Anesth Analg 2004;99:893-895
© 2004 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000133002.42742.92
CRITICAL CARE AND TRAUMA
Ketamine for Long-Term Sedation and Analgesia of a Burn Patient
Thomas Edrich, MD PhD*,
Andrew D. Friedrich, MD*,
Holger K. Eltzschig, MD*,
, and
Thomas W. Felbinger, MD*
*Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
Department of Anesthesiology and Intensive Care Medicine, Tübingen University Hospital, Tübingen, Germany
Address correspondence and reprint requests to Thomas W. Felbinger, MD, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115. Address e-mail to tfelbinger{at}partners.org
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Abstract
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We present a case in which ketamine was used for long-term sedation and analgesia of a burn patient. Under escalating opiate dosages, the patient had developed persistent ileus as well as abdominal distension that caused respiratory compromise, without receiving sufficient analgesia. The opiate-sparing effect of the continuous ketamine infusion was more than 90%. The ileus resolved within 24 h. The quality of sedation also changed favorably. There were no obvious adverse effects of ketamine.
IMPLICATIONS: The care of critically ill burn patients can be challenging because of a rapidly escalating tolerance for opioids. In this case, a large-dose ketamine infusion was useful for both analgesia and sedation. It significantly reduced the opioid requirement and overcame the adverse effects of opioids.
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Introduction
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Selection of sedatives and analgesics for patients in the intensive care unit (ICU) varies widely and most frequently includes morphine, lorazepam, diazepam, and haloperidol (1). Ketamine, an antagonist at the N-methyl-D-aspartate receptor that combines strong analgesic and sedative effects, is used less often (2). We report a case in which ketamine was useful for long-term sedation and analgesia of a burn patient, reducing opiate requirements considerably and thereby minimizing their adverse effects.
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Case Report
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A 28-yr-old man fell forward into a bonfire and sustained second- to third-degree burns to the face and neck (26% body-surface area). After tracheal intubation and admission to the ICU, he underwent several skin graft procedures. Progressively larger dosages of sedatives and opiates were required to control pain and agitation (Figs. 1 and 2). Because several different opiates were being administered simultaneously, they were converted to morphine-equivalent doses for better clarity (3). On the 13th ICU day, the sedative and analgesic regimen included midazolam 20 mg/h IV, diazepam 900 mg/d via jejunostomy tube, propofol 300 mg/h IV, hydromorphone 30 mg/h IV, and fentanyl 700 µg/h IV. Adjuvant medications included clonidine and olanzapine. However, the patient was still not sedated to comfort levels, as evidenced by spontaneous intermittent bursts of agitation and movements threatening the integrity of the skin grafts (Ramsay = 1, Riker Sedation-Agitation Scale; SAS = 7). In addition, he developed paralytic bowel obstruction with severe abdominal distension and mechanical impairment of breathing, despite intensive therapy with laxatives and prokinetic drugs. At this time, a ketamine infusion was started at 2.7 mg · kg–1 · h–1. Within 12 h, the opiates could be titrated down from 200–270 mg/h to 4–17 mg/h (morphine equivalents) while the sedatives were also reduced (Figs. 1 and 2). The ileus resolved the following day. The patient’s level of sedation was more constant (Ramsay 3, SAS 3–4). Over the following weeks, he remained in the ICU because he required frequent extensive graft revisions. He demonstrated acceptable control of pain (visual analog scale 3 of 10) and denied having had hallucinations or vivid dreams. On the 37th ICU day, the ketamine could be tapered over 2 days. Transfer to a rehabilitation facility was possible on the 66th hospital day.
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Figure 1. Analgesic medication administered during the hospital stay. The different opiates being administered simultaneously were converted to their morphine equivalents. ICU = intensive care unit.
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Figure 2. Sedative medications that were administered during the hospital stay. ICU = intensive care unit.
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Discussion
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We report the use of ketamine for long-term analgesia and sedation of a burn patient. Increasing tolerance to opioids and benzodiazepines often complicates the management of burn patients (4,5). This may be due to modulation (6), downregulation, arrestin function (7), or endocytosis of receptors (8). Cross-tolerance to opiates can also be induced by alcohol (9). Although no history of substance abuse could be elicited in this case, it may have been an unrecognized contributor to the patient’s large narcotic requirement. Ketamine has been shown to attenuate the development of acute tolerance to opioids in an animal model (10). Furthermore, ketamine, when compared with morphine, demonstrated better analgesia after mild burn injury under experimental conditions (10): ketamine significantly reduced secondary hyperalgesia and windup pain, possibly because of a reduction of central hyperexcitability via the N-methyl-D-aspartate receptor.
In this case, a patient with severe burns received a large-dose ketamine infusion for 24 days and experienced a reduction of his opiate requirement by more than 90%. Both the patient’s assessment of his discomfort and the ICU team’s evaluation of his behavior indicated improved pain control. The ketamine dosage (2.3–2.7 mg · kg–1 · h–1) was chosen on the basis of studies investigating long-term ICU sedation for nonburn patients (11,12). Although ketamine has often been used for short procedures involving burn injuries (13), data on long-term ketamine infusions in burn patients are very limited. In a 14-month-old child with severe burns, a 31-day infusion of ketamine 1.3 mg · kg–1 · h–1 did not result in an opiate-sparing effect (14). However, studies involving postsurgical nonburn patients receiving patient-controlled analgesia with opiates have reported up to a 50% opiate-sparing effect when small doses of ketamine were added (<0.2 mg · kg–1 · h–1) (15–17).
During the ketamine infusion, an improved quality of sedation also occurred. Consequently, the amount of sedative medication could be reduced considerably without jeopardizing the safety of the skin grafts. Ketamine reduces rapid reactions to stimuli, likely because of its actions on the limbic system and the cortex (18), and can attenuate the emotional response and suffering experienced by the patient (dissociative state) (16).
After initiation of the ketamine infusion and reduction of opiate medications, the severe paralytic ileus resolved. In principle, delayed gastrointestinal transit is mediated through the µ-opiate receptor and can become the limiting factor in opiate use, thereby compromising pain control (19). Ketamine, however, does not inhibit bowel motility (20) and was shown to be associated with fewer feeding complications than the use of opiates for postoperative pain management (21).
In summary, ketamine may improve the quality of analgesia and sedation in patients with severe burn injury, with a reduction of opioid requirements and opiate-associated side effects.
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References
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Accepted for publication March 16, 2004.
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Abstract
Introduction
