Perspectives of Ketamine Use in COVID-19 Patients

Emerging Viral Infections (ZIKV, SARS-CoV-2, and MPXV) and Depression: Ketamine and (S, R)-Ketamine as Promising Antidepressants

Emerging viral pathogens, newly reported or rapidly evolving viruses, are a significant public health concern worldwide. Beyond their characteristic clinical presentations, emerging viruses, such as monkeypox virus (MPXV) and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), have been increasingly implicated in the development of various neuropsychiatric complications including depression, mainly due to their ability to induce neuroinflammation, immune dysfunction, and neurotransmitter imbalances. Depression is a common mental health condition characterised by continuous low mood or sadness, pessimism, anxiety, and even a tendency to suicide as the main symptoms. Post viral depression commonly shows significant challenges, as traditional antidepressant agents exhibit suboptimal efficacy and prolonged onset of action. Regarding this, ketamine and its enantiomers, S-ketamine and R-ketamine, have recently received increasing attention as potential options in light of their potent and effective antidepressant properties. The present review describes the underlying pathophysiological mechanisms of depression associated with emerging viruses, highlighting the role of neuroinflammation and disturbances inneurotransmitter systems. It also discusses the antidepressant mechanisms of ketamine and its enantiomers, the current clinical evidence demonstrating their effectiveness and safety, especially in the case of treatment-resistant depression, and their growing relevance for mood complications linked to emerging viral infections, including depression. Although preliminary reports propose effectiveness, additional studies are needed to present optimal treatment strategies, long-term safety, and incorporation into clinical practice. Addressing these challenges will be critical for optimising the effectiveness of ketamine- and (S, R)-ketamine-containing therapeutic protocols in treating depression linked to emerging viral infections.

Experiential Learning with Ketamine: A Mixed-Methods Exploratory Study on Prescription and Perception

Background

Incorporating unfamiliar therapies into practice requires effective longitudinal learning and the optimal way to achieve this is debated. Though not a novel therapy, ketamine in critical care has a paucity of data and variable acceptance, with limited research describing intensivist perceptions and utilization. The Coronavirus-19 pandemic presented a particular crisis where providers rapidly adapted analgosedation strategies to achieve prolonged, deep sedation due to a surge of severe acute respiratory distress syndrome (ARDS).

Question

How does clinical experience with ketamine impact the perception and attitude of clinicians toward this therapy?

Methods

We conducted a mixed-methods study using quantitative ketamine prescription data and qualitative focus group data. We analyzed prescription patterns of ketamine in a tertiary academic ICU during two different time points: pre-COVID-19 (March 1-June 30, 2019) and during the COVID-19 surge (March 1-June 30, 2020). Two focus groups (FG) of critical care attendings were held, and data were analyzed using the Framework Method for content analysis.

Results

Four-hundred forty-six medical ICU patients were mechanically ventilated (195 pre-COVID-19 and 251 during COVID-19). The COVID-19 population was more likely to receive ketamine (81[32.3%] vs 4 [2.1%], p < 0.001). Thirteen respondents participated across two FG sessions (Pre-COVID = 8, Post-COVID=5). The most prevalent attitude among our respondents was discomfort, with three key themes identified as follows: 1) lack of evidence regarding ketamine, 2) lack of personal experience, and 3) desire for more education and protocols.

Conclusion

Despite a substantial increase in ketamine prescription during COVID-19, intensivists continued to feel discomfort with utilization. Factors contributing to this discomfort include a lack of evidence, a lack of experience, and a desire for more education and protocols. Increase in experience with ketamine alone was not sufficient to minimize provider discomfort. These findings should inform future curricula and call for process improvement to optimize continuing education.

Ketamine-based Sedation Use in Mechanically Ventilated Critically Ill Patients with COVID-19: A Multicenter Cohort Study

Backgrounds

Ketamine possesses analgesia, anti-inflammation, anticonvulsant, and neuroprotection properties. However, the evidence that supports its use in mechanically ventilated critically ill patients with COVID-19 is insufficient. The study's goal was to assess ketamine's effectiveness and safety in critically ill, mechanically ventilated (MV) patients with COVID-19.

Methods

Adult critically ill patients with COVID-19 were included in a multicenter retrospective-prospective cohort study. Patients admitted between March 1, 2020, and July 31, 2021, to five ICUs in Saudi Arabia were included. Eligible patients who required MV within 24 hours of ICU admission were divided into two sub-cohort groups based on their use of ketamine (Control vs. Ketamine). The primary outcome was the length of stay (LOS) in the hospital. P/F ratio differences, lactic acid normalization, MV duration, and mortality were considered secondary outcomes. Propensity score (PS) matching was used (1:2 ratio) based on the selected criteria.

Results

In total, 1,130 patients met the eligibility criteria. Among these, 1036 patients (91.7 %) were in the control group, whereas 94 patients (8.3 %) received ketamine. The total number of patients after PS matching, was 264 patients, including 88 patients (33.3 %) who received ketamine. The ketamine group's LOS was significantly lower (beta coefficient (95 % CI): -0.26 (-0.45, -0.07), P = 0.008). Furthermore, the PaO2/FiO2 ratio significantly improved 24 hours after the start of ketamine treatment compared to the pre-treatment period (6 hours) (124.9 (92.1, 184.5) vs. 106 (73.1, 129.3; P = 0.002). Additionally, the ketamine group had a substantially shorter mean time for lactic acid normalization (beta coefficient (95 % CI): -1.55 (-2.42, -0.69), P 0.01). However, there were no significant differences in the duration of MV or mortality.

Conclusions

Ketamine-based sedation was associated with lower hospital LOS and faster lactic acid normalization but no mortality benefits in critically ill patients with COVID-19. Thus, larger prospective studies are recommended to assess the safety and effectiveness of ketamine as a sedative in critically ill adult patients.

Pain in critically ill COVID-19 patients: An Italian retrospective study

We retrospectively analyzed the data from patients admitted to the intensive care unit (ICU) of the Hospital of L'Aquila during the first and second waves of pandemic to identify pain related to COVID-19. Pain was evaluated by using the Numerical Rating Scale, and the assessment for neuropathic disturbances of pain was performed with von Frey's hair and Lindblom tests. Pain increased significantly during hospitalization (from 48% at hospital admission to 94.3% at ICU discharge). Female patients were affected by somatic pain in 32.8% of the cases and by somatic pain and pain with neuropathic features (NFs) in 23.5% of the cases, during the ICU stay. Somatic pain and pain with NFs affected more frequently patients with cardiological and respiratory comorbidities. Patients treated with continuous positive airway pressure via helmet had a higher frequency of somatic pain and pain with neuropathic disturbances (84 and 74%, respectively). The frequency of somatic pain and pain with neuropathic disturbances was lower in patients sedated with propofol combined with ketamine. Females have been associated with a higher risk of somatic pain and pain with NFs. Patients with cardiological and respiratory comorbidities undergoing noninvasive ventilation had higher levels of pain. As conclusion, ketamine may reduce the promotion or the worsening of pain in COVID-19 patients.

Ketamine inhibits TNF-α-induced cecal damage by enhancing RIP1 ubiquitination to attenuate lethal SIRS

Systemic inflammatory response syndrome (SIRS) is a sepsis-associated inflammatory state and a self-defense mechanism against specific and nonspecific stimuli. Ketamine influences many key processes that are altered during sepsis. However, the underlying mechanisms remain incompletely understood. In this study, TNF-α-treated mice, as well as HT-29 and L929 cell models, were applied to characterize TNF-α-induced systemic and local cecal tissue inflammatory responses. Behavioral, biochemical, histological, and molecular biological approaches were applied to illustrate the related processes. Mice with TNF-α-induced SIRS showed systemic and local cecal tissue inflammatory responses, as indicated by increased levels of high mobility group box 1 protein (HMGB1), chemokines (C-X-C motif) ligand 10 (CXCL10), interleukin-6 (IL-6), and IL-10, as well as high mortality. Ketamine pretreatment alleviated death rates, symptoms, and the production of inflammatory cytokines induced by TNF-α in mice. Moreover, ketamine also protected the mice from TNF-α-induced cecal damage by suppressing the phosphorylation of receptor-interacting serine/threonine-protein kinase 3 (RIP3) and mixed lineage kinase domain-like protein (MLKL). In addition, our results showed that ketamine efficiently inhibited TNF-α-induced necroptosis in HT-29 and L929 cells. Furthermore, we explored the mechanism using different L929 cell lines. The results displayed that ketamine inhibited TNF-α-induced necroptosis by enhancing RIP1 ubiquitination and reducing the RIP1-RIP3 and RIP3-MLKL interactions, as well as the formation of necrosomes. Thus, our study may provide a new theoretical and experimental basis for treating diseases characterized by SIRS-associated inflammatory factor storms. Moreover, our exploration may provide potential molecular mechanisms and targets for therapeutic intervention and clinical application of ketamine.

SARS-CoV-2 Psychiatric Sequelae: A Review of Neuroendocrine Mechanisms and Therapeutic Strategies

From the earliest days of the coronavirus disease 2019 (COVID-19) pandemic, there have been reports of significant neurological and psychological symptoms following Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection. This narrative review is designed to examine the potential psychoneuroendocrine pathogenic mechanisms by which SARS-CoV-2 elicits psychiatric sequelae as well as to posit potential pharmacologic strategies to address and reverse these pathologies. Following a brief overview of neurological and psychological sequelae from previous viral pandemics, we address mechanisms by which SARS-CoV-2 could enter or otherwise elicit changes in the CNS. We then examine the hypothesis that COVID-19-induced psychiatric disorders result from challenges to the neuroendocrine system, in particular the hypothalamic-pituitary-adrenal stress axis and monoamine synthesis, physiological mechanisms that are only further enhanced by the pandemic-induced social environment of fear, isolation, and socioeconomic pressure. Finally, we evaluate several FDA-approved therapeutics in the context of COVID-19-induced psychoneuroendocrine disorders.

The pain in the Emergency Department: Choosing and treating wisely before and during the COVID-19 era

Pain is a frequent reason for referral to the Emergency Department (ED). Adequate management of pain is a moral and ethical imperative. If not correctly treated, acute pain can cause physical and psychological complications, and become chronic with severe consequences such as anxiety, depression, and social isolation. As consequence, emergency clinicians should treat pain as soon as possible, avoiding delays even in case of acute abdominal pain. Pain management is particularly complex in the elderly and emergency clinicians should always consider AGS Beers criteria ® to avoid inappropriate medications, severe side-effects, and drug-drug interactions. Pain is also a common cause of delirium in older patients. The SARS CoV-2 infection not only can cause acute pain, but also exacerbate chronic pain, particularly in the elderly, who are at high risk to be infected. Looking at all this evidence, emergency clinicians should treat pain with different strategies according to their experience and cultural background, making the right choice for each patient. This work is a critical review of the pain management in the ED, with a particular attention on the effects of COVID-19 in the EDs. We conducted a systematic search of the following databases: PubMed, Google Scholar, Science Direct, Medline from 2000 to 2020, using the keywords of “pain”, “emergency”, “COVID19”, “elderly”, “palliative care”, “ketamine”, “dexmedetomidine”, and “post-traumatic stress disorder”. The aim of this review is to help emergency clinicians to correctly manage pain in the ED with a new point of view regarding the pain management in COVID-19 patients.

Harnessing the Neurobiology of Resilience to Protect the Mental Well-Being of Healthcare Workers During the COVID-19 Pandemic

Healthcare workers are at a high risk of psychological morbidity in the face of the COVID-19 pandemic. However, there is significant variability in the impact of this crisis on individual healthcare workers, which can be best explained through an appreciation of the construct of resilience. Broadly speaking, resilience refers to the ability to successfully adapt to stressful or traumatic events, and thus plays a key role in determining mental health outcomes following exposure to such events. A proper understanding of resilience is vital in enabling a shift from a reactive to a proactive approach for protecting and promoting the mental well-being of healthcare workers. Research in the past decade has identified six areas that provide promising leads in understanding the biological basis of individual variations in resilience. These are: (1) the key role played by the monoamines noradrenaline and serotonin, (2) the centrality of the hypothalamic-pituitary-adrenal axis in influencing stress vulnerability and resilience, (3) the intimate links between the immune system and stress sensitivity, (4) the role of epigenetic modulation of gene expression in influencing the stress response, (5) the role played by certain neuropeptides as a natural “brake” mechanism in the face of stress, and (6) the neurobiological mechanisms by which environmental factors, such as exercise, diet, and social support, influence resilience to subsequent life events. Though much of this research is still in its early stages, it has already provided valuable information on which strategies – including dietary changes, lifestyle modification, environmental modification, psychosocial interventions, and even pharmacological treatments – may prove to be useful in fostering resilience in individuals and groups. This paper examines the above evidence more closely, with a specific focus on the challenges faced by healthcare workers during the COVID-19 pandemic, and provides suggestions regarding how it may be translated into real-world interventions, as well as how the more tentative hypotheses advanced in this field may be tested during this critical period.