Do ketamine infusions increase delirium? This study suggests that they do, but we need to look into this a bit more deeply... read at the abstract and see what you think! #Rantorial 1/8
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To date, one RCT found that ketamine ⬇️ delirium in the ICU. The current study is a multivariable, associative secondary analysis of a cohort study. It's unclear what an associative study is supposed to *add* to an RCT. So the entire justification for this study is dubious. 2/8
The primary result was that ketamine correlated with increased rates of delirium (albeit barely, p=0.04). Opioids and benzos correlated MUCH more strongly with delirium. This could actually *support* the use of ketamine as an opioid-sparing agent 😛. 3/8
If we dig deeper, we find that delirious patients treated with ketamine received doses well *above* the range typically used for analgesia (0.1-0.3 mg/kg/hr). So the problem may not be ketamine itself, but rather sub-dissociative dosing (which can definitely cause delirium). 4/8
I would disagree with both of these highlighted statements. IMHO:
😵💫 Psychomimetic side effects can start to emerge around ~0.25 mg/kg/hr-ish (with **huge** variability between pts)
😵💫 Psychomimetic effects are *widely* variable (including sedation, euphoria, agitated delirium)
😵💫 Psychomimetic side effects can start to emerge around ~0.25 mg/kg/hr-ish (with **huge** variability between pts)
😵💫 Psychomimetic effects are *widely* variable (including sedation, euphoria, agitated delirium)
So, in summary, we have a cohort study which weakly associated hefty ketamine doses with delirium. In comparison, opioids and benzodiazepines had much *stronger* associations with delirium. What does this mean??? (6/8)
Your guess is as good as mine. There are a ton of methodological problems with the study, including many not yet mentioned (eg, patients receiving scheduled antipsychotics were defined as having "delirium"). The study doesn't add meaningfully to available scientific literature.
Ketamine gtts are great, but not perfect. You need to pay attention to the dosing & monitor carefully for adverse events. Using lower doses & co-administration with propofol or dexmed may help maximize benefit/risk ratio. More RCTs are needed. #KetaDex
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