Ketamine + Morphine

Link to Abstract

Jennings PA, Cameron P, Bernard S, Walker T, Jolley D, Fitzgerald M, Masci K: Morphine and ketamine is superior to morphine alone for out-of-hospital trauma analgesia: a randomized controlled trial. Ann Emerg Med. 2012, 59: 497-503. 10.1016/j.annemergmed.2011.11.012.

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Ketamine: Mechanism of Action

Link to Abstract

Link to FULL FREE Article

K Hirota, D G Lambert, Ketamine: its mechanism(s) of action and unusual clinical uses., BJA: British Journal of Anaesthesia, Volume 77, Issue 4, Oct 1996, Pages 441–444.

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Pregabalin to Avoid Opioids

I’m hard at work on a protocol for my shop to decrease opioid usage as well as preparing my lectures on opioid sparing medications. Amongst those are the gabapentinoids. You’ve seen them often, I’m sure, mostly to treat neuropathic pain such as diabetic neuropathy as well as trigeminal neuralgia but what about for actual painful procedures? This family of medications reduce the abnormal hypersensitivity induced by inflammatory responses or nerve injury. What not just place it in the drinking water for our patients? That’s kind of where I’m going with this.

This study was published in 2011 and they gave patients Pregabalin, also known as Lyrica, to see how much opioids the pts would need. They got 150mg before the surgery and then 75mg twice a day until post-op day 5. The main drawback is how it delayed the time to extubation. I don’t know if I am interpreting the data correctly but patients on Pregabalin were on the vent for about 2 hours longer than those not on it. Perhaps the 150mg 1 hour before the surgery was too much. Either way, as noted on the abstract slide, it reduced the post-op consumption of opioids by 44-48%. That’s a big win.

Do you all routinely use Pregabalin or Gabapentin for pain management at your institutions? I’m going to go through more data on this topic in the upcoming week.

-EJ

Link to Abstract

Link to FULL FREE Article

Pesonen A, Suojaranta-Ylinen R, Hammaren E, Kontinen VK, Raivio P, Tarkkila P, Rosenberg PH. Pregabalin has an opioid sparing effect in elderly patients after cardiac surgery: a randomized placebo-controlled trial. Br J Anaesth 2011;106:873–81

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Magnesium for Sedation in Mechanically Ventilated Patients?

This is cool, really cool. We need more data, but this is a great start. I learned a lot of basic science from reading the introduction as well as discussion on this article and it all makes sense. I don't see myself using this anytime soon until there's a study where they add magnesium to a different agent that's not midazolam because I do not use benzodiazepines in my practice for sedation unless there are extreme cases.

I encourage you read this article yourself as it's interesting and I don't want to divulge too much out of respect for the authors.

-EJ



Link to Abstract

Link to FREE FULL PDF

Altun, Dilek. (2019). Can we use Magnesium for sedation in Intensive Care Unit for critically ill patients; Is it as effective as other sedatives?. Ağrı - The Journal of The Turkish Society of Algology. 31.

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Ketamine Continuous Infusions for Sedation in the ICU

One of the lectures I’m working on is regarding minimizing opioid utilization in the ICU on our critically ill patients on mechanical ventilation.

I honestly do not use ketamine as often as I’d like and I have been reviewing all the data behind continuous infusions over the last two days.

Unfortunately, the data isn’t incredibly robust (small sample sizes, mostly retrospective, heterogenous non-MICU patient populations) and there is a wide variation in the doses used in the different studies. This study published earlier this year used ketamine in conjunction with other agents, mostly propofol or fentanyl. The authors found that using ketamine decreases the doses the other agents with no changes in all the other outcomes. Most clinicians are looking for miracle drugs rather than incremental (albeit small) improvements here and there.

One of the problems I have with ketamine is, depending on how it’s mixed, is the sheer volume of the drip. I try to keep my patients potato chip dry and if the ketamine is basically a maintenance fluid, I’m not going to be as excited about it. 

Do you all use ketamine in your ICU for continuous sedation? Do you use it as monotherapy or with other infusions?



Link to Abstract

Garber, P. M., Droege, C. A., Carter, K. E., Harger, N. J. and Mueller, E. W. (2019), Continuous Infusion Ketamine for Adjunctive Analgosedation in Mechanically Ventilated, Critically Ill Patients. Pharmacotherapy, 39: 288-296.

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Analgesia and Sedation in the ICU

Link to Abstract

Sessler, C. N., Grap, M. J., & Brophy, G. M. (2001). Multidisciplinary Management of Sedation and Analgesia in Critical Care. Seminars in Respiratory and Critical Care Medicine, 22(02), 211–226.

Cardiogenic Shock: NICOM vs. Swan-Ganz Catheter

There are four types of shock: cardiogenic, distributive, obstructive, and hypovolemic.

I routinely make a big deal of volume resuscitation regarding septic shock which obviously falls under the distributive shock type. Part of the problem is that with all these well intentioned "Surviving Sepsis Campaigns", I feel that we are under-recognizing cardiogenic shock which can also present with hypotension and an elevated lactic acid. When you provide 30cc/kg of IVF arbitrarily because the "sepsis screen" pops up on your EMR forcing you to give the fluids, you end up causing harm to your patients.

This is where the history and physical plays a huge role. The physical should include a quick targeted POCUS/bedside echo to make sure you're not missing anything that's staring you in the face. If you see an RVOT on the parasternal long axis that's the size of a tennis ball, you're not dealing with sepsis. If you see an LV on the apical four chamber that is barely moving, you're likely not dealing with sepsis. Remember, if the patient is in septic shock, the systemic vascular resistance (SVR) hits the ground. There's no afterload for the LV to deal with. The LV will be clapping happily like a bodybuilder curling a 10lb weight. The "eyeball test" on POCUS is widely criticized but it has some uses.

But once you make the diagnosis of cardiogenic shock, how do you manage that patient? This is where I feel you may have some value in trending a CVP. I know Swan-Ganz catheters are out of favor, but I feel they're very useful if you know what to do with the numbers. Knowing how to apply the numbers clinically, though, takes some practice. Like everything else, you need to get your reps in. I'm fortunate that I trained at an institution where all the post-op hearts came out with a Swan. It was very helpful in my training and allowed me the opportunity to see the value in it rather than just being a nay-sayer. The Swan does have its limitations, though. It's not the easiest procedure to perform and it comes with some potential cardiac risks that I am not going to list here for the sake of my sanity. Is there something that we can use instead?

I will admit that I personally do not have any experience with the NICOM device. I look forward to playing with the technology one day. I like non-invasive things for my patients. I typically use another device which I will not name but I feel it is very helpful when used appropriately. No technology is perfect, not even the Swan. I was excited when I read this article because I was hoping for an out to not have to float Swans in this patient population. I also very much enjoyed how the authors conducted the study. Simultaneous measurements on the same patient was definitely the way to go and I applaud them on that.

Without boring you all with the details, the authors found that the NICOM correlates poorly with indirect Fick and therm-dilution measurements of cardiac output. The authors attribute it to the biorreactance technology being interfered with by pulmonary and interstitial edema. Makes sense to me. They also listed other factors as well which are on the full article. Nonetheless, what method do you use at your institution to manage cardiogenic shock?

-EJ



Link to Abstract

Rali, A. S., Buechler, T., Van Gotten, B., Waters, A., Shah, Z., Haglund, N., & Sauer, A. (2019). Non-Invasive Cardiac Output Monitoring in Cardiogenic Shock – The NICOMTM Study. Journal of Cardiac Failure.

Great article for indirect Fick
De Maria AN, Raisinghani A. Comparative overview of cardiac output measurement methods: Has impedance cardiography come of age? Congestive Heart Failure. 2000;6:60–73.

Indirect Fick Abstract

Indirect Fick PDF

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17 years from research evidence to clinical practice

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Link to PDF

Morris ZS, Wooding S, Grant J. The answer is 17 years, what is the question: understanding time lags in translational research. J Roy Soc Med. 2011;104:510–20.

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Awake Intubation Guidelines

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Ahmad, I. , El‐Boghdadly, K. , Bhagrath, R. , Hodzovic, I. , McNarry, A. F., Mir, F. , O'Sullivan, E. P., Patel, A. , Stacey, M. and Vaughan, D. (2019), Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia. doi:10.1111/anae.14904

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Spontaneous Breathing Trials: How Does Your Shop Handle This?

There has been quite a bit of variation regarding pressure support trials, spontaneous breathing trials, liberation trials, whatever you want to call it.
I recently looked at the data for my academic curiosity and would like your input as to how you do it at your shop. I’d like to apologize in advance if I don’t write back to each of you in a timely fashion. I’ll try my best.

Here’s how I like to approach it (in the ideal world).
1. Patient isn’t deteriorating and they’ve done well on their spontaneous awakening trial (SAT).
2. RT goes ahead and places them on pressure support (PS or PSV are the lingo)
3. PS for 30 minutes and the RT flips them back into their prior setting on the vent if they don’t fly.
4. If they do fly, I eyeball the patient and have my RT teammate pull the tube.

I usually have HFNC or NIPPV at the bedside in case they have a high likelihood of needing reintubation.

I know many clinicians check ABGs prior to extubating their patients. I very rarely do. I think I’ve checked maybe 2 or 3 prior to extubating in the almost 2.5 years that I’ve been out of training.

A 🎩 tip to the authors.

Let’s reduce the mechanical ventilation days with this! 💪🏼




Link to Abstract

Link to FULL FREE Article

Ouellette DR, Patel S, Girard TD, Morris PE, Schmidt GA, Truwit JD, et al. Liberation From Mechanical Ventilation in Critically Ill Adults: An Official American College of Chest Physicians/American Thoracic Society Clinical Practice Guideline: Inspiratory Pressure Augmentation During Spontaneous Breathing Trials, Protocols Minimizing Sedation, and Noninvasive Ventilation Immediately After Extubation. Chest. 2017;151:166–180.

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