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1.
Anaesthesiol Intensive Ther ; 54(1): 23-29, 2022.
Article in English | MEDLINE | ID: covidwho-1771540

ABSTRACT

BACKGROUND: Effective analgosedation for control of dyspnoea and for toleration of prone positioning (PP) in severe coronavirus disease 2019 (COVID-19) associated acute respiratory distress syndrome (ARDS) is difficult to adjust. This study was designed to evaluate the feasibility and safety of sedation with inhaled sevoflurane in combination with intravenous esketamine during PP in patients with COVID-19-ARDS (CARDS). METHODS: All mechanically ventilated COVID-19 patients admitted to the departmental intensive care unit from March to June 2020 were included in this epidemiological cohort study. Patients were sedated with inhaled sevoflurane in combination with eske-tamine during PP and not or only lightly sedated during the supine position. Assisted spontaneous breathing was applied in both prone and supine position. RESULTS: Adverse events were documented prospectively, and routine ventilation parameters, hemodynamic parameters, Richmond Agitation and Sedation Scale (RASS) and sevoflurane consumption were monitored. Altogether, 146 episodes of PP in 15 patients were observed. No severe sedation-related event was observed during 2610 hours of PP. In 2498 hours (96%) patients were successfully converted to a pressure-supported spontaneous breathing mode. CONCLUSIONS: Inhaled sedation with the AnaConDa-S-System (Sedana Medical AB, Danderyd, Sweden) alone is insufficient as soon as minute volume exceeds 7-8 L min-1, most likely due to technical reasons. Inhaled sedation with sevoflurane in combination with esketamine, however, safely enables prolonged prone positioning in patients with CARDS. Moreover, sedation depth was light enough to enable assisted spontaneous breathing during prone positioning.


Subject(s)
COVID-19 , COVID-19/therapy , Cohort Studies , Humans , Ketamine , Prone Position , Respiration, Artificial , Sevoflurane
2.
CNS Drugs ; 36(3): 239-251, 2022 03.
Article in English | MEDLINE | ID: covidwho-1756960

ABSTRACT

Intravenous (IV) ketamine is increasingly used off-label at subanesthetic doses for its rapid antidepressant effect, and intranasal (IN) esketamine has been recently approved in several countries for treating depression. The clinical utility of these treatments is limited by a paucity of publicly funded IV ketamine and IN esketamine programs and cost barriers to private treatment programs, as well as the drug cost for IN esketamine itself, which makes generic ketamine alternatives an attractive option. Though evidence is limited, use of non-parenteral racemic ketamine formulations (oral, sublingual, and IN) may offer more realistic access in less rigidly supervised settings, both for acute and maintenance treatment in select cases. However, the psychiatric literature has repeatedly cautioned on the addictive potential of ketamine and raised caution for both less supervised and longer-term use of ketamine. To date, these concerns have not been discussed in view of available evidence, nor have they been discussed within a broader clinical context. This paper examines the available relevant literature and suggests that ketamine misuse risks appear not dissimilar to those of other well-established and commonly prescribed agents with abuse potential, such as stimulants or benzodiazepines. As such, ketamine prescribing should be considered in a similar risk/benefit context to balance patient access and need for treatment with concern for potential substance misuse. Our consortium of mood disorder specialists with significant ketamine prescribing experience considers prescribing of non-parenteral ketamine a reasonable clinical treatment option in select cases of treatment-resistant depression. This paper outlines where this may be appropriate and makes practical recommendations for clinicians in judicious prescribing of non-parenteral ketamine.


Subject(s)
Depressive Disorder, Treatment-Resistant , Ketamine , Antidepressive Agents/adverse effects , Depression , Depressive Disorder, Treatment-Resistant/drug therapy , Humans , Ketamine/adverse effects , Mood Disorders/drug therapy
4.
Pol J Vet Sci ; 23(1): 127-132, 2020 Mar.
Article in English | MEDLINE | ID: covidwho-1575092

ABSTRACT

INTRODUCTION: Effective and safe anesthesia for rodents has long been a leading concern among biomedical researchers. Intraperitoneal injection constitutes an alternative to inhalant anesthesia. PURPOSE: The aim of this study was to identify a safe, reliable, and effective anesthesia and postoperative analgesia protocol for laboratory rats exposed to painful procedures. MATERIAL AND METHODS: Twenty-seven female Wistar rats in an ongoing study that required surgery were randomized into groups for three different intraperitoneal anesthesia protocols and three different analgesia regimens. The anesthesia groups were (1) medetomidine + ketamine (MK), (2) ketamine + xylacine (KX), and (3) fentanyl + medetomidine (FM). Three analgesia groups were equally distributed among the anesthesia groups: (1) local mepivacaine + oral ibuprofen (MI), (2) oral tramadol + oral ibuprofen (TI), and (3) local tramadol + oral tramadol + + oral ibuprofen (TTI). A core was assigned to measure anesthesia (0-3) and analgesia (0-2) effectiveness; the lower the score, the more effective the treatment. RESULTS: The mean MK score was 0.44 versus 2.00 for FM and 2.33 for KX. Mean score for analgesia on the first postoperative day was TTI (4.66) TI (9.13), and MI (10.14). Mean score 48 hours after surgery was TTI (3.4), TI (6.71), and MI (9.5). These differences were statistically significant. CONCLUSION: MK was shown to be a reliable, safe, and effective method of anesthesia. The TTI analgesia regimen is strongly recommended in light of these results.


Subject(s)
Fentanyl/pharmacology , Ketamine/pharmacology , Medetomidine/pharmacology , Xylazine/pharmacology , Adjuvants, Anesthesia/administration & dosage , Adjuvants, Anesthesia/pharmacology , Anesthetics, Dissociative/administration & dosage , Anesthetics, Dissociative/pharmacology , Animals , Drug Therapy, Combination , Female , Fentanyl/administration & dosage , Hypnotics and Sedatives/administration & dosage , Hypnotics and Sedatives/pharmacology , Ketamine/administration & dosage , Medetomidine/administration & dosage , Random Allocation , Rats , Rats, Wistar , Xylazine/administration & dosage
5.
Am J Emerg Med ; 54: 328.e1-328.e2, 2022 Apr.
Article in English | MEDLINE | ID: covidwho-1514111

ABSTRACT

BACKGROUND: Status Epilepticus is the most common non-traumatic neurologic emergency in childhood. Current algorithms prioritize the use of benzodiazepines as first line treatment followed by Levetiracetam or Valproic Acid, possibly Fosphenytoin and eventually high dose Propofol and intubation. CASE REPORT: A 9-month old girl was brought to the emergency department with a continuous seizure involving the right upper and lower extremity for 45 min prior to arrival. Patient received a dose of rectal Diazepam, intramuscular Midazolam, 2 doses of Lorazepam, Levetiracetam, Fosphenytoin and 2 additional doses of Lorazepam. The seizure remained refractory and generalized. In anticipation of intubation, and because of its action on the NMDA receptor, Ketamine (1 mg/kg IV) was administered. The clonic movements and eye deviations stopped. Patient was intubated for airway protection, sedated with Propofol, then admitted to the PICU. EEG showed no evidence of a seizure pattern. Labs (CBC, CMP, COVID) were unremarkable except for WBC 24.5, blood glucose of 346 and CO2 of 17 with normal anion gap. Urinalysis showed a urinary tract infection. Patient was at her baseline on 1 week post-discharge re-evaluation. Ketamine theoretically may abort seizures through blockade of NMDA receptors which are unregulated in status epilepticus. To date, no randomized controlled trials have been reported. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Ketamine may have a role in treating status epilepticus. It may be considered for induction for rapid sequence intubation and possibly as a third or fourth line agent in refractory cases.


Subject(s)
COVID-19 , Ketamine , Propofol , Status Epilepticus , Aftercare , Anticonvulsants/therapeutic use , Female , Humans , Infant , Ketamine/adverse effects , Levetiracetam , Lorazepam/therapeutic use , Patient Discharge , Propofol/therapeutic use , Seizures/drug therapy , Status Epilepticus/drug therapy
6.
Respir Med ; 189: 106667, 2021.
Article in English | MEDLINE | ID: covidwho-1487955

ABSTRACT

PURPOSE: Deep sedation is sometimes needed in acute respiratory distress syndrome. Ketamine is a sedative that has been shown to have analgesic and sedating properties without having a detrimental impact on hemodynamics. This pharmacological profile makes ketamine an attractive sedative, potentially reducing the necessity for other sedatives and vasopressors, but there are no studies evaluating its effect on these medications in patients requiring deep sedation for acute respiratory distress syndrome. MATERIALS AND METHODS: This is a retrospective, observational study in a single center, quaternary care hospital in southeast Texas. We looked at adults with COVID-19 requiring mechanical ventilation from March 2020 to September 2020. RESULTS: We found that patients had less propofol requirements at 72 h after ketamine initiation when compared to 24 h (median 34.2 vs 54.7 mg/kg, p = 0.003). Norepinephrine equivalents were also significantly lower at 48 h than 24 h after ketamine initiation (median 38 vs 62.8 mcg/kg, p = 0.028). There was an increase in hydromorphone infusion rates at all three time points after ketamine was introduced. CONCLUSIONS: In this cohort of patients with COVID-19 ARDS who required mechanical ventilation receiving ketamine we found propofol sparing effects and vasopressor requirements were reduced, while opioid infusions were not.


Subject(s)
COVID-19/epidemiology , Deep Sedation , Hypnotics and Sedatives/administration & dosage , Ketamine/administration & dosage , Respiration, Artificial , Respiratory Distress Syndrome/epidemiology , Adult , Aged , Aged, 80 and over , Analgesics, Opioid/therapeutic use , COVID-19/therapy , Drug Utilization/statistics & numerical data , Female , Humans , Hydromorphone/therapeutic use , Male , Middle Aged , Norepinephrine/therapeutic use , Propofol/therapeutic use , Respiratory Distress Syndrome/therapy , Retrospective Studies , Texas/epidemiology
7.
Acta Anaesthesiol Scand ; 65(1): 128-134, 2021 01.
Article in English | MEDLINE | ID: covidwho-1455487

ABSTRACT

BACKGROUND: Post-operative pain treatment with ketamine has been demonstrated to have post-operative opioid-sparing and anti-hyperalgesic effects. However, evidence regarding the beneficial and harmful effects and the optimal dose and timing of perioperative treatment with ketamine for patients undergoing spinal surgery is unclear. The objective of this systematic review is to assess the analgesic, serious and non-serious adverse effects of perioperative pain treatment with ketamine for patients undergoing spinal surgery. METHODS: This protocol for a systematic review is written according to The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. We will search Embase, CENTRAL, PubMed, WHO's ICTRP, EU Clinical Trial Register and ClinicalTrials.gov to identify relevant randomised clinical trials. We will include all randomised clinical trials assessing perioperative ketamine treatment versus placebo or no intervention for patients undergoing spinal surgery. Two authors will independently screen trials for inclusion using Covidence, extract data and assess risk of bias using Cochrane's RoB tool. We will analyse data using Review Manager and Trial Sequential Analysis. Meta-analysis will be performed according to the Cochrane guidelines and results will be validated according to the eight-step procedure suggested by Jakobsen et al. We will present our primary findings in a 'summary of findings' table. We will evaluate the overall certainty of evidence using the GRADE approach. DISCUSSION: This systematic review will assess the beneficial and harmful effects of perioperative pain treatment with ketamine for patients undergoing spinal surgery and have the potential to inform best practice and advance research.


Subject(s)
Ketamine , Humans , Ketamine/therapeutic use , Meta-Analysis as Topic , Pain, Postoperative/drug therapy , Systematic Reviews as Topic
9.
Nurs Stand ; 36(9): 77-81, 2021 09 01.
Article in English | MEDLINE | ID: covidwho-1369911

ABSTRACT

Ketamine is a synthetic drug with unique properties which started to be used therapeutically in humans in the 1970s and is now widely used in all fields of nursing. Ketamine acts on the central nervous system, primarily through inhibiting N-methyl-D-aspartate receptors. However, the precise understanding of its mechanisms of action remains elusive in many respects. Ketamine is frequently used as an anaesthetic in medical and surgical procedures and as an analgesic in children and adults. It is increasingly used in mental health settings to treat depression. It has potential to be used more often in areas such as palliative care and mental health care. This article reviews the physiological and pharmacological properties of ketamine, explores its main therapeutic uses, and considers the associated implications for nursing practice.


Subject(s)
Analgesics , Anesthetics , Ketamine , Analgesics/pharmacology , Analgesics/therapeutic use , Anesthetics/pharmacology , Anesthetics/therapeutic use , Anti-Inflammatory Agents/pharmacology , Anti-Inflammatory Agents/therapeutic use , Antidepressive Agents/pharmacology , Antidepressive Agents/therapeutic use , Humans , Ketamine/pharmacology , Ketamine/therapeutic use
11.
Psychiatry Res ; 303: 114086, 2021 09.
Article in English | MEDLINE | ID: covidwho-1303645

ABSTRACT

Herein we evaluate the impact of COVID-19 restrictions on antidepressant effectiveness of intravenous (IV) ketamine in adults with treatment-resistant depression (TRD). We conducted a case series analysis of adults with TRD (n = 267) who received four ketamine infusions at an outpatient clinic in Ontario, Canada, during COVID-19 restrictions (from March 2020 - February 2021; n = 107), compared to patients who received treatment in the previous year (March 2019 - February 2020; n = 160). Both groups experienced significant and comparable improvements in depressive symptoms, suicidal ideation, and anxiety with repeated ketamine infusions. Effectiveness of IV ketamine was not attenuated during the COVID-19 period.


Subject(s)
COVID-19 , Depressive Disorder, Major , Depressive Disorder, Treatment-Resistant , Ketamine , Adult , Depression , Depressive Disorder, Major/drug therapy , Depressive Disorder, Treatment-Resistant/drug therapy , Humans , Infusions, Intravenous , Ketamine/therapeutic use , Ontario , Pandemics , SARS-CoV-2
12.
Pain Med ; 22(7): 1642-1650, 2021 07 25.
Article in English | MEDLINE | ID: covidwho-1258791

ABSTRACT

OBJECTIVES: Cancer-related neuropathic pain (CNP) affects an increasing proportion of cancer patients, given improved survival, but it remains difficult to treat. There are no studies on an extended intravenous ketamine protocol and its synergies with common neuropathy treatments to treat CNP. This study aims to 1) evaluate the safety and effectiveness of an intravenous ketamine protocol to treat refractory CNP and 2) uncover synergies between ketamine and common neuropathy treatments. METHODS: This is a single-center, retrospective review of 57 patients and 192 infusions, with prospective follow-up on 14 enrolled patients during the coronavirus disease 2019 (COVID-19) pandemic. RESULTS: The etiologies of CNP were as follows: 13 from tumor compression, 25 with chemotherapy-induced peripheral neuropathy, 13 from surgery, and 6 from radiation therapy. Overall, 42 of 57 patients (73.7%) were responders, and 71.8% of responders received >3 weeks of pain relief on their last infusion. Analysis of adjuvant treatments revealed that the combination of serotonin-norepinephrine reuptake inhibitors and ketamine resulted in an increase in responders compared with nonresponders (P < 0.01). Adverse events occurred in 32 of 192 infusions (16.7%). All side effects self-resolved or resolved with intervention per the adverse events protocol. During the pandemic, all 14 currently enrolled patients did not receive ketamine infusions. Thirteen of the 14 patients returned to baseline pain, with 61.5% increasing medications. All experienced worsened function, mobility, mood, or anorexia. CONCLUSION: Intravenous ketamine may be a safe and effective adjuvant treatment for CNP, especially with serotonin-norepinephrine reuptake inhibitors. Larger, prospective studies are warranted and should explore parameters to help prognosticate response to ketamine infusions.


Subject(s)
COVID-19 , Ketamine , Neoplasms , Analgesics/therapeutic use , Humans , Infusions, Intravenous , Neoplasms/complications , Neoplasms/drug therapy , Pain Management , Pandemics , Prospective Studies , Retrospective Studies , SARS-CoV-2
13.
Indian J Ophthalmol ; 69(6): 1635-1636, 2021 06.
Article in English | MEDLINE | ID: covidwho-1248139
14.
Pain Med ; 21(7): 1318-1319, 2020 11 07.
Article in English | MEDLINE | ID: covidwho-1170903
17.
J Affect Disord ; 282: 252-254, 2021 03 01.
Article in English | MEDLINE | ID: covidwho-1065258

ABSTRACT

Ketamine's rapid antisuicidal action has gathered significant clinical interest in treatment of depression though concerns exist that its actions occur through the Opioid pathway. A recent study additionally reported that Naltrexone blocks antisuicidal effects of Ketamine suggesting that its antisuicidal effects are also due to opioid mechanisms. We present a case of treatment refractory depression with recent suicide attempt and active suicidal ideations who was on an Opioid partial agonist, Buprenorphine, for management of pain. Patient responded to a trial of IV ketamine treatment with rapid improvement in suicidal thoughts. Patient's suicidal ideations decreased after first Ketamine treatment and resolved after second treatment while maintained on Buprenorphine. Our finding shows that Buprenorphine does not block Ketamine's effects on suicidal ideations and therefore Ketamine treatment could be provided safely in controlled environment to those with substance use disorders or with chronic pain while being maintained on Buprenorphine. Additionally, our case suggests that non-Opioid mechanisms may be involved in Ketamine's antidepressant effects and its response to suicidal ideations in those on Opioid partial agonists.


Subject(s)
Buprenorphine , Depressive Disorder, Treatment-Resistant , Ketamine , Antidepressive Agents/therapeutic use , Buprenorphine/therapeutic use , Depressive Disorder, Treatment-Resistant/drug therapy , Humans , Ketamine/therapeutic use , Suicidal Ideation
18.
J Korean Med Sci ; 36(4): e28, 2021 Jan 25.
Article in English | MEDLINE | ID: covidwho-1048950

ABSTRACT

Hospitalized coronavirus disease 2019 (COVID-19)-infected patients suffer from both physical impairments and mental stress. Respiratory insufficiency and cardiovascular disturbances require most of the intensive care interventions, but they are also accompanied by depressive conditions, sadness and fear of dying. Sedatives are mostly respiratory and cardiovascular depressants and do not provide resistance to the pro-inflammatory burst induced by the virus. Ketamine is a unique and safe drug that enables well-controlled sedation and anesthesia, attenuates depression and mitigates suicidal thoughts, without depressing respiratory or cardiovascular mechanics. This brief communication highlights the benefits potentially provided by ketamine to patients hospitalized for COVID-19 infection.


Subject(s)
COVID-19/drug therapy , COVID-19/psychology , Depression/drug therapy , Ketamine/therapeutic use , Stress, Psychological/drug therapy , Anesthesia , Anxiety/drug therapy , Critical Care , Depression/complications , Hemodynamics , Hospitalization , Humans , Hypnotics and Sedatives , Immune System , Respiratory Insufficiency , Stress, Psychological/complications , Suicidal Ideation , Treatment Outcome
19.
Indian J Ophthalmol ; 69(2): 395-399, 2021 Feb.
Article in English | MEDLINE | ID: covidwho-1034651

ABSTRACT

PURPOSE: The current pandemic of COVID-19 has made airway procedures like intubation and extubation, potential sources of virus transmission among health care workers. The aim of this work was to study the safety profile of combined ketamine and regional anesthesia in pediatric ocular surgeries during the COVID-19 pandemic. METHODS: This prospective study included pediatric patients undergoing ocular surgery under general anesthesia from April to October 2020. Children were premedicated with oral midazolam (0.25-0.50 mg/kg) or intramuscular ketamine (7-10 mg/kg), ondensetron (0.1 mg/kg) and atropine (0.02 mg/kg). Anesthesia was achieved with intravenous ketamine (4-5 mg/kg) and local anesthesia (peribulbar block or local infiltration). The patient's vital signs were monitored. Serious complications and postoperative adverse reactions related to anesthesia were documented. RESULTS: A total of 55 children (62 eyes) were operated. Lid tear was the most common surgical procedure performed [n = 18 (32.7%)]. Dose of ketamine needed ranged from 30 to 120 mg (66.67 ± 30.45). No intubation or resuscitation was needed. Four children complained of nausea and two needed an additional dose of intravenous ondansetron due to vomiting in the post-operative period. Incidence of postoperative nausea and vomiting was not affected by age, duration of surgery or dose of ketamine used (P > 0.05). There was no correlation between increase in pulse and dose of ketamine. CONCLUSION: Combined ketamine and regional anesthesia is a safe and effective alternative to administer anesthesia in a child during ocular surgeries.


Subject(s)
Anesthesia, Conduction/methods , Anesthetics, Local/administration & dosage , COVID-19/epidemiology , Eye Diseases/surgery , Ketamine/administration & dosage , Ophthalmologic Surgical Procedures/methods , Pandemics , Anesthetics, Dissociative/administration & dosage , Child , Child, Preschool , Comorbidity , Eye Diseases/epidemiology , Female , Follow-Up Studies , Humans , Infant , Male , Prospective Studies , SARS-CoV-2
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