Adjunct Sedative Research Articles

Phenobarbital as an adjunctive agent for sedation in pediatric intensive care unit patients: A single-center, retrospective study from Colorado

Abstract Background: Pediatric patients require pharmacological management of pain and agitation associated with mechanical ventilation. Pain and agitation may be refractory to opioids and alpha-2 agonists, prompting the use of adjunctive analgesics and sedatives with alternative mechanisms. The purpose of this study was to describe the use of phenobarbital as an adjunctive agent for refractory agitation in critically ill, mechanically ventilated pediatric patients. Subjects and Methods: This was a single-center, retrospective chart review at a pediatric intensive care unit (PICU) at a pediatric academic medical center in America between 2016 and 2021. Children aged 2 months to 18 years old were admitted to the PICU were mechanically ventilated and received phenobarbital for adjunct sedation. Sixty-three patients had phenobarbital dosing data evaluated, and the 38 patients who were not receiving continuous neuromuscular blockade were included in the primary and secondary outcome analysis of time within the goal sedation score. Descriptive statistics was used to assess baseline characteristics and the primary outcome. Wilcoxon signed-rank tests were used to evaluate secondary outcomes. Results: Patients spent significantly more time within the goal sedation score range after phenobarbital compared to before phenobarbital. The median number of rescue sedative boluses, morphine equivalents (MEs), and benzodiazepine equivalents (BZDE) significantly decreased 2 days after the first phenobarbital dose compared to the 2 days before the first phenobarbital dose. Conclusions: The use of phenobarbital as an adjunct sedative was associated with a statistically significant increase in time spent in the goal sedation score range and decrease in ME, BZDE, and concomitant sedative boluses.

Enteral Pentobarbital in the Difficult to Sedate Critically Ill Children

OBJECTIVE Difficult analgosedation is common and challenging in the pediatric intensive care unit (PICU). It is important to study alternative and supplemental sedatives for when the first-line agents become ­insufficient. METHODS In this retrospective chart-review study, we report our center’s experience in using intermittent doses of enteral pentobarbital as an adjunct sedative in 13 difficult to sedate critically ill and mechanically ventilated children. We compare the average sedation score and cumulative doses of other ­sedatives (opioids, benzodiazepines and alpha-2 agonists) in the 24 hours before and 24 hours after enteral ­pentobarbital initiation. RESULTS The addition of enteral pentobarbital was associated with lower State Behavioral State (SBS) scores in 8 out of the 13 patients and on average smaller doses of opioids (decreased by 11%), ­benzodiazepines (BZD) (decreased by 5%) and alpha-agonists (decreased by 20%). No adverse effects were noted attributable to pentobarbital administration. CONCLUSION Enteral pentobarbital seems to be safe and effective agent in the difficult to sedate critically ill child.

Characterization of Propofol Use For Non-Procedural Sedation in a Pediatric Intensive Care Unit

OBJECTIVE Given the limited literature describing propofol use in pediatric patients, this study aimed to describe the dosing and duration of propofol infusions for non-procedural sedation in the pediatric intensive care unit (PICU). The secondary objectives were to describe the change in concomitant sedative requirements from the 24-hour period before propofol initiation to the 24-hour period after discontinuation of propofol and to review the frequency of adverse events. METHODS This retrospective descriptive cohort study evaluated children 1 month to less than 18 years old who received a continuous infusion of propofol for non-procedural sedation in the PICU between May 2018 and August 2020. RESULTS One hundred thirty propofol infusions representing 127 unique patients (median age, 2.9 years) were included. The median (IQR) propofol infusion duration was 18 (10–28) hours, and the median (IQR) average dose was 4.1 (2.9–5.6) mg/kg/hr. Extubation was attempted in 96 patients (74%) within 24 hours of propofol infusion discontinuation. For patients that remained intubated with continuous sedation, concomitant continuous opioid and midazolam requirements decreased by 20% (p = 0.865) and 43% (p = 0.011), respectively. Patients receiving propofol for over 24 hours experienced the largest percent decrease in concomitant sedation with midazolam. There were no confirmed cases of propofol-related infusion syndrome (PRIS). CONCLUSIONS Durations and doses of propofol infusions for non-procedural sedation vary widely at our institution. Propofol may be beneficial as an adjunct sedative, but prospective studies are needed to further explore the effect of propofol on decreasing the requirements of concomitant opioids and benzodiazepines.

RNA-sequencing approach for exploring the protective mechanisms of dexmedetomidine on pancreatic injury in severe acute pancreatitis.

Background: Severe acute pancreatitis (SAP) is a severe form of acute pancreatitis with the potential to cause life-threatening complications. Patients with acute SAP require surgical intervention and are admitted to the intensive care unit for non-invasive ventilation. Dexmedetomidine (Dex) is currently used by intensive care clinicians and anaesthesiologists as an adjunctive sedative. Therefore, the clinical availability of Dex makes it easier to implement in SAP treatment than developing new drugs. Methods: Randomly dividing thirty rats into sham-operated (Sham), SAP, and Dex groups. The severity of pancreatic tissue injury in each rat was assessed by Hematoxylin and eosin (HE) staining. Serum amylase activity and inflammatory factor levels were measured using commercially available kits. The expressions of necroptosis-related proteins, myeloperoxidase (MPO), CD68, and 4-hydroxy-trans-2-nonenal (HNE) were detected using immunohistochemistry (IHC). Transferase-mediated dUTP nick-end labeling (TUNEL) staining was utilized to identify pancreatic acinar cell apoptosis. The subcellular organelle structure of pancreatic acinar cells was observed using transmission electron microscopy. The regulatory effect of Dex on the gene expression profile of SAP rat pancreas tissue was investigated using RNA sequencing. We screened for differentially expressed genes (DEGs). Quantitative real-time PCR (qRT-PCR) measured critical DEG mRNA expression in rat pancreatic tissues. Results: Dex attenuated SAP-induced pancreatic injury, infiltration of neutrophils and macrophages, and oxidative stress. Dex inhibited the expression of necroptosis-associated proteins RIPK1, RIPK3, and MLKL and alleviated apoptosis in acinar cells. Dex also mitigated the structural damage caused by SAP to mitochondria and endoplasmic reticulum. Dex inhibited SAP-induced 473 DEGs, as determined by RNA sequencing. Dex may regulate SAP-induced inflammatory response and tissue damage by inhibiting the toll-like receptor/nuclear factor κB (TLR/NF-κB) signaling pathway and neutrophil extracellular trap formation. Conclusion: This study elucidated the remarkable effect of Dex against SAP and investigated the potential mechanism of action, providing an experimental base for the future clinical application of Dex in the treatment of SAP.

Ketamine infusions as an adjunct for sedation in critically ill children.

Limited reports have described ketamine's role as an adjunct sedative. The purpose was to describe ketamine's role as an adjunct to achieve goal sedation in mechanically ventilated children. Retrospective, descriptive study. Thirteen-bed pediatric intensive care unit (ICU) and 12-bed pediatric cardiovascular ICU. Seventy-three ketamine courses were included, representing 62 mechanically ventilated children <18 years receiving ketamine for ≥12 hours. The primary outcome was to determine the median dose and time to achieve goal sedation (80 percent of State Behavioral Scale scores between 0 and -1) based on ketamine's place in therapy as an adjunct in the sedation regimen. Secondary outcomes included a comparison of sedative dosing pre- and post-ketamine initiation between place in therapy groups and paralyzed/nonparalyzed patients, and identification of ketamine-attributed adverse drug event (ADEs) or iatrogenic withdrawal syndrome (IWS). The median age was 1.0 years (interquartile range: 0.4-4.9). Ketamine was initiated as first-line (n = 7; 9.6 percent), second-line (n = 39; 53.4 percent), third-line (n = 26; 35.6 percent), or fourth-line (n = 1; 1.4 percent) sedation. The median initial and peak doses were 0.6 mg/kg/h (0.3-0.6) and 0.9 mg/kg/h (0.9-1.2), respectively. The median dose and time to achieve goal sedation was 0.8 mg/kg/h (0.6-1.1) and 2 hours (1-7), respectively. ADEs were noted during three courses (4.1 percent) and IWS after discontinuation of one course (1.4 percent). The majority were initiated on ketamine as a second- or third-line adjunct sedative. The median initial dose was 0.6 and dose to achieve goal sedation was 0.8 mg/kg/h. Ketamine-attributed ADEs and IWS episodes were rare.

Impact of ketamine as an adjunct sedative in acute respiratory distress syndrome due to COVID-19 Pneumonia

PurposeDeep 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 methodsThis 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. ResultsWe 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. ConclusionsIn 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.

830: Ketamine Infusion for Adjunctive Sedation in Mechanically Ventilated Patients

830: Ketamine Infusion for Adjunctive Sedation in Mechanically Ventilated Patients

Safety and Effectiveness of Sedation With Adjunctive Ketamine Versus Nonketamine Sedation in the Medical Intensive Care Unit

Background: Ketamine, an N-methyl-d-aspartate receptor antagonist with sedative and analgesic properties, is becoming more popular as an adjunctive sedative in the critically ill patients. Methods: We conducted a single center, retrospective cohort study of patients admitted to the medical intensive care unit (MICU) between 2013 and 2018. Patients who received continuous infusion ketamine or nonketamine sedatives (NKS) including dexmedetomidine, fentanyl, midazolam, or propofol were identified. The primary outcome was percentage of Richmond Agitation-Sedation Scale (RASS) scores at goal in patients receiving ketamine as adjunct to NKS compared to those on NKS alone. Results: A total of 172 patients were included (n = 86 ketamine, n = 86 NKS). Baseline characteristics were similar with the exception of antipsychotic use, which was higher in the ketamine group (P = .008). Percentage of RASS scores at goal was not different between groups (78.7% vs 81.4%, P = .29). Fewer patients in the ketamine group received continuous infusion fentanyl (76.7% vs 94.2%, P = .002). Patients on adjunctive ketamine required fewer days of intermittent benzodiazepines (0 [0-1] vs 1 [1-2], P < .0001). Patients receiving ketamine required less norepinephrine, receiving a median of 6.32 mg (2.4-20) versus 11.7 mg (5.2-45.2; P = .03). There was no difference in receipt of new antipsychotics or occurrence of arrhythmias. Conclusion: Addition of ketamine did not increase the percentage of RASS scores at goal versus NKS but was well tolerated. Ketamine was associated with reductions in norepinephrine requirements, days of intermittent benzodiazepine administration, and number of patients receiving continuous infusion fentanyl. Continuous infusion ketamine appears safe and effective for sedation in the MICU.

Comparison of health record vitals and continuously acquired vitals data identifies key differences in clinical impression

Abstract This study aimed to investigate how intermittent ICU data documented by nursing in the electronic medical record (EMR) corresponds to that obtained from continuous data acquisition (CDA) and the differences in perception by medical providers. Both descriptive statistics and impact on decision-making were compared. We performed a secondary analysis of de-identified physiologic data collected as part of a study exploring the impact of dexmedetomidine adjunctive sedation on ICP and primary sedation dose (C3PO study). Data was in two sets, one derived from nurse charting in the health record, the other was continuous digital acquisition. We compared the number and timing of clinical events within each dataset that were outside the clinical treatment goals for that parameter. We also made graphs of concurrent 3-h periods from the two datasets and surveyed providers about their impressions and the need for intervention based on the visual review of the trends. Data consisted of 74,143 measures of ICP compiled from 40 neurocritically ill patients. We found no significant difference in overall means. The CDA dataset captured significantly more ICP elevation events defined as ICP >20 mmHg. Survey of ICU providers revealed that CDA data segments were perceived as “less controlled” and were more likely to be considered as “not meeting goals” for the vital parameter. We conclude that there are no significant differences in mean ICP measures between EMR and CDA vitals data, however, EMR data underreported the number of ICP elevation events and may not represent the overall patient exposure to out of goal vitals measures. We conclude that potentially significant differences exist between EMR and CDA data for ICU patients and that further consideration of this is needed in ICU trial design and as more machine learning and surveillance algorithms are developed for patient monitoring and predictions of deterioration.

Adjunctive Sedation With Dexmedetomidine for the Prevention of Severe Inflammation and Septic Encephalopathy

Adjunctive Sedation With Dexmedetomidine for the Prevention of Severe Inflammation and Septic Encephalopathy

Sedation with alfentanil versus fentanyl in patients receiving extracorporeal membrane oxygenation: outcomes from a single-centre retrospective study.

In November 2016, our institution switched from alfentanil to fentanyl for analgesia and sedation in adult patients receiving extracorporeal membrane oxygenation. There is no published evidence comparing the use of alfentanil with fentanyl for sedation in extracorporeal membrane oxygenation patients. We conducted a retrospective observational study to explore any significant differences in patient outcomes or in the prescribing of adjunct sedatives before and after the switch. Patients were retrospectively identified from a prospectively recorded database of all patients who received extracorporeal membrane oxygenation at our institution between January 2016 and October 2017. Patients included those sedated with alfentanil or fentanyl. The total daily doses of intravenous opioids (alfentanil or fentanyl) were calculated for each patient, and the prescribing of adjunctive sedative or analgesic agents was recorded. Patient demographics, extracorporeal membrane oxygenation modality, clinical outcomes including mortality and length of intensive care and hospital stay were recorded. A total of 174 patients were identified, 69 on alfentanil and 95 on fentanyl. There was no difference found between groups for mode of extracorporeal membrane oxygenation, age, Acute Physiology and Chronic Health Evaluation 2 score (APACHE II) and Charlson score, except for body mass index (p = 0.002). No differences in patient outcomes was observed between groups, although patients in the alfentanil group received a significantly higher median total daily dose of adjuvant sedatives (quetiapine (p = 0.016) and midazolam (p = 0.009)). No differences in patient outcomes were found between extracorporeal membrane oxygenation patients sedated with alfentanil compared with fentanyl. There was a statistically significant reduction in some adjunctive sedatives in patients managed with a fentanyl-based regimen. Prospective studies are required to confirm these results.

Use of diphenhydramine as an adjunctive sedative for colonoscopy in patients on chronic opioid therapy: a randomized controlled trial

Chronic opioid use increases tolerance to sedatives. Diphenhydramine is recommended for difficult-to-sedate patients during endoscopic procedures. We hypothesized that the addition of diphenhydramine to midazolam and fentanyl would improve objective and subjective measures of procedural sedation. This randomized, double-blind, placebo-controlled trial included patients on chronic opioids undergoing colonoscopy. Patients were randomized to receive 50 mg of diphenhydramine intravenously (n= 61) or placebo (n= 58), in addition to fentanyl and midazolam. Baseline characteristics, amount of fentanyl and midazolam, procedure times, and adverse events were recorded. Quality of sedation was assessed by the physician and nurse. Patients rated pain and amnesia on a 10-point scale. There was no difference in amounts of fentanyl (125.4 ± 56.2 μg vs 126.9 ± 53.5 μg, P= .88) and midazolam (4.9 ± 2.1 mg vs 5 ± 1.9 mg, P= .79) used. The mean sedation scores from the physician (6.2±1.1 vs 5.3 ± 1.2, P=.0002) and nurses (5.6 ± 1.5 vs 5.1 ± 1.4, P=.04) were statistically significant in favorof the diphenhydramine arm. Patient scores for pain (2.05 ± 2.17 vs 3.09 ± 3.95, P=.047) and amnesia (7.8±3.4 vs 6.5 ± 3.8, P=.047) favored the group that received diphenhydramine. Qualitative assessment showed no significant difference between the groups. There was no difference in induction time (P= .86), procedure duration (P= .98), or recovery time (P= .16). Hypotensive episodes were more common in the placebo group (P=.027). In patients on chronic opioid therapy, administration of diphenhydramine does not allow for lower doses of procedural sedatives but improves quality of sedation without increasing the number of adverse events. (Clinical trial registration number: NCT T01967433.).

Impact of Ketamine Use on Adjunctive Analgesic and Sedative Medications in Critically Ill Trauma Patients.

Ketamine may be used to manage pain and agitation that is refractory to what are usually considered traditional agents such as fentanyl, propofol, benzodiazepines, and dexmedetomidine; however, literature describing the use of ketamine continuous infusions for this purpose in critically ill trauma patients is limited. The primary objective of this study was to determine the impact of the initiation of a ketamine continuous infusion on sedative and analgesic use in critically ill trauma patients. Secondary objectives were to identify the patient population in which ketamine was initiated, assess the proportion of time patients were at their goal level of sedation, and determine the dosing patterns of adjunctive sedative agents. This single-center retrospective chart review over a 19-month period included critically ill mechanically ventilated adult trauma patients in whom a ketamine continuous infusion was initiated for management of sedation and agitation. Patients who received ketamine for other indications or by the acute pain management service were not included in this evaluation. Thirty-six patients were included in the study. Patients in whom ketamine was initiated tended to be white men with blunt trauma. Overall, the initiation of ketamine was associated with a decrease in the amount of opioids and propofol used and an increase in the amount of ziprasidone and dexmedetomidine needed to achieve the goal Richmond Agitation Sedation Score. When compared with the time period before ketamine initiation, the proportion of time that patients achieved goal sedation was not significantly different after the addition of ketamine. Although the use of ketamine in critically ill mechanically ventilated adult trauma patients was associated with decreased opioid use, it was also associated with increased use of dexmedetomidine and ziprasidone to achieve and maintain sedation. Further examination of clinical outcomes associated with these differences in drug use in a larger population of trauma patients is warranted before routine use of ketamine for analgesia and sedation can be recommended.

Full Spectrum (FUSE®) Colonoscopy Is Associated With Longer Cecal Insertion Time and Higher Sedative Requirement

Introduction: Wide-angle endoscopy is an emerging technique that aims to improve lesion detection through better visualization with a trend toward improved adenoma detection rate (ADR). We sought to evaluate the procedural characteristics of the Full-Spectrum Endoscopy (Fuse®) system. Methods: This single-center retrospective cohort study reviews 974 colonoscopies performed since January 2015. The type of colonoscope used was randomly determined for a given endoscopy block on the day of the procedure by the nursing staff. Data were collected on age, gender, indication for colonoscopy, and bowel preparation quality. Insertion and withdrawal time (WT), as well as sedative doses (midazolam, fentanyl, diphenhydramine), and reversal agent use (naloxone, flumazenil) were recorded. The primary outcomes of insertion time and sedative requirements were compared between the Fuse® and conventional (Olympus 190) colonoscope exams.Table: Table. Colonoscopy Descriptive AnalysisTable: Table. Standard Colonoscopy vs Fuse Colonoscopy Baseline Data Comparison:Results: Of the total 974 patients, 770 underwent standard colonoscopy while 204 underwent Fuse® colonoscopy. Mean age was 59.4 years and majority were female (56.9%). Colorectal cancer screening or surveillance was the most common indication (50.9%), followed by gastrointestinal bleeding (19.4%). Cecal intubation rate was 98.4% while mean WT was 13.5 minutes. There were no significant differences in demographics, preparation quality, or cecal intubation rate between both groups. Adenoma Detection Rate (ADR), calculated on a subset of patients who underwent screening colonoscopy with two endoscopists, was higher with Fuse® colonoscopy compared to standard colonoscopy however this did not meet statistical significance (32.5% vs 25.1%, p=0.146). There was no difference in mean WT (Fuse® 13.9 min vs standard 13.4 min, P=0.36) however mean insertion time was longer for Fuse® colonoscopies (12.3 mins vs 9.2 mins, P= < 0.01). Adjunctive sedative use (diphenhydramine) was more often required with Fuse® (33.5%) than standard colonoscopy (27.3%, p = 0.008). The mean fentanyl dose administered was higher in the Fuse® group (111.7 mcg vs 101.4 mcg, P= < 0.01). No difference existed between midazolam dose or the use of reversal agents. Conclusion: Insertion time was significantly longer for Fuse® cases, with higher sedative requirements. It is unclear if the increased insertion time was related to patient's discomfort and increased sedative requirements. Further prospective studies are needed to evaluate the technical performance of the Fuse® colonoscope.

General Endoscopy.

General Endoscopy.

Stimulation of Central α2 Receptors Attenuates Experimental Necrotizing Pancreatitis.

Severe necrotizing pancreatitis (SNP) is a disease with relevant morbidity and mortality until today. No specific therapy is in sight. Central α2 agonists such as clonidine and dexmedetomidine are known to have anti-inflammatory effects though the cholinergic anti-inflammatory pathway and are implemented in the clinical routine as adjunct sedative drugs. Their potential effect on SNP has not yet been tested. Severe necrotizing pancreatitis was induced in male Wistar rats. Four treatment groups received either clonidine or dexmedetomidine before (prophylactic) or after induction of SNP (therapeutic). After 12 hours, pancreatic morphologic injury, systemic proinflammatory high-mobility group box 1 protein, and pancreatic and pulmonary myeloperoxidase levels were evaluated. Severe necrotizing pancreatitis was fully established 12 hours after induction. "Prophylactic" and "therapeutic" administration of clonidine and dexmedetomidine reduced pancreatic morphologic injury (P < 0.05 vs SNP), serum proinflammatory high-mobility group box 1 protein (P < 0.0001 vs SNP), as well as pancreatic and pulmonary myeloperoxidase levels (P < 0.01 vs SNP). Prophylactic and therapeutic applications of the central α2 agonists clonidine and dexmedetomidine are effective to attenuate local and systemic injury in experimental SNP and should be evaluated in the clinical setting.

Continuous Infusion Ketamine for Adjunctive Sedation in Medical Intensive Care Unit Patients: A Case Series

Continuous Infusion Ketamine for Adjunctive Sedation in Medical Intensive Care Unit Patients: A Case Series

Safety and Efficacy of Flumazenil for Reversal of Iatrogenic Benzodiazepine-Associated Delirium Toxicity During Treatment of Alcohol Withdrawal, a Retrospective Review at One Center

Both alcohol withdrawal syndrome (AWS) and benzodiazepines can cause delirium. Benzodiazepine-associated delirium can complicate AWS and prolong hospitalization. Benzodiazepine delirium can be diagnosed with flumazenil, a GABA-A receptor antagonist. By reversing the effects of benzodiazepines, flumazenil is theorized to exacerbate symptoms of AWS and precludes its use. For patients being treated for alcohol withdrawal, flumazenil can diagnose and treat benzodiazepine delirium without precipitating serious or life-threatening adverse events. Hospital admission records were retrospectively reviewed for patients with the diagnosis of AWS who received both benzodiazepines and flumazenil from December 2006 to June 2012 at a university-affiliated inpatient toxicology center. The day of last alcohol consumption was estimated from available blood alcohol content or subjective history. Corresponding benzodiazepine, flumazenil, and adjunctive sedative pharmacy records were reviewed, as were demographic, clinical course, and outcome data. Eighty-five patients were identified (average age 50.3years). Alcohol concentrations were detectable for 42 patients with average 261mg/dL (10-530mg/dL). Eighty patients were treated with adjunctive agents for alcohol withdrawal including antipsychotics (n = 57), opioids (n = 27), clonidine (n = 35), and phenobarbital (n = 23). Average time of flumazenil administration was 4.7days (1-11days) after abstinence, and average dose was 0.5mg (0.2-1mg). At the time of flumazenil administration, delirium was described as hypoactive (n = 21), hyperactive (n = 15), mixed (n = 41), or not specified (n = 8). Response was not documented in 11 cases. Sixty-two (72.9%) patients had significant objective improvement after receiving flumazenil. Fifty-six patients required more than one dose (average 5.6 doses). There were no major adverse events and minor adverse effects included transiently increased anxiety in two patients: 1 patient who received 0.5mg on abstinence day 2 and another patient who received 0.2mg flumazenil on abstinence day 11. This is the largest series diagnosing benzodiazepine delirium after AWS in patients receiving flumazenil. During the treatment of AWS, if delirium is present on day 5, a test dose of flumazenil may be considered to establish benzodiazepine delirium. With the limited data set often accompanying patients with AWS, flumazenil diagnosed benzodiazepine delirium during the treatment of AWS and improved impairments in cognition and behavior without serious or life-threatening adverse events in our patients.

Abstract WP4: Conscious Sedation With Dexmedetomidine For Acute Stroke Patients Undergoing Intrarterial Therapy.

Background: The aim of this pilot study was to prospectively determine safety and feasibility of Conscious sedation (CS) with dexmedetomidine in stroke patients undergoing intra-arterial therapy (IAT). Methods: This industry sponsored prospective single arm study was conducted with institutional IRB approval. The following data points were collected: demographics, pre-procedure NIHSS, mean time to treatment, treatment modalities, sedation and procedure times and the use of adjunctive sedation medications. Outcome measures included intraprocedural pain scores and Richmond agitation sedation scale (RASS), recanalization score, intraprocedural complications, conversion to GA, modified Rankin scale at 30 days as well as a personal account of the patients experience during the procedure. Results: Fifty- one patients were enrolled in this study of which 41 patients underwent acute stroke therapy and were included in this analysis. Baseline characteristics are included in table 1. Site of occlusion was the MCA in 27 patients, ICA-terminus in 10 patients and BA in 4 patients. IAT was performed using the MERCI device in 30 patients, Penumbra device in 3, manual aspiration in 5, and angioplasty and stenting in 3 patients. Adjunctive IA tPA was administered in 6 patients. All patients tolerated treatment under CS. The mean procedural RASS was 0 and the mean pain score was 1. Thrombolysis in Cerebral Ischemia (TICI) 2B/3 recanalization was achieved in 32 patients (78%). Two intra-procedural wire perforations (5%) were recorded. Ten patients (24%) had a mRs of &lt; 2 at 30 days and 6 patients died (14%). Thirty-one patients described their experience. Only 6 patients were able to remember having the procedure of which 1 had a negative experience. Conclusion: To our knowledge, this is the first prospective study to evaluate the safety and efficacy of CS in stroke patients who undergo IAT. In our cohort, CS was safe, feasible and well tolerated.

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Introduction: The number of sedative options for use in mechanically ventilated patients remains limited. Ketamine is an NMDA antagonist with sedative, analgesic and bronchodilator properties. It also demonstrates favorable hemodynamic and pharmacokinetic profiles. While used commonly intra-operatively and by emergency room clinicians, a precedent for ketamine use in the intensive care unit is lacking outside of brief non-surgical procedures and rapid sequence intubation. Hypothesis: Continuous infusion ketamine can be utilized safely for adjunctive analgesia and sedation in mechanically ventilated medical intensive care unit patients. Methods: All patients who received continuous infusion ketamine for adjunctive sedation and analgesia between 1/1/2010 and 7/1/2012 were retrospectively identified via an informatics query. Patient demographics, process of care data and hemodynamic variables were collected and assessed. Results: Twelve patients met criteria. Mean age was 41; 60% were Caucasian and 60% were female. Median weight was 100kg. Four patients were known polysubstance abusers. Six patients were admitted for HCAP, three for asthma exacerbation. The median duration of ketamine therapy was 1.57 days. The median minimum and maximum rates were 0.24 mg/kg/hr and 0.83 mg/kg/hr. The median rate over the first 24h of infusion was 0.56 mg/kg/hr. The maximum documented dose used was 2.8 mg/kg/hr. The ketamine infusion was discontinued secondary to tachycardia or hypertension in two patients. One patient was receiving only concomitant propofol, the other dexmedetomidine and fentanyl infusions. No patient who received concomitant benzodiazepines experienced hemodynamic changes prompting ketamine cessation. Median maximum SBP, DBP, and HR while on ketamine were 154, 96 and 121, respectively. No further ADRs were identified, including rash, although 83% of patients received concurrent corticosteroids for their underlying illness. Conclusions: Continuous infusion ketamine may likely be utilized safely as adjunctive sedative and analgesic therapy in mechanically ventilated MICU patients if concomitant benzodiazepine therapy is provided. Larger trials are needed to further define optimal dosing and confirm safety.