NM-367
Analysis of adverse outcomes in pediatric patients receiving subanesthetic ketamine infusions in non-intensive care units
1Masaracchia M, 2Lee J, 1Fernandez P
1Children's Hospital Colorado, Aurora, CO, USA; 2University of Colorado School of Medicine, Aurora, CO, USA
Background:
Sub-anesthetic ketamine infusions are often employed as adjuvants for treating perioperative pain or used as the primary source of non-opioid based analgesia. Although high doses of ketamine have been associated with adverse effects (nervous system excitation, sedation, hypertension, tachycardia), sub-hypnotic infusions (<0.3mg/kg/hr) have a reasonably favorable margin of safety. However, because of these concerns, many hospitals restrict low-dose infusions to units that can administer higher levels of care (ICU). This can be both cost-prohibitive and limits access to an otherwise useful treatment. Our institution has been administering low dose infusions on unmonitored pediatric units for several years. We believe we have established what is effective care in doing so; however, to date, adverse outcomes have not been quantified in pediatric patients.
Methods:
Following IRB approval, we analyzed data on patients ages 0-21 years who received a low-dose ketamine infusion (<0.3mg/kg/hr) outside of the ICU between 2012 and 2017. We queried our hospital’s electronic medical record to extract information about demographics, and specific quality metrics [acute vs. chronic pain, maximum infusion rates, duration of infusion, average daily morphine equivalents (mg/kg) and VAS pain scores pre- and post-infusion]. All adverse events [sedation, neurologic excitability, hemodynamic changes, rapid response team (RRT) triggers], and escalations in level of care (from unmonitored to monitored units) were captured.
Results:
164 patients received 250 sub-hypnotic ketamine infusions. Of these infusions, 181 were on patients with ASA physical status >3 (72.4%). The majority were administered for chronic pain exacerbations (n=190, 76%), while fewer were utilized for acute postoperative pain control (n=60). The average maximum infusion dose was 0.205 mg/kg/hr. Mean infusion duration was 97 hours. Overall, there was no change in total daily oral morphine equivalents (mg/kg); however, when analyzing infusions for acute postoperative pain only, opioid use was significantly reduced (1.48 to 1.0, p<0.0001). Additionally, there was a reduction in highest VAS for all patients (8.9 to 6.37).
Although there were 64 incidences of some side effect [sedation (13.5%); neurologic excitability (10.8%); hemodynamic changes (0.8%)], no patients required termination of the infusion as a result. Furthermore, 3 RRTs were noted over the 5-year period. Two instances reflected tachycardia that could have been attributed to other causes, and one patient required a PICU admission for a more rapid titration of ketamine in the setting of end-of-life care.
Discussion:
Low dose ketamine infusions are useful adjuncts in mitigating pain; however, many institutions restrict use to monitored units because of potential side effects. Our 5-year experience highlights a minimal side effect profile, with no attributable elevations in care or adverse events in pediatric patients. Based on our results, we anticipate an increase in the utilization of ketamine infusions on the wards.
References:
Sheehy KA, et al. Subanesthetic ketamine for pain management in hospitalized children, adolescents, and young adults: a single-center cohort study. J Pain Res. 2017. 10:787-795.
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