lunes, 4 de mayo de 2015

Ketamina en graves/Ketamine uin critical care cases

Ketamina en cirugía cardiaca y la UCI de adultos. Evidencia basada en revisión clínica
Ketamine in adult cardiac surgery and the cardiac surgery Intensive Care Unit: An evidence-based clinical review.
Mazzeffi M, Johnson K, Paciullo C.
Ann Card Anaesth 2015;18:202-9
Abstract
Ketamine is a unique anesthetic drug that provides analgesia, hypnosis, and amnesia with minimal respiratory and cardiovascular depression. Because of its sympathomimetic properties it would seem to be an excellent choice for patients with depressed ventricular function in cardiac surgery. However, its use has not gained widespread acceptance in adult cardiac surgery patients, perhaps due to its perceived negative psychotropic effects. Despite this limitation, it is receiving renewed interest in the United States as a sedative and analgesic drug for critically ill-patients. In this manuscript, the authors provide an evidence-based clinical review of ketamine use in cardiac surgery patients for intensive care physicians, cardio-thoracic anesthesiologists, and cardio-thoracic surgeons. All MEDLINE indexed clinical trials performed during the last 20 years in adult cardiac surgery patients were included in the review.
Keywords: Cardiac surgery; dissociative anesthesia; intensive care; ketamine
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 Combinación de ketamina-propofol (Ketofol) para intubación endotraqueal en pacientes graves. Estudio de casos
Ketamine and propofol combination ("ketofol") for endotracheal intubations in critically ill patients: a case series.
Gallo de Moraes A, Racedo Africano CJ, Hoskote SS, Reddy DR, Tedja R, Thakur L, Pannu JK, Hassebroek EC, Smischney NJ.
Am J Case Rep. 2015 Feb 13;16:81-6. doi: 10.12659/AJCR.892424.
Abstract
BACKGROUND: Endotracheal intubation is a common procedure performed for critically ill patients that can have immediate life-threatening complications. Induction medications are routinely given to facilitate the procedure, but most of these medications are associated with hypotension. While etomidate is known for its neutral hemodynamic profile, it has been linked with increased mortality in septic patients and increased morbidity in trauma patients. Ketamine and propofol are effective anesthetics with counteracting cardiovascular profiles. No data are available about the use of this combination in critically ill patients undergoing endotracheal intubation. CASE REPORT: We describe 6 cases in which the combination of ketamine and propofol ("ketofol") was used as an induction agent for endotracheal intubation in critically ill patients with a focus on hemodynamic outcomes. All patients received a neuromuscular blocker and fentanyl, while 5 patients received midazolam. We recorded mean arterial pressure (MAP) 1 minute before induction and 15 minutes after intubation with the combination. Of the 6 patients, 5 maintained a MAP ≥ 65 mmHg 15 minutes after intubation. One patient was on norepinephrine infusion with a MAP of 64 mmHg, and did not require an increase in the dose of the vasopressor 15 minutes after intubation. No hemodynamic complications were reported after any of the intubations. CONCLUSIONS: This case series describes the use of the "ketofol" combination as an induction agent for intubation in critically ill patients when hemodynamic stability is desired. Further research is needed to establish the safety of this combination and how it compares to other induction medications.
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Ketamina para sedación continua en paciente con ventilación mecánica
Ketamine for continuous sedation of mechanically ventilated patients.
Umunna BP1, Tekwani K1, Barounis D1, Kettaneh N1, Kulstad E1.
J Emerg Trauma Shock. 2015 Jan-Mar;8(1):11-5. doi: 10.4103/0974-2700.145414.Author
Abstract
CONTEXT: Long-term sedation with midazolam or propofol has been demonstrated to have serious adverse side effects, such as toxic accumulation or propofol infusion syndrome. Ketamine remains a viable alternative for continuous sedation as it is inexpensive and widely available, however, there are few analyses regarding its safety in this clinical setting. OBJECTIVE: To review the data related to safety and efficacy of ketamine as a potential sedative agent in mechanically ventilated patients admitted to the intensive care unit (ICU). MATERIALS AND METHODS: This was a single-center retrospective study from September 2011 to March 2012 of patients who required sedation for greater than 24 hours, in whom ketamine was selected as the primary sedative agent. All patients greater than 18 years of age, regardless of admitting diagnosis, were eligible for inclusion. Patients that received ketamine for continuous infusion but died prior to receiving it for 24 hours were not included. RESULTS: Thirty patients received ketamine for continuous sedation. In four patients, ketamine was switched to another sedative agent due to possible adverse side effects. Of these, two patients had tachydysrhythmias, both with new onset atrial fibrillation and two patients had agitation believed to be caused by ketamine. The adverse event rate in our patient population was 13% (4/30). CONCLUSIONS: Among ICU patients receiving prolonged mechanical ventilation, the use of ketamine appeared to have a frequency of adverse events similar to more common sedative agents, like propofol and benzodiazepines.
KEYWORDS: Adverse event; Ketamine; continuous sedation
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