KETAMINE IN THE ICU: TREATMENT OF POLYPHARMACY WITHDRAWAL SYNDROME

Abstract

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: We present a case of severe polypharmacy withdrawal syndrome that was successfully treated with intravenous ketamine. CASE PRESENTATION: A 39-year-old male presented with aspiration pneumonia and hypoxic respiratory failure requiring mechanical ventilation for adult respiratory distress syndrome. He had a history of polysubstance abuse, bipolar disorder and severe anxiety, requiring psychiatric medications. High doses of propofol, midazolam, fentanyl, and dexmedetomidine were needed to control severe agitation while on the ventilator. There was substantial improvement in gas exchange and chest imaging to the extent that extubation was attempted following a successful spontaneous breathing trial. Soon after, the patient developed severe agitation with combative behavior and tachypnea that persisted despite sedative agents. The patient was reintubation followed by repeated attempts to adjust midazolam, propofol, fentanyl, and dexmedetomidine to levels that would control his agitation. A second extubation attempt was unsuccessful, and he required reintubation due to severe agitation, combative behavior as well as inability to control secretions. Intravenous ketamine was started - initial bolus 1 mg/kg followed by rapid titration to 2 mg/kg/hour to achieve coma. Fentanyl, propofol, midazolam, and dexmedetomidine were reduced and eventually discontinued completely. Ketamine was reduced until the patient was alert, calm, and cooperative followed by successful extubation. Ketamine was then tapered off, and the patient was transferred to the medical floors. DISCUSSION: We report the empiric use of ketamine to control severe agitation that was associated with successful extubation. Likely a history of polypharmacy recreational drug use combined with the need for very high dose of sedatives and opiates required for safe ventilatory support resulted in a severe withdrawal syndrome. Thus ketamine was chosen as a single agent to control delirium and combative behavior while discontinuing sedatives. Ketamine, an NMDA (N-Methyl-D-Aspartate) receptor antagonist in the central nervous system and spinal cord, is used as a sedative with dissociative and analgesic properties. This drug has several advantages: quick onset of action in thirty seconds of intravenous administration, short half-life, preservation of respiratory drive, and sympathomimetic effect that reduces risk of hypotension that is common with sedative agents. There are several reports its use in severe alcohol syndrome. Our case illustrates the potential benefit of ketamine to control polypharmacy withdrawal syndrome. CONCLUSIONS: This case shows that ketamine may have utility for control of severe agitation that is associated with withdrawal from high doses of sedatives and opiates required for the critically ill patient on mechanical ventilatory support with history of psychiatric illness and polysubstance drug use. Reference #1: Benken, S. T., & Goncharenko, A. (2016). The Future of Intensive Care Unit Sedation: A Report of Continuous Infusion Ketamine as an Alternative Sedative Agent. Journal of Pharmacy Practice, 30(5), 576-581. Reference #2: Malnoske, M. L, & Quill C (2017). Ketamine to facilitate weaning from mechanical ventilation: A case report. Journal of Anesthesia and Critical Care Case Reports, 3 (1), 11-13. Reference #3: Shah P, McDowell M, Ebisu R, Hanif T, Toerne T. Adjunctive Use of Ketamine for Benzodiazepine-Resistant Severe Alcohol Withdrawal: a Retrospective Evaluation. Journal of Medical Toxicology. 2018 Sep 1;14(3):229-36. DISCLOSURES: No relevant relationships by MORDECHAI GRABIE, source=Web Response No relevant relationships by Becky Lou, source=Web Response No relevant relationships by Paul Mayo, source=Web Response