NYMC Faculty Publications

Ketamine Use in the Intubation of Critically Ill Children With Neurological Indications: A Multicenter Retrospective Analysis

Mervin V. Loi, Department of Pediatric Subspecialties, Children's Intensive Care Unit, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, Singapore. mervin.loi.v.t@singhealth.com.sg.
Jan Hau Lee, Department of Pediatric Subspecialties, Children's Intensive Care Unit, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, Singapore.
Jimmy W. Huh, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
Palen Mallory, Department of Pediatric Critical Care Medicine, Duke Children's Hospital and Health Center, Durham, NC, USA.
Natalie Napolitano, Respiratory Therapy Department, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
Justine Shults, Department of Biostatistics, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
Conrad Krawiec, Departments of Pediatric Critical Care Medicine and Pediatrics, Penn State Health Children's Hospital, Hershey, PA, USA.
Asha Shenoi, Department of Pediatrics, University of Kentucky, Lexington, KY, USA.
Lee Polikoff, Department of Pediatric Critical Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA.
Awni Al-Subu, Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Wisconsin, School of Medicine and Public Health, Madison, WI, USA.
Ronald Sanders, Division of Critical Care Medicine, Arkansas Children's Hospital, Little Rock, AR, USA.
Megan Toal, Division of Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA.
Aline Branca, Department of Pediatric Critical Care Medicine, Phoenix Children's Hospital, Phoenix, AZ, USA.
Lily Glater-Welt, Department of Pediatric Critical Care Medicine, Cohen Children's Medical Center of New York, New Hyde Park, NY, USA.
Laurence Ducharme-Crevier, Division of Pediatric Critical Care Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Canada.
Ryan Breuer, Division of Critical Care Medicine, Department of Pediatrics, John R. Oishei Children's Hospital, Buffalo, NY, USA.
Simon Parsons, Section of Critical Care Medicine, Alberta Children's Hospital, Calgary, Canada.
Ilana Harwayne-Gidansky, Division of Pediatric Critical Care Medicine, Department of Pediatrics, Albany Medical College, Albany, NY, USA.
Serena Kelly, Division of Pediatric Critical Care Medicine, Department of Pediatrics, Oregon Health and Science University Doernbecher Children's Hospital, Portland, OR, USA.
Makoto Motomura, Division of Pediatric Critical Care Medicine, Aichi Children's Health and Medical Center, Aichi, Japan.
Kelsey Gladen, Department of Pediatric Critical Care Medicine, Phoenix Children's Hospital, Phoenix, AZ, USA.
Matthew G. Pinto, New York Medical CollegeFollow
John Giuliano, Section of Pediatric Critical Care, Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA.
Gokul Bysani, Department of Pediatrics, Medical City Children's Hospital, Dallas, TX, USA.
John Berkenbosch, Department of Pediatric Critical Care, University of Louisville and Norton Children's Hospital, Louisville, KY, USA.
Katherine Biagas, Division of Pediatric Critical Care Medicine, Department of Pediatrics, Renaissance School of Medicine at Stony, Brook University, Stony Brook, NY, USA.
Kyle Rehder, Division of Pediatric Critical Care, Duke Children's Hospital, Durham, NC, USA.
Mioko Kasagi, Division of Pediatric Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan.
Anthony Lee, Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, USA.
Philipp Jung, Department of Pediatrics, University Hospital Schleswig-Holstein, Campus Luebeck, Luebeck, Germany.
Rakshay Shetty, Pediatric Intensive Care, Rainbow Children's Hospital, Bengaluru, India.
Vinay Nadkarni, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.

Author Type(s)

Faculty

DOI

10.1007/s12028-023-01734-0

Journal Title

Neurocritical Care

First Page

205

Last Page

214

Document Type

Article

Publication Date

2-1-2024

Department

Pediatrics

Abstract

BACKGROUND: Ketamine has traditionally been avoided for tracheal intubations (TIs) in patients with acute neurological conditions. We evaluate its current usage pattern in these patients and any associated adverse events. METHODS: We conducted a retrospective observational cohort study of critically ill children undergoing TI for neurological indications in 53 international pediatric intensive care units and emergency departments. We screened all intubations from 2014 to 2020 entered into the multicenter National Emergency Airway Registry for Children (NEAR4KIDS) registry database. Patients were included if they were under the age of 18 years and underwent TI for a primary neurological indication. Usage patterns and reported periprocedural composite adverse outcomes (hypoxemia < 80%, hypotension/hypertension, cardiac arrest, and dysrhythmia) were noted. RESULTS: Of 21,562 TIs, 2,073 (9.6%) were performed for a primary neurological indication, including 190 for traumatic brain injury/trauma. Patients received ketamine in 495 TIs (23.9%), which increased from 10% in 2014 to 41% in 2020 (p < 0.001). Ketamine use was associated with a coindication of respiratory failure, difficult airway history, and use of vagolytic agents, apneic oxygenation, and video laryngoscopy. Composite adverse outcomes were reported in 289 (13.9%) Tis and were more common in the ketamine group (17.0% vs. 13.0%, p = 0.026). After adjusting for location, patient age and codiagnoses, the presence of respiratory failure and shock, difficult airway history, provider demographics, intubating device, and the use of apneic oxygenation, vagolytic agents, and neuromuscular blockade, ketamine use was not significantly associated with increased composite adverse outcomes (adjusted odds ratio 1.34, 95% confidence interval CI 0.99-1.81, p = 0.057). This paucity of association remained even when only neurotrauma intubations were considered (10.6% vs. 7.7%, p = 0.528). CONCLUSIONS: This retrospective cohort study did not demonstrate an association between procedural ketamine use and increased risk of peri-intubation hypoxemia and hemodynamic instability in patients intubated for neurological indications.

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