Ketamine/propofol admixture (ketofol) at induction in the critically ill against etomidate (KEEP PACE trial): study protocol for a randomized controlled trial

Inducción Anestésica: Propofol, Ketamina o Ketofol ¿Cuándo utilizarlos?

Introducción: La anestesia general se subdivide en diferentes etapas donde una de las más importantes es la etapa de la inducción anestésica y los fármacos que se utilizan en ella, siendo el Propofol y la Ketamina los más nombrados Objetivo: Realizar una revisión de las propiedades farmacocinéticas y farmacodinámicas de estos dos medicamentos, para la toma de decisiones sobre en qué situaciones debería usarse cada uno de ellos o de forma concomitante Materiales y métodos: Se realizaron 4 búsquedas separadas en la base de datos de PUBMED, obteniendo un total de 27 bibliografías utilizadas para la revisión. Resultados: El propofol es un agente hipnótico útil para procedimientos cortos, en pacientes estables hemodinámicamente. La ketamina tiene un perfil farmacodinámico ideal para pacientes con inestabilidad hemodinámica. El ketofol es una alternativa que logra adecuado sinergismo permitiendo mantener los beneficios de cada uno de estos medicamentos y disminuyendo la probabilidad de efectos adversos. Conclusión: Dependiendo de la cirugía que se vaya a realizar y de la estabilidad hemodinámica de cada paciente se puede preferir un medicamento sobre otro.

BIS feedback closed-loop target-controlled infusion of propofol or etomidate in elderly patients with spinal surgery

OBJECTIVE

To investigate the safety of etomidate anesthesia induction combined with Bispectral index (BIS) feedback closed-loop target-controlled infusion of propofol for spinal surgery in elderly patients.

METHODS

Clinical data of 90 elderly patients who underwent elective spinal surgery were retrospectively analyzed. The patients were assigned to an etomidate group (n=48) and a propofol group (n=42) according to the different anesthesia methods. The etomidate group was anesthetized with etomidate combined with BIS feedback closed-loop target-controlled infusion, and the propofol group was anesthetized with closed-loop target-controlled infusion induced by propofol. The mean arterial pressure (MAP) and heart rate (HR) of the two groups were statistically analyzed 5 min after admission to the operating room (T0), the moment of the intubation (T1), 3 min after intubation (T2), 1 min before prone position (T3), 3 min after prone position (T4), the end of suture skin (T5) and 3 min after supine position (T6). In addition, the vasoactive drug application, awakening time, tracheal tube extraction time and incidence of postoperative complications were compared between the two groups.

RESULTS

There were significant changes in MAP and HR from T0 to T1 in both groups (MAP: etomidate group t=5.677, P<0.001, propofol group t=8.093, P<0.001; HR: etomidate group t=2.731, P=0.008, propofol group t=3.967, P<0.001). MAP changes in etomidate group from T0 to T1 were less (MAP: t=4.236, P<0.001; t=2.082, P=0.040), and there was no significant difference in HR between the two groups (P>0.05). There were fewer patients receiving vasoactive drugs in the etomidate group (χ²=5.070, P=0.024), but no significant difference was found in the incidence of complications between the two groups, χ²=3.670, P=0.055.

CONCLUSION

Compared to propofol, the application of etomidate combined with BIS feedback closed-loop target-controlled infusion in spinal surgery anesthesia for elderly patients can keep hemodynamics in a stable state, without affecting postoperative resuscitation, showing high safety, so it is worthy of clinical application.

Evidence-based airway management protocol for a critical ill patient in medical intensive care unit: Systematic review

Background

Airway management outside the theatre is performed either to resuscitate a physiologically unstable critically ill patients or to secure an emergency airway in the absence of essential equipments. It is a life saving procedure for critically ill and injured patients. Delaying in securing airway or awaking the patient is not an option in case of difficult airway in intensive care unit. Therefore, developing and implementation of an evidence-based airway management protocol is important.

Objective

This review was conducted to develop a clear airway management protocol for a critical ill patient in medical intensive care unit.

Methods

After formulating the key questions, scope, and eligibility criteria for the evidences to be included, a comprehensive search strategy of electronic sources was conducted. The literatures were searched using advanced searching methods from data bases and websites to get evidences on airway management of a critical ill patient. Duplication of literatures was avoided by endnote. Screening of literatures was conducted based on the level of significance with proper appraisal. This review was carried out in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2020 statement.

Results

A total of 626 articles were identified from data bases and websites using an electronic search. Of these articles, 95 were removed for duplication and 305 studies were excluded after reviewing their titles and abstracts. At the screening stage, 79 articles were retrieved and evaluated for the eligibility. Finally, 40 studies related to airway management of a critical ill patient in medical ICU were included in this systematic review.

Conclusion

A critical ill patient needs oxygenation and ventilation support. A focused and rapid assessment, with special attention of the airway and hemodynamic status of the critical ill patient is paramount. An appropriate airway management option should be employed to resuscitate or to control an emergency airway of a critical ill patent. This could be non invasive ventilation or invasive airway intervention.

Impact of Ketamine on Analgosedative Consumption in Critically Ill Patients: A Systematic Review and Meta-Analysis

Objective:

The aim of this study was to synthesize evidence available on continuous infusion ketamine versus nonketamine regimens for analgosedation in critically ill patients.

Data sources

A search of MEDLINE, EMBASE, CINAHL, CDSR, and ClinicalTrials.gov was performed from database establishment to November 2021 using the following search terms: critical care, ICU, ketamine, sedation, and anesthesia. All studies included the primary outcome of interest: daily opioid and/or sedative consumption.

Study selection and data extraction

Relevant human studies were considered. Randomized controlled trials (RCT), quasi-experimental studies, and observational cohort studies were eligible. Two reviewers independently screened articles, extracted data, and appraised studies using the Cochrane RoB and ROBINS-I tools.

Data synthesis

A total of 13 RCTs, 5 retrospective, and 1 prospective cohort study were included (2255 participants). The primary analysis of six RCTs demonstrated reduced opioid consumption with ketamine regimens (n = 494 participants, −13.19 µg kg⁻¹ h⁻¹ morphine equivalents, 95% CI −22.10 to −4.28, P = 0.004). No significant difference was observed in sedative consumption, duration of mechanical ventilation (MV), ICU or hospital length of stay (LOS), intracranial pressure, and mortality. Small sample size of studies may have limited ability to detect true differences between groups.

Relevance to patient care and clinical practice

This meta-analysis examining ketamine use in critically ill patients is the first restricting analysis to RCTs and includes up-to-date publication of trials. Findings may guide clinicians in consideration and dosing of ketamine for multimodal analgosedation.

Conclusion

Results suggest ketamine as an adjunct analgosedative has the potential to reduce opioid exposure in postoperative and MV patients in the ICU. More RCTs are required before recommending routine use of ketamine in select populations.

Intraoperative Hypotension Is Associated With Adverse Clinical Outcomes After Noncardiac Surgery

Intraoperative hypotension (IOH) occurs frequently during surgery and may be associated with organ ischemia; however, few multicenter studies report data regarding its associations with adverse postoperative outcomes across varying hemodynamic thresholds. Additionally, no study has evaluated the association between IOH exposure and adverse outcomes among patients by various age groups.

Shock Index as a Predictor of Post-Intubation Hypotension and Cardiac Arrest; A Review of the Current Evidence

Endotracheal intubation is a lifesaving procedure that is performed in various settings within the hospital or even in the pre-hospital field. However, it can result in serious hemodynamic complications, such as post-intubation hypotension (PIH) and cardiac arrest. The most promising predictor of such complications is the shock index (SI), which holds great prognostic value for multiple disorders. On the other hand, most of the studies that have assessed the predictability of the pre-intubation SI have been small and were limited to a particular setting of a single center; thus, the results were not generalizable, and the predictive value vary according to the setting. This review comprehensively assessed the utility of the pre-intubation SI for predicting PIH and post-intubation cardiac arrest by classifying and comparing evidence compiled from various settings, such as pre-hospital settings, emergency departments (EDs), intensive care units (ICUs), and operating rooms (ORs). The vast majority of these studies, conducted in ED and ICU settings, which revealed a significant correlation between an elevated SI and PIH or post-intubation cardiac arrest. The reliability and simplicity of obtaining a pre-intubation SI value are important considerations that encourage the extension of its use to all in-hospital intubations. Further studies are required to assess the predictive value of the SI in the pre-hospital setting.

Community Consultation for Planned Emergent Use Research: Experiences From an Academic Medical Center

BACKGROUND

Emergent use research-research involving human subjects that have a life-threatening medical condition and who are unlikely to provide informed consent-in critical illness is fraught with challenges related to obtaining informed consent. Per federal regulations, to meet criteria to conduct such trials, the investigators have to seek community consultations. Effective ways of obtaining this consultation remains ill-defined.

OBJECTIVE

We sought to describe methods, interpretations, and our experiences of conducting community consultation in a planned emergent use randomized controlled trial.

METHODS

As part of a planned emergent use clinical trial in our study, community consultation consisted of four focus groups sessions with members from the community in which the clinical trial was conducted. Three focus group sessions were conducted with members who had an affiliation to Mayo Clinic, and the other focus group session was conducted with non-Mayo affiliation members. The feedback from the focus group sessions led to the creation of the public notification plan. The public was notified of the trial through community meetings as well as social media.

RESULTS

As compared to community meetings, focus group sessions resulted in greater attendance with more interactive discussions. Moreover, focus group sessions resulted in greater in-depth conversations leading to institutional acceptance of the clinical trial under study.

CONCLUSIONS

Exception from informed consent can be acceptable to the community. Focus groups provided better participation and valuable interactive insight as compared to community meetings in our study. This could serve as a valuable guide for investigators pursuing exception from informed consent in their research studies.

Proposals to Conduct Randomized Controlled Trials Without Informed Consent: a Narrative Review

BACKGROUND

Individual informed consent from all participants is required for most randomized clinical trials (RCTs). However, some exceptions-for example, emergency research-are widely accepted.

METHODS

The literature on various approaches to randomization without consent (RWOC) has never been systematically reviewed. Our goal was to provide a survey and narrative synthesis of published proposals for RWOC. We focused on proposals to randomize at least some participants in a study without first obtaining consent to randomization. This definition included studies that omitted informed consent entirely, omitted informed consent for selected patients (e.g., the control group), obtained informed consent to research but not to randomization, or only obtained informed consent to randomization after random assignment had already occurred. It omitted oral and staged consent processes that still obtain consent to randomization from all participants before randomization occurs.

RESULTS

We identified ten different proposals for RWOC: two variants of cluster randomization, two variants of the Zelen design, consent to postponed information, two-stage randomized consent, cohort multiple RCT, emergency research, prompted optional randomization trials, and low-risk pragmatic RCTs without consent.

CONCLUSION

Of all designs discussed here, only cluster randomized designs and emergency research are routinely used, with the justification that informed consent is infeasible in those settings. Other designs have raised concerns that they do not appropriately respect patient autonomy. Recent proposals have emphasized the importance for RWOC of demonstrating such respect through systematic patient engagement, transparency, and accountability, potentially in the context of learning health care systems.

Optimizing Outcomes for Mechanically Ventilated Patients in an Era of Endovascular Acute Ischemic Stroke Therapy

Endovascular mechanical thrombectomy is a new standard of care for acute ischemic stroke (AIS). The majority of these patients receive mechanical ventilation (MV), which has been associated with poor outcomes. The implication of this is significant, as most neurointerventionalists prefer general compared to local anesthesia during the procedure. Consequences of hemodynamic and respiratory perturbations during general anesthesia and MV are thought to contribute significantly to the poor outcomes that are encountered. In this review, we first describe the unique risks associated with MV in the specific context of AIS and then discuss evidence of brain goal-directed approaches that may mitigate these risks. These strategies include an individualized approach to hemodynamic parameters (eg, adherence to a minimum blood pressure goal and adequate volume resuscitation), respiratory parameters (eg, arterial carbon dioxide optimization), and the use of ventilator settings that optimize neurological outcomes (eg, arterial oxygen optimization).

Etomidate: to use or not to use for endotracheal intubation in the critically ill?

Endotracheal intubation is frequently performed in the intensive care unit (ICU). It can be life-saving for many patients who present with acute respiratory distress. However, it is equally associated with complications that may lead to unwanted effects in this patient population. According to the literature, the rate of complications associated with endotracheal intubation is much higher in an environment such as the ICU as compared to other, more controlled environments (i.e., operating room). Thus, the conduct of performing such a procedure needs to be accomplished with the utmost care. To facilitate establishment of the breathing tube, sedation is routinely administered. Given the tenuous hemodynamic status of the critically ill, etomidate was frequently chosen to blunt further decreases in blood pressure and/or heart rate. Recently however, reports have demonstrated a possible association with the use of etomidate for endotracheal intubation and mortality in the critically ill. In addition, this association seems to be predominantly in patients diagnosed with sepsis. As a result, some have advocated against the use of this medication in septic patients. Due to the negative associations identified with etomidate and mortality, several investigators have evaluated potential alternatives to this solution (e.g., ketamine and ketamine-propofol admixture). These studies have shown promise. However, despite the evidence against using etomidate for endotracheal intubation, other studies have demonstrated no such association. This leaves the critical care clinician with uncertainty regarding the best sedative to administer in this patient population. The following editorial discusses current evidence regarding etomidate use for endotracheal intubation and mortality. In particular, we highlight a recent article with the largest population to date that found no association between etomidate and mortality in the critically ill and illustrate important findings that the reader should be aware of regarding this article.

Ketamine/propofol admixture (ketofol) at induction in the critically ill against etomidate (KEEP PACE trial): study protocol for a randomized controlled trial

BACKGROUND

Endotracheal intubation (ETI) is commonly performed as a life-saving procedure in the intensive care unit (ICU). It is often associated with significant hemodynamic perturbations and can severely impact the outcome of ICU patients. Etomidate is often chosen by many critical care providers for the patients who are hypotensive because of its superior hemodynamic profile compared to other induction medications. However, recent evidence has raised concerns about the increased incidence of adrenal insufficiency and mortality associated with etomidate use. A combination of ketamine and propofol (known as ketofol) has been studied in various settings as an alternative induction agent. In recent years, studies have shown that this combination may provide adequate sedation while maintaining hemodynamic stability, based on the balancing of the hemodynamic effects of these two individual agents. We hypothesized that ketofol may offer a valuable alternative to etomidate in critically ill patients with or without hemodynamic instability.

METHODS/DESIGN

A randomized controlled parallel-group clinical trial of adult critically ill patients admitted to either a medical or surgical ICU at Mayo Clinic in Rochester, MN will be conducted. As part of planned emergency research, informed consent will be waived after appropriate community consultation and notification. Patients undergoing urgent or emergent ETI will receive either etomidate or a 1:1 admixture of ketamine and propofol (ketofol). The primary outcome will be hemodynamic instability during the first 15 minutes following drug administration. Secondary outcomes will include ICU length of stay, mortality, adrenal function, ventilator-free days and vasoactive medication use, among others. The planned sample size is 160 total patients.

DISCUSSION

The overall goal of this trial is to assess the hemodynamic consequences of a ketamine-propofol combination used in critically ill patients undergoing urgent or emergent ETI compared to etomidate, a medication with an established hemodynamic profile. The trial will address a crucial gap in the literature regarding the optimal induction agent for ETI in patients that may have potential or established hemodynamic instability. Greater experience with planned emergency research will, hopefully, pave the way for future prospective randomized clinical trials in the critically ill population.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT02105415. 31 March 2014.