RESUMEN
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.
Asunto(s)
COVID-19/epidemiología , Sedación Profunda , Hipnóticos y Sedantes/administración & dosificación , Ketamina/administración & dosificación , Respiración Artificial , Síndrome de Dificultad Respiratoria/epidemiología , Adulto , Anciano , Anciano de 80 o más Años , Analgésicos Opioides/uso terapéutico , COVID-19/terapia , Utilización de Medicamentos/estadística & datos numéricos , Femenino , Humanos , Hidromorfona/uso terapéutico , Masculino , Persona de Mediana Edad , Norepinefrina/uso terapéutico , Propofol/uso terapéutico , Síndrome de Dificultad Respiratoria/terapia , Estudios Retrospectivos , Texas/epidemiologíaRESUMEN
Background: Cortisol thresholds defining adrenal insufficiency (AI) in some cirrhosis-specific studies differ from those recommended by the SCCM/ESICM (Society of Critical Care Medicine/European Society of Intensive Care Medicine) guidelines, which may influence treatment decisions. Objective: To determine if stress-dose hydrocortisone (HC) improves outcomes in vasopressor-dependent patients meeting cirrhosis-specific criteria for AI. Methods: In this retrospective study, AI was defined using criteria from 2 studies in critically ill cirrhosis patients showing mortality reduction with HC (random cortisol <20 µg/dL, or if a standard-dose cosyntropin test was performed, baseline cortisol <15 µg/dL or delta cortisol <9 µg/dL if baseline = 15-34 µg/dL). Use of HC was at the discretion of the intensivist. The primary endpoint was days of vasopressor therapy. Secondary endpoints included hospital mortality and newly acquired infections. Sixty-four patients were evaluated; 40 patients received HC and 24 did not. Results: Mean random cortisol was significantly lower in the HC group (9.8 ± 3.2 vs 12.0 ± 3.7 µg/dL, P = 0.04). Delta cortisol also tended to be lower in the HC group (8.2 ± 4.4 vs 11.3 ± 6.4 µg/dL, P = 0.25). Patients in the HC group exhibited significantly fewer median days of vasopressor therapy (4.0 [2.0-7.0] vs 7.0 [4.2-10.8], P = 0.006), lower mortality (22.5% vs 50%, P = 0.02), and a similar incidence of newly acquired infections. Conclusion and Relevance: The use of HC in patients meeting cirrhosis-specific criteria for AI resulted in significantly shorter duration of vasopressor therapy, lower mortality, and no increased risk of infection. Use of traditional AI definitions may exclude patients with cirrhosis that could benefit from HC therapy.
Asunto(s)
Insuficiencia Suprarrenal/tratamiento farmacológico , Hidrocortisona/sangre , Cirrosis Hepática/tratamiento farmacológico , Norepinefrina/uso terapéutico , Vasoconstrictores/uso terapéutico , Insuficiencia Suprarrenal/sangre , Insuficiencia Suprarrenal/complicaciones , Insuficiencia Suprarrenal/mortalidad , Adulto , Cuidados Críticos , Enfermedad Crítica , Femenino , Humanos , Hidrocortisona/administración & dosificación , Incidencia , Cirrosis Hepática/sangre , Cirrosis Hepática/complicaciones , Cirrosis Hepática/mortalidad , Masculino , Persona de Mediana Edad , Norepinefrina/administración & dosificación , Estudios Retrospectivos , Factores de Tiempo , Vasoconstrictores/administración & dosificaciónRESUMEN
Hydromorphone is a potent opioid analgesic commonly utilized in the hospital setting for the management of acute pain. Initial dose recommendations range from 0.1 to 2 mg of hydromorphone for opioid-naïve patients. This creates a challenge to optimally dose hydromorphone in opioid-naïve patients with the goals of avoiding opioid toxicities while also providing adequate pain management. In order to minimize the incidence of opioid toxicity, a community hospital implemented a dose-substitution hydromorphone policy that allows practitioners to automatically use a lower dose of hydromorphone within criteria limits. This pilot study was conducted to assess if the implementation of a low-dose hydromorphone protocol reduces the incidence of opioid toxicity while maintaining adequate pain management. This retrospective, observational, single-center cohort study examined hospitalized patients treated with hydromorphone between January 2013 and November 2013. Inpatients over 18 years of age who received hydromorphone were included in the study. The primary outcome of the study was the incidence of opioid toxicity. The secondary outcome of the study was adequate pain management. The results of this study showed no difference in opioid toxicity; however, patients required less per day hydromorphone and other opioids while still adequately managing patients' pain.