ABSTRACT
INTRODUCTION: The use of ketamine as a sedative agent has increased dramatically in patients who are mechanically ventilated (MV) due to COVID-19 in intensive care units (ICU). Ketamine primarily acts as an NMDA receptor antagonist that blocks the excitatory effects of glutamate. In comparison to other sedatives, ketamine has a more favorable hemodynamic profile and does not produce significant respiratory depression. The study sought to analyze the impact of initiating ketamine continuous infusions for sedation in MV patients on co-sedation dosing. METHOD(S): This was a single-center, retrospective, observational study. All MV patients admitted to the medical intensive care unit from October 1st, 2019 to October 31st, 2021 who received ketamine continuous infusions for sedation for more than 12 hours were be eligible for inclusion. RESULT(S): Of 167 patients identified, 76 (45.5%) patients were included. The average ketamine infusion rate was 0.65 mg/kg/hr and average duration was 3.9 days. At the start of ketamine, 74 patients were on fentanyl, 27 (36.5%) of those patients were successfully weaned off fentanyl (10.8%) or had a decrease in infusion rate (25.7%). A total of 47 patients were on propofol, 39 (83%) patients were successfully weaned off propofol (55.3%) or had a decrease in infusion rate (25.7%). Seventeen patients were on midazolam infusions, of those, 12 (70.6%) patients were successfully weaned off (52.9%) or had a decrease in rate (17.6%). There were 15 patients on dexmedetomidine, 6 (40%) patients were successfully weaned off (20%) or had a decrease in infusion rate (20%). At the start of ketamine, 71 patients were on norepinephrine + vasopressin + epinephrine. Of the 71 patients, 48 (67.6%) were able to wean off vasoactive agents or had a decrease in rate. Twelve patients had documented emergence reactions or adverse reactions during infusion. CONCLUSION(S): Ketamine continuous infusion as an adjunct analgosedative agent resulted in successful weans off co-sedative agents or in decreased infusion rates. It was particularly impactful on propofol and midazolam continuous infusions as more than 50% of patients on these two agents were successfully weaned off.
ABSTRACT
INTRODUCTION: Tocilizumab has been used for treatment of COVID-19 in hospitalized patients who require supplementation oxygen. Various concerns regarding its use in pregnant patients have been presented, however very limited data exists regarding the use of tocilizumab in this population. METHOD(S): Between July 2021 and November 2021, 7 pregnant patients unvaccinated against COVID-19 were admitted to the medical intensive care unit with acute hypoxemic respiratory failure secondary to COVID-19 infection. The average age of patients was 29 with average gestational term of 27 weeks and average BMI of 38kg/m2. All patients had received dexamethasone and remdesivir per standard hospital protocols and antibiotics for superimposed bacterial pneumonia in patients with infiltrates concerning for concomitant bacterial picture. However, these patients still had high oxygen requirements prompting administration of tocilizumab. Each patient received 800mg of tocilizumab as a single dose. RESULT(S): After administration of tocilizumab, oxygen requirements decreased in 6 out of 7 patients, resulting in an avoidance of mechanical ventilation. Typical serum markers used to measure inflammatory response in COVID-19, including C-reactive protein and D-dimer, showed improvement after administration of tocilizumab in 6 out of 7 patients. All pregnancies progressed to successful live birth with no notable fetal deformities or malformations. Out of the 7 patients, there were 5 preterm deliveries, defined as gestational age of 37-38 weeks. 2 of the 7 patients underwent caesarean delivery for maternal hypoxia, both in the setting of severe COVID-19 infection. All infants had a birth weight within normal limits for their gestational age. No complications were noted during vaginal birth of caesarean delivery. CONCLUSION(S): Based on this review, it appears that the use of tocilizumab provided benefit in 85.7% of patients, preventing progression to mechanical ventilation. Based on this case series, tocilizumab seems to be a safe option for pregnant woman and subsequently their babies, with no severe complications or deformities noted during birth. However, 71.4% of patients did undergo preterm labor, prompting future research into whether these is any correlation between tocilizumab and preterm labor.