a dyad) and were eligible for delirium detection (i.e., Richmond Agitation-Sedation Scale score ≥ − 3). Generalized Anxiety Disorder-7 (GAD-7) was used to assess self-reported symptoms of anxiety. Clinical assessment (Confusion Assessment Method for ICU, CAM-ICU) and family-administered delirium detection (Sour Seven) were completed once daily for up to five days. Results We included 147 family caregivers; the mean age was 54.3 years (standard deviation [SD] 14.3 years) and 74% (n = 129) were female. Fifty (34% [95% confidence interval [CI] 26.4–42.2]) caregivers experienced clinically significant symptoms of anxiety (median GAD-7 score 16.0 [interquartile range 6]). The most prevalent symptoms of anxiety were “Feeling nervous, anxious or on edge” (96.0% [95%CI 85.2–99.0]); “Not being able to stop or control worrying” (88.0% [95%CI 75.6–94.5]; “Worrying too much about different things” and “Feeling afraid as if something awful might happen” (84.0% [95%CI 71.0–91.8], for both). Family caregivers of critically ill adults with delirium were significantly more likely to report “Worrying too much about different things” more than half of the time (CAM-ICU, Odds Ratio [OR] 2.27 [95%CI 1.04–4.91]; Sour Seven, OR 2.28 [95%CI 1.00–5.23]). Conclusions Family caregivers of critically ill adults with delirium frequently experience clinically significant anxiety and are significantly more likely to report frequently worrying too much about different things. Future work is needed to develop mental health interventions for the diversity of anxiety symptoms experienced by family members of critically ill patients. Trial registration This study is registered on ClinicalTrials.gov (https://clinicaltrials.gov/ct2/show/NCT03379129).

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