Introduction
Optimization of sedation and analgesia in severe TBI patients
What is the appropriate level of sedation and how to monitor it?
Is ketamine an option for sedation in severe TBI?
Which are the systemic effects of ketamine?
Which are the cerebral effects of ketamine?
What is the available clinical evidence?
Author | Year | Population | Number | Study | Doses | ICP response | CPP response | Adverse effects | ||
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Bar Joseph et al. | 2009 | Adult Mechanical ventilated Severe TBI | N = 25 | Prospective Group A: normal ICP Group B: high ICP | Bolus 1–1.5 mg/kg | Group A: No increase Group B: Decrease 32% (Mean 25.7 to 17.6 mmHg) | NA | None | ||
Bar Joseph et al. | 2009 | Pediatric mechanical ventilated severe TBI | N = 30 | Prospective Group 1: ketamine prevention Group B: ketamine to reduce ICP | Bolus 1–1.5 mg/kg | Group A: ICP decrease (Mean 25.2 to 17.9 mmHg) Group B: ICP decrease (Mean 26 to 17.5 mmHg) | Group A and Group B: CPP increase | None | ||
Boirgoin et al. | 2005 | Adult mechanical ventilated severe TBI | N = 30 | Prospective Group 1: sufentanyl + Midazolam Group 2: ketamine + midazolam | Continuous infusión to achieve plasma concentration of 1 mcg/ml | No difference in ICP ICP non increase (non reported values) | No difference | None | ||
Boirgoin et al. | 2003 | Adult mechanical ventilated severe TBI | N = 25 | Prospective Group 1: ketamine + Midazolam Group 2: Midazolam + sufentanyl | Continuous infusión 82 mcg/kg/min | No difference between groups (Mean 19 vs 15.7 mmHg-p = 0.28) | NA | Non significant increase in HR | ||
Albanese et al. | 1997 | Adult mechanical ventilated severe TBI | N = 8 | Prospective | Bolus 1.5; 3; and 5 mg/kg | ICP decrease from baseline at all doses (Mean 2, 4 and 5 mmHg at 1,5; 3 and 5 mg/kg, respectively) | NA | None | ||
Kolenda et al. | 1996 | Adult mechanical ventilated moderate and severe TBI | N = 24 | Prospective Group 1: ketamine + Midazolam Group 2: fentanyl + midazolam | Continuous infusión 104 mg/kg/day | ICP 2 mmHg higher in ketamine group only at day 8 of infusion | CPP 8 mmHg higher in ketamine group | None | ||
Schmitter et al. | 2007 | Adult mechanical ventilated severe TBI | N = 24 | Prospective Group 1: fentanyl + methohexitone Group 2: ketamine + methohexitone | Continuous infusión 2 mg/kg/h | No difference between groups Mean 15.9 vs 14.7 mmHg) | No difference between groups | None |
Safety profile
Is ketamine cost-effective?
When not to use ketamine?
When to use ketamine
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Prehospital setting. In the acute phase of resuscitation, especially in low-resource regions, ketamine can be an interesting option because it potentially helps to maintain a stable hemodynamic profile, avoiding hypotension, reducing the use of fluids and maintaining spontaneous ventilation.
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Conscious sedation. In this sedation modality, it is necessary to be able to neurologically evaluate the patient while maintaining spontaneous ventilation and stable hemodynamics, such as during the weaning process.
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Gastrointestinal dysfunction (gastroparesis, ileus, nutrition intolerance). Ketamine, unlike opioids agents, does not interfere with gastrointestinal motility, a multifactorial and frequent condition in severe TBI.