Resuscitation Group / ACLSpdx

07/30/2025

Identifying Respiratory Failure – Michael Christie
https://www.resuscitationgroup.com/blog/63/identifying-respiratory-failure/

Identifying respiratory failure in patients involves careful analysis of clinical symptoms, diagnostic tests, and consideration of underlying conditions. The clinical presentation commonly includes signs of hypoxia or hypercapnia, such as dyspnea, tachypnea, and altered mental status Nitu & Eigen, 2009). Initially, the use of quantitative waveform capnography (EtCO2) and pulse oximetry (SpO2) can assist in the early identification of respiratory failure, through the observation of EtCO2 raising, Respiratory Rate Rising, and SpO2 falling. Measurements of arterial blood gases (ABGs) are useful for confirming respiratory failure, typically indicating hypoxemia (PaO2 < 60 mmHg) or hypercapnia (PaCO2 > 50 mmHg) following initial management goals (Nitu & Eigen, 2009; Hasan et al., 2020).

In patients with underlying conditions, such as myasthenia gravis (MG) or chronic obstructive pulmonary disease (COPD), the identification of respiratory failure becomes more nuanced due to the complexity of these diseases.

In COVID-19 patients, two-thirds have been reported to develop respiratory failure, particularly associated with pneumonia and significant inflammatory responses (Ohuabunwa et al., 2022; . This underscores the importance of comprehensive assessment in older adults with viral infections, where specific characteristics can predict the likelihood of respiratory failure and related mortality (Ohuabunwa et al., 2022). The role of noninvasive ventilation is becoming increasingly acknowledged as an effective strategy to manage acute respiratory failure in these populations, significantly reducing mortality in severe cases (Pavliša, 2023; Bhurayanontachai, 2021).

Myasthenia gravis is another condition that demands attention when considering respiratory failure. Respiratory muscle weakness can be life-threatening, with individuals potentially experiencing myasthenic crises that necessitate mechanical ventilation (Shiozumi et al., 2023). It is significant that respiratory failure often manifests as a presenting symptom in MG, particularly in cases involving muscle-specific kinase (MuSK) antibodies, emphasizing the need for vigilance in recognizing these symptoms early (Shiozumi et al., 2023; Wang et al., 2024). Reports suggest that myasthenic crises may occur in approximately 7.7% of MG patients, complicating their clinical management (Shiozumi et al., 2023).

Moreover, patients with relapsing polychondritis may present with respiratory failure during sedation due to underlying muscle weakness affecting ventilation (Lee et al., 2022). In advanced COPD, chronic daytime hypercapnia can precede significant respiratory events, and nocturnal hypoventilation, often linked to sleep-disordered breathing, can contribute to ongoing respiratory insufficiency (Lee et al., 2022). A thorough understanding of these diverse presentations across various underlying conditions is crucial in identifying and appropriately managing respiratory failure in patients.

In summary, the identification of respiratory failure relies on a combination of clinical assessment, laboratory analysis, and an understanding of the patient's medical history and coexisting conditions. The integration of these factors is essential for timely intervention and improved patient outcomes in respiratory distress scenarios, particularly in conditions known to predispose individuals to acute respiratory failure, such as COVID-19, MG, and COPD (Ohuabunwa et al., 2022; Shiozumi et al., 2023; Lee et al., 2022; Nitu & Eigen, 2009).

References:
Adler, D. and Janssens, J. (2018). The pathophysiology of respiratory failure: control of breathing, respiratory load, and muscle capacity. Respiration, 97(2), 93-104.
https://doi.org/10.1159/000494063
Ambrosino, N., Casaburi, R., Chetta, A., Clini, E., Donner, C., Dreher, M., … & ZuWallack, R. (2015). 8th international conference on management and rehabilitation of chronic respiratory failure: the long summaries – part 3. Multidisciplinary Respiratory Medicine, 10(1).
https://doi.org/10.1186/s40248-015-0028-x
Balbay, Ö. (2019). Noninvasive mechanical ventilation in acute hypoxemic respiratory failure. Düzce Tıp Fakültesi Dergisi, 21(1), 4-8.
https://doi.org/10.18678/dtfd.559057
Bhurayanontachai, R. (2021). Mechanical ventilator support and prone positioning in covid-19 related pneumonia. Clinical Critical Care.
https://doi.org/10.54205/ccc.v29i.251359
Ding, M., Han, X., Bai, L., Huang, S., & Duan, J. (2021). Impact of hacor score on noninvasive ventilation failure in non-copd patients with acute-on-chronic respiratory failure. Canadian Respiratory Journal, 2021, 1-7.
https://doi.org/10.1155/2021/9960667
Ergan, B., Oczkowski, S., Rochwerg, B., Carlucci, A., Chatwin, M., Clini, E., … & Windisch, W. (2019). European respiratory society guidelines on long-term home non-invasive ventilation for management of copd. European Respiratory Journal, 54(3), 1901003.
https://doi.org/10.1183/13993003.01003-2019
Hasan, S., Capstick, T., Ahmed, R., Kow, C., Mazhar, F., Merchant, H., … & Zaidi, S. (2020). Mortality in covid-19 patients with acute respiratory distress syndrome and corticosteroids use: a systematic review and meta-analysis. Expert Review of Respiratory Medicine, 14(11), 1149-1163.
https://doi.org/10.1080/17476348.2020.1804365
Kreit, J. (2017). Respiratory failure and the indications for mechanical ventilation..
https://doi.org/10.1093/med/9780190670085.003.0007
Lee, J., Moon, H., Hong, S., Chon, J., Kwon, H., Park, H., … & Lee, J. (2022). Respiratory failure during bis-guided sedation in a patient with relapsing polychondritis: a case report. Medicina, 59(1), 65.
https://doi.org/10.3390/medicina59010065
Nitu, M. and Eigen, H. (2009). Respiratory failure. Pediatrics in Review, 30(12), 470-478.
https://doi.org/10.1542/pir.30-12-470
Ohuabunwa, U., Afolabi, P., Tom‐Aba, D., & Fluker, S. (2022). Clinical presentation of covid‐19 and association with outcomes among hospitalized older adults. Journal of the American Geriatrics Society, 71(2), 599-608.
https://doi.org/10.1111/jgs.18163
Pavliša, G. (2023). Noninvasive mechanical ventilation in covid-19 related acute respiratory failure. Acta Clinica Croatica.
https://doi.org/10.20471/acc.2023.62.s1.16
Rochwerg, B., Brochard, L., Elliott, M., Hess, D., Hill, N., Nava, S., … & Raoof, S. (2017). Official ers/ats clinical practice guidelines: noninvasive ventilation for acute respiratory failure. European Respiratory Journal, 50(2), 1602426.
https://doi.org/10.1183/13993003.02426-2016
Shiozumi, T., Okada, N., Matsuyama, T., Yamahata, Y., & Ohta, B. (2023). Anti-muscle-specific kinase (musk) antibody-positive myasthenia gravis presenting with dyspnea in an elderly woman: a case report. Cureus.
https://doi.org/10.7759/cureus.50480
Veldhoen, E., Wijngaarde, C., Eijk, R., Asselman, F., Seddiqi, N., Otto, L., … & Pol, W. (2022). Lung function decline preceding chronic respiratory failure in spinal muscular atrophy: a national prospective cohort study..
https://doi.org/10.21203/rs.3.rs-2083566/v1
Wang, F., Cheng, J., Niu, X., & Li, L. (2024). Respiratory failure as first presentation of myasthenia gravis: a case report. Journal of International Medical Research, 52(3).
https://doi.org/10.1177/03000605241234585
Yasuda, H., Okano, H., Mayumi, T., Narita, C., Onodera, Y., Nakane, M., … & Shime, N. (2021). Post-extubation oxygenation strategies and mortality and reintubation rates in acute respiratory failure: a systematic review and network meta-analysis..
https://doi.org/10.21203/rs.3.rs-270103/v1

This paper summarizes the Part 3 of the proceedings of the 8th International Conference on Management and Rehabilitation of Chronic Respiratory Failure, held in Pescara, Italy, on 7 and 8 May, 2015. It summarizes the contributions from numerous experts in the field of chronic respiratory disease and...

07/24/2025

The role of quantitative waveform capnography in airway management and respiratory failure – Michael Christie
https://www.resuscitationgroup.com/blog/62/the-role-of-quantitative-waveform-capnography-in-airway-management-and-respiratory-failure/

Quantitative waveform capnography (EtCO2) plays a critical role in airway management and the assessment of respiratory failure, particularly in emergency situations. This method of monitoring provides a real-time assessment of carbon dioxide levels in exhaled breath, which is essential for confirming the correct placement of endotracheal tubes (ETT). The use of quantitative waveform capnography helps clinicians differentiate between proper tracheal placement and misplacements, such as esophageal intubation, which can lead to significant morbidity if not identified promptly. Studies indicate that the use of quantitative waveform capnography substantially reduces the risk of undiagnosed esophageal intubation, ensuring patient safety by confirming correct ETT placement with greater reliability than traditional methods such as auscultation or visual confirmation of tube placement alone (Nichols et al., 2013; , (Abdelrahman et al., 2020; , Bullock et al., 2017).

The American Heart Association's guidelines for advanced cardiac life support endorse quantitative waveform capnography as the gold standard for ETT verification (Abdelrahman et al., 2020; , Ching et al., 2021). This method is especially favored in the hospital setting due to its ability to continuously measure and graphically display CO2 levels, allowing for instant verification of ventilation effectiveness. Meena et al. highlighted the superiority of quantitative waveform capnography over other methods in detecting correct ETT placement, emphasizing its ability to provide immediate feedback on ventilatory function post-intubation (Meena et al., 2022; , (Schlag et al., 2013). Moreover, studies have demonstrated that patients whose ETT placements were confirmed via quantitative waveform capnography exhibited quicker detection of exhaled CO2, significantly improving the time it takes for clinicians to ensure respiratory adequacy during emergencies (Hunt et al., 2018).

The practical application of capnography is complemented by an understanding of its limitations. For instance, waveform capnography may not be available in all emergency departments, which can affect its widespread use (Thomas et al., 2017). Additionally, factors such as low cardiac output, which may occur during CPR, can lead to misleading capnographic readings, making it a less reliable indicator of ETT placement under specific conditions (Herrería‐Bustillo et al., 2016; , Ku & Lee, 2022). These challenges underscore the need for clinicians to be trained in interpreting capnographic data, as well as the importance of having backup confirmation methods available, such as colorimetric detectors or ultrasonography (King et al., 2019; , Saeed et al., 2023).

Furthermore, the role of quantitative waveform capnography extends beyond simple confirmation of ETT placement; it serves as a valuable indicator of overall respiratory status in patients experiencing respiratory failure. By continuously monitoring CO2 levels, clinicians can detect immediate changes in ventilation, such as in the event of an airway obstruction or hypoventilation (Waugh et al., 2011). This real-time monitoring capability allows for rapid intervention, making quantitative waveform capnography an essential tool in treating patients during procedural sedation and managing critical airway situations (Schlag et al., 2013).

To support the effectiveness of quantitative waveform capnography, studies have consistently shown its high accuracy in confirming endotracheal tube placement across diverse patient populations and clinical settings (Adi et al., 2013; , Moghawri et al., 2019). Additionally, findings suggest that supplementary techniques, such as ultrasound and clinical evaluations like the assessment of breath sounds or chest rise, can enhance the reliability of ETT verification when combined with waveform capnography (Abdelrahman et al., 2020; , Prasad, 2020). This integrative approach is particularly useful in emergency scenarios where misplacement can have immediate life-threatening consequences (Pradeep & Benny, 2024).

In summary, the analysis of quantitative waveform capnography portrays it as a cornerstone in airway management and the evaluation of respiratory function during critical care. Its advantages, including rapid feedback, real-time monitoring, and high specificity for proper tube placement, solidify its position as an indispensable tool for healthcare providers involved in emergency medicine and anesthesiology. As healthcare providers continue to refine their utilization of capnography, particularly in the pediatric population and in those with challenging airway anatomies, the integration of workflow improvements and technological advancements can further enhance patient safety and care outcomes in airway management contexts (Das et al., 2014).

References:
Abdelrahman, T., Abdelhameed, G., & Armanious, S. (2020). Evaluation of real-time tracheal ultrasound versus colorimetric capnography as a point of care tool for confirmation of endotracheal intubation: a randomized controlled study. Ain-Shams Journal of Anesthesiology, 12(1).
https://doi.org/10.1186/s42077-020-00117-3
Adi, O., Chuan, T., & Manikam, R. (2013). A feasibility study on bedside upper airway ultrasonography compared to waveform capnography for verifying endotracheal tube location after intubation. Critical Ultrasound Journal, 5(1), 7.
https://doi.org/10.1186/2036-7902-5-7
Bullock, A., Dodington, J., Donoghue, A., & Langhan, M. (2017). Capnography use during intubation and cardiopulmonary resuscitation in the pediatric emergency department. Pediatric Emergency Care, 33(7), 457-461.
https://doi.org/10.1097/pec.0000000000000813
Ching, C., Leong, B., Nair, P., Chan, K., Seow, E., Lee, F., … & Lim, S. (2021). Singapore advanced cardiac life support guidelines 2021. Singapore Medical Journal, 62(08), 390-403.
https://doi.org/10.11622/smedj.2021109
Das, S., Choupoo, N., Haldar, R., & Lahkar, A. (2014). Transtracheal ultrasound for verification of endotracheal tube placement: a systematic review and meta-analysis. Canadian Journal of Anesthesia/Journal Canadien D Anesthésie, 62(4), 413-423.
https://doi.org/10.1007/s12630-014-0301-z
Herrería‐Bustillo, V., Kuo, K., Burke, P., Cole, R., & Bacek, L. (2016). A pilot study evaluating the use of cervical ultrasound to confirm endotracheal intubation in dogs. Journal of Veterinary Emergency and Critical Care, 26(5), 654-658.
https://doi.org/10.1111/vec.12507
Hunt, K., Yamada, Y., Murthy, V., Bhat, P., Campbell, M., Fox, G., … & Greenough, A. (2018). Detection of exhaled carbon dioxide following intubation during resuscitation at delivery. Archives of Disease in Childhood - Fetal and Neonatal Edition, 104(2), F187-F191.
https://doi.org/10.1136/archdischild-2017-313982
King, A., Blank, D., Bhatia, R., Marzbanrad, F., & Malhotra, A. (2019). Tools to assess lung aeration in neonates with respiratory distress syndrome. Acta Paediatrica, 109(4), 667-678.
https://doi.org/10.1111/apa.15028
Ku, H. and Lee, S. (2022). Factors for advancing emergency airway management practice. SV.
https://doi.org/10.22514/sv.2022.032
Meena, R., Roy, P., Joshi, N., Garg, M., & Bhati, S. (2022). Comparison of ultrasonography, clinical method and capnography for detecting correct endotracheal tube placement- a prospective, observational study. Indian Journal of Anaesthesia, 66(12), 826-831.
https://doi.org/10.4103/ija.ija_240_22
Moghawri, M., Zayed, N., & Ibrahim, D. (2019). Reliability of ultrasound in confirming endotracheal tube placement as a new and fast tool. Egyptian Journal of Bronchology, 13(5), 684-689.
https://doi.org/10.4103/ejb.ejb_79_19
Nichols, M., Acker, J., Bendall, J., & Asha, S. (2013). Evaluating the incidence of unrecognised oesophageal intubation by paramedics. Journal of Paramedic Practice, 5(4), 212-218.
https://doi.org/10.12968/jpar.2013.5.4.212
Pradeep, S. and Benny, H. (2024). Comparison of upper airway ultrasonography against quantitative waveform capnography for validating endotracheal tube position in a south indian population. Cureus.
https://doi.org/10.7759/cureus.52628
Prasad, B. (2020). The accuracy of ultrasonography in confirming endotracheal tube placement in emergency department. Medpulse International Journal of Medicine, 16(2), 57-60.
https://doi.org/10.26611/10211622
Saeed, R., Hamza, M., Bangash, T., Latif, A., Ammar, T., & Kakepotto, I. (2023). Diagnostic accuracy of ultrasound for confirmation of endotracheal tube placement taking capnography as a gold standard. Proceedings of Shaikh Zayed Medical Complex Lahore, 37(4), 46-52.
https://doi.org/10.47489/szmc.v37i4.436
Schlag, C., Wörner, A., Wagenpfeil, S., Kochs, E., Schmid, R., & Delius, S. (2013). Capnography improves detection of apnea during procedural sedation for percutaneous transhepatic cholangiodrainage. Canadian Journal of Gastroenterology, 27(10), 582-586.
https://doi.org/10.1155/2013/852454
Thomas, V., Paul, C., Rajeev, P., & Palatty, B. (2017). Reliability of ultrasonography in confirming endotracheal tube placement in an emergency setting. Indian Journal of Critical Care Medicine, 21(5), 257-261.
https://doi.org/10.4103/ijccm.ijccm_417_16
Waugh, J., Epps, C., & Khodneva, Y. (2011). Capnography enhances surveillance of respiratory events during procedural sedation: a meta-analysis. Journal of Clinical Anesthesia, 23(3), 189-196.
https://doi.org/10.1016/j.jclinane.2010.08.012

Background In emergency settings, verification of endotracheal tube (ETT) location is important for critically ill patients. Ignorance of oesophageal intubation can be disastrous. Many methods are used for verification of the endotracheal tube location; none are ideal. Quantitative waveform capnogra...

04/11/2025

Is the Bedside Lung Ultrasound Exam (BLUE) better than a chest Xray for emergency care? – Michael Christie
https://www.resuscitationgroup.com/blog/61/bedside-lung-ultrasound-exam-vs-chest-xray-for-emergency-care/

In the urgent setting of emergency care, the choice between bedside lung ultrasound (LUS) and chest X-ray (CXR) can significantly impact patient outcomes, particularly when diagnosing conditions such as pneumonia and other respiratory pathologies. Numerous studies indicate that LUS offers considerable advantages over traditional CXR in various aspects.

Firstly, LUS has been shown to possess superior diagnostic accuracy. For instance, a study by Annapurna et al. reveals that LUS demonstrated a sensitivity of 96% for detecting pneumonic consolidations compared to only 74% for CXR (Annapurna et al., 2020). Alkhayat and Alam‐Eldeen support this by stating that LUS offers a rapid diagnostic pathway that can often eliminate the need for additional imaging such as CT, thus avoiding radiation exposure, which is particularly important for vulnerable patient populations, including children and pregnant women (Alkhayat & Alam‐Eldeen, 2014).

In addition to accuracy, LUS also provides timely diagnosis, which is critical in emergencies. For example, research conducted in the postoperative context showed that LUS detected clinically relevant pulmonary complications earlier than CXR, allowing for timely intervention (Touw et al., 2018). Additionally, Rinaldi et al. reinforced that LUS proved to be a more effective diagnostic tool, as it can be performed directly at the bedside, ensuring immediate results that facilitate quicker clinical decision-making (Rinaldi et al., 2019).

Moreover, the practicality of LUS in emergency settings is underscored by its applicability to various conditions beyond pneumonia. Studies have demonstrated its efficacy in diagnosing pleural effusions and guiding thoracocentesis (Soni et al., 2015; Sikora et al., 2012). This versatility further solidifies LUS as an essential component of point-of-care diagnostics, enabling healthcare providers to tackle overlapping conditions without the delay that often accompanies traditional radiographic methods.

Nevertheless, it is important to acknowledge that while LUS has many benefits, certain limitations exist. For instance, factors such as subcutaneous emphysema and surgical dressings can obstruct the ultrasound waves, impacting the quality of the images obtained (Traslaviña et al., 2017). Additionally, although X-ray remains beneficial in specific scenarios like assessing complex thoracic injuries that may not be adequately visualized with ultrasound, it still provides essential diagnostic information, particularly in traumatic injuries (Damasy et al., 2023).

In conclusion, the evidence overwhelmingly suggests that bedside lung ultrasound provides a more reliable, faster, and safer alternative to chest X-ray in emergency settings, particularly for the diagnosis of pneumonia and related respiratory conditions. Its growing incorporation into emergency care protocols is indicative of a transformative shift towards maximizing patient safety and diagnostic efficiency.

References:
Alkhayat, K. and Alam‐Eldeen, M. (2014). Value of chest ultrasound in diagnosis of community acquired pneumonia. Egyptian Journal of Chest Diseases and Tuberculosis, 63(4), 1047-1051.
https://doi.org/10.1016/j.ejcdt.2014.06.002
Annapurna, S., Gupta, U., Boppanna, S., Dixit, V., & Mallula, B. (2020). Comparative study of lung ultrasonography and chest radiography in suspected cases of pneumonia in critically ill patients. International Journal of Radiology and Diagnostic Imaging, 3(1), 101-104.
https://doi.org/10.33545/26644436.2020.v3.i1b.61
Damasy, M., Khan, A., Badheeb, A., & Shaigi, M. (2023). Spontaneous haemopneumothorax: a rare illness with unusual presentation and aetiology. Open Journal of Clinical and Medical Case Reports, 9(32).
https://doi.org/10.52768/2379-1039/2115
Rinaldi, L., Milione, S., Fascione, M., Pafundi, P., Altruda, C., Caterino, M., … & Adinolfi, L. (2019). Relevance of lung ultrasound in the diagnostic algorithm of respiratory diseases in a real‐life setting: a multicentre prospective study. Respirology, 25(5), 535-542.
https://doi.org/10.1111/resp.13659
Sikora, K., Perera, P., Mailhot, T., & Mandavia, D. (2012). Ultrasound for the detection of pleural effusions and guidance of the thoracentesis procedure. Isrn Emergency Medicine, 2012, 1-10.
https://doi.org/10.5402/2012/676524
Soni, N., Franco, R., Velez, M., Schnobrich, D., Dancel, R., Restrepo, M., … & Mayo, P. (2015). Ultrasound in the diagnosis and management of pleural effusions. Journal of Hospital Medicine, 10(12), 811-816.
https://doi.org/10.1002/jhm.2434
Touw, H., Parlevliet, K., Beerepoot, M., Schober, P., Vonk, A., Twisk, J., … & Tuinman, P. (2018). Lung ultrasound compared with chest x‐ray in diagnosing postoperative pulmonary complications following cardiothoracic surgery: a prospective observational study. Anaesthesia, 73(8), 946-954.
https://doi.org/10.1111/anae.14243
Traslaviña, J., Martínez, M., Olivera, M., & Balsalobre, R. (2017). Comparative study of transthoracic ultrasound and chest x-ray in the postoperative period of thoracic surgery. International Surgery Journal, 4(9), 2925.
https://doi.org/10.18203/2349-2902.isj20173872

03/28/2025

Are Redheads Resistant to Anesthetic Agents? – Michael Christie
https://www.resuscitationgroup.com/blog/60/are-redheads-resistant-to-anesthetic-agents/

Research has indicated that individuals with red hair exhibit distinct responses to various anesthetic agents, partly due to genetic factors associated with their hair color. A notable genetic variant in red-haired individuals is the mutation in the melanocortin-1 receptor (MC1R) gene, which has been correlated with altered sensitivity to anesthesia and pain perception (Chua et al., 2004; Myles et al., 2012; Augustinsson et al., 2024).

Studies have demonstrated that red-haired individuals may require higher doses of inhaled anesthetics, such as desflurane and isoflurane, to achieve comparable levels of anesthesia when compared to those with darker hair (Meretsky et al., 2024; Myles et al., 2012). This increased requirement has been documented across multiple studies, including a comprehensive review that specifically noted the greater anesthetic potency needed for red-haired patients during general anesthesia (Meretsky et al., 2024). Furthermore, these subjects show heightened sensitivity to thermal pain, which implies that their pain threshold may be lower, contributing to their altered anesthetic requirements (Liem et al., 2005; Gradwohl et al., 2015).

The findings from Chua et al. suggest that midazolam, a commonly used sedative, results in significantly less sedation in red-haired individuals compared to those with other hair colors (Chua et al., 2004; Gradwohl et al., 2015). This phenomenon indicates a potential resistance to certain anesthetic agents, underscoring the need for anesthesiologists to consider hair color as a variable in anesthetic management. Intraoperative awareness, defined as the patient’s awareness of their surroundings during anesthesia, appears to be more prevalent among red-haired patients, reinforcing the necessity for careful monitoring and tailored anesthetic approaches (Gradwohl et al., 2015; Sessler, 2015).

Moreover, local anesthetics, notably lidocaine, have shown reduced efficacy in red-haired individuals, leading to potential challenges in achieving adequate analgesia in dental procedures or other settings requiring local anesthesia (Liem et al., 2005; Droll et al., 2012). This resistance to local anesthetics could be a contributing factor to the anxiety some individuals with red hair experience regarding dental care (Binkley et al., 2009).

In summary, the evidence strongly supports the notion that red-haired individuals display resistance or altered responses to various anesthetic agents, necessitating an individualized approach in their anesthetic management to ensure effective and safe outcomes.

References:
Augustinsson, A., Franze, E., Almqvist, M., Stomberg, M., Sjöberg, C., & Jildenstål, P. (2024). Red-haired people’s altered responsiveness to pain, analgesics, and hypnotics: myth or fact?—a narrative review. Journal of Personalized Medicine, 14(6), 583.
https://doi.org/10.3390/jpm14060583
Binkley, C., Beacham, A., Neace, W., Gregg, R., Liem, E., & Sessler, D. (2009). Genetic variations associated with red hair color and fear of dental pain, anxiety regarding dental care and avoidance of dental care. The Journal of the American Dental Association, 140(7), 896-905.
https://doi.org/10.14219/jada.archive.2009.0283
Chua, M., Tsueda, K., & Doufas, A. (2004). Midazolam causes less sedation in volunteers with red hair. Canadian Journal of Anesthesia/Journal Canadien D Anesthésie, 51(1), 25-30.
https://doi.org/10.1007/bf03018542
Droll, B., Drum, M., Nusstein, J., Reader, A., & Beck, M. (2012). Anesthetic efficacy of the inferior alveolar nerve block in red-haired women. Journal of Endodontics, 38(12), 1564-1569.
https://doi.org/10.1016/j.joen.2012.08.014
Gradwohl, S., Aranake, A., Abdallah, A., McNair, P., Lin, N., Fritz, B., … & Avidan, M. (2015). Intraoperative awareness risk, anesthetic sensitivity, and anesthetic management for patients with natural red hair: a matched cohort study. Canadian Journal of Anesthesia/Journal Canadien D Anesthésie, 62(4), 345-355.
https://doi.org/10.1007/s12630-014-0305-8
Liem, E., Joiner, T., Tsueda, K., & Sessler, D. (2005). Increased sensitivity to thermal pain and reduced subcutaneous lidocaine efficacy in redheads. Anesthesiology, 102(3), 509-514.
https://doi.org/10.1097/00000542-200503000-00006
Meretsky, C., Plitt, V., Friday, B., Schiuma, A., & Ajebli, M. (2024). A comparative analysis of the efficacy of local anesthetics and systemic anesthetics in the red-headed versus non-red-headed patient population: a comprehensive review. Cureus.
https://doi.org/10.7759/cureus.61797
Myles, P., Buchanan, F., & Bain, C. (2012). The effect of hair colour on anaesthetic requirements and recovery time after surgery. Anaesthesia and Intensive Care, 40(4), 683-689.
https://doi.org/10.1177/0310057x1204000415
Sessler, D. (2015). Red hair and anesthetic requirement. Canadian Journal of Anesthesia/Journal Canadien D Anesthésie, 62(4), 333-337.
https://doi.org/10.1007/s12630-015-0325-z

Red hair has been linked to altered sensitivity to pain, analgesics, and hypnotics. This alteration may be impacted by variants in the melanocortin-1 receptor (MC1R) gene, which are mainly found in redheads. The aim of this narrative review was to explore and present the current state of knowledge o...

03/15/2025

Ketamine as a monotherapeutic agent for mechanical ventilation – Michael Christie
https://www.resuscitationgroup.com/blog/59/ketamine-as-a-monotherapeutic-agent-for-mechanical-ventilation/

Ketamine is increasingly recognized as a viable option for monotherapeutic sedation in mechanically ventilated patients, particularly due to its unique pharmacological properties. As an NMDA receptor antagonist, ketamine can provide effective sedation without the respiratory depression often associated with traditional sedatives such as benzodiazepines and propofol. This characteristic is especially beneficial in patients requiring prolonged mechanical ventilation, where maintaining respiratory function is crucial (Jung et al., 2022; Hui et al., 2022).

Recent studies underscore the safety and feasibility of continuous ketamine infusions for sedation in mechanically ventilated patients across diverse clinical populations, including adults and children in intensive care units (ICUs). A study demonstrated that continuous ketamine infusion provided adequate sedation and analgesia in mechanically ventilated patients, achieving desired sedation scores within acceptable ranges (Mishra et al., 2024; Heiberger et al., 2018). The approach has been particularly beneficial during the COVID-19 pandemic due to extended ventilation durations and shortages of alternative agents, prompting the exploration of ketamine as a primary sedative (Jung et al., 2022; Wyler et al., 2023).

Furthermore, ketamine's analgesic benefits can help reduce opioid requirements, thereby minimizing the risk of opioid-related side effects and tolerance in critically ill patients. In pediatric populations, introducing ketamine as part of a sedation rotation protocol significantly decreased fentanyl use, which highlights its potential in creating more balanced analgesic-sedation strategies for mechanically ventilated patients (Heiberger et al., 2018; Haliloğlu, 2022; Bradshaw et al., 2019). By effectively combining sedation with analgesia, ketamine is a favorable alternative for patients intolerant of standard sedation regimens, especially considering its minimal respiratory depressant effects (Hui et al., 2022; Treu et al., 2017).

However, the potential for emergence reactions—characterized by agitation upon awakening—remains a concern with ketamine. Despite this, studies indicate that the incidence of such reactions is manageable and rarely necessitates treatment interventions (Riccardi et al., 2023; Pruskowski et al., 2017). While there are discussions regarding long-term effects associated with ketamine use, particularly concerning cholestatic liver injuries reported in specific populations, these findings suggest the need for careful patient monitoring rather than outright contraindication (Wendel‐Garcia et al., 2022; Henrie et al., 2023).

In summary, ketamine is a promising monotherapeutic sedative for mechanically ventilated patients due to its analgesic properties, ability to preserve respiratory function, and reduced opioid requirements. Continued research and clinical application will likely further establish its role in sedation protocols, especially in response to evolving patient needs in critical care settings.

References:
Bradshaw, P., Droege, C., Carter, K., Harger, N., & Mueller, E. (2019). Continuous infusion ketamine for adjunctive analgosedation in mechanically ventilated, critically ill patients. Pharmacotherapy the Journal of Human Pharmacology and Drug Therapy, 39(3), 288-296.
https://doi.org/10.1002/phar.2223
Haliloğlu, M. (2022). Continuous infusion of ketamine for adjunctive analgosedation in mechanically ventilated patients with chronic obstructive pulmonary disease. Eurasian Journal of Pulmonology.
https://doi.org/10.14744/ejp.2022.3005
Heiberger, A., Ngorsuraches, S., Olgun, G., Luze, L., Leimbach, C., Madison, H., … & Lakhani, S. (2018). Safety and utility of continuous ketamine infusion for sedation in mechanically ventilated pediatric patients. The Journal of Pediatric Pharmacology and Therapeutics, 23(6), 447-454.
https://doi.org/10.5863/1551-6776-23.6.447
Henrie, J., Gérard, L., Declerfayt, C., Lejeune, A., Baldin, P., Robert, A., … & Hantson, P. (2023). Profile of liver cholestatic biomarkers following prolonged ketamine administration in patients with covid-19. BMC Anesthesiology, 23(1).
https://doi.org/10.1186/s12871-023-02006-2
Hui, C., Monteiro, J., Trivedi, D., Vasant, D., & Carino, G. (2022). Effect of ketamine on vasopressor needs in mechanically ventilated patients: a retrospective study., 1(3).
https://doi.org/10.56305/001c.36988
Jung, H., Lee, J., Ahn, H., Yang, J., Suh, G., Ko, R., … & Chung, C. (2022). Safety and feasibility of continuous ketamine infusion for analgosedation in medical and cardiac icu patients who received mechanical ventilation support: a retrospective cohort study. Plos One, 17(9), e0274865.
https://doi.org/10.1371/journal.pone.0274865
Mishra, R., Pokharel, K., & Gautam, A. (2024). Comparison of intravenous ketamine and fentanyl sedation in duration of mechanical ventilation in intensive care unit. Journal of Nepalese Society of Critical Care Medicine, 2(1), 10-16.
https://doi.org/10.3126/jnsccm.v2i1.62100
Pruskowski, K., Harbourt, K., Pajoumand, M., Chui, S., & Reynolds, H. (2017). Impact of ketamine use on adjunctive analgesic and sedative medications in critically ill trauma patients. Pharmacotherapy the Journal of Human Pharmacology and Drug Therapy, 37(12), 1537-1544.
https://doi.org/10.1002/phar.2042
Riccardi, A., Serra, S., Iaco, F., Fabbri, A., Shiffer, D., & Voza, A. (2023). Uncovering the benefits of the ketamine–dexmedetomidine combination for procedural sedation during the italian covid-19 pandemic. Journal of Clinical Medicine, 12(9), 3124.
https://doi.org/10.3390/jcm12093124
Treu, C., Groth, C., & Patel, J. (2017). The use of continuous ketamine for analgesia and sedation in critically ill patients with opioid abuse: a case series. The Journal of Critical Care Medicine, 3(4), 148-152.
https://doi.org/10.1515/jccm-2017-0026
Wendel‐Garcia, P., Erlebach, R., Hofmaenner, D., Camen, G., Schuepbach, R., Jüngst, C., … & David, S. (2022). Long-term ketamine infusion-induced cholestatic liver injury in covid-19-associated acute respiratory distress syndrome. Critical Care, 26(1).
https://doi.org/10.1186/s13054-022-04019-8
Wyler, D., Torjman, M., Leong, R., Baram, M., Denk, W., Long, S., … & Schwenk, E. (2023). Observational study of the effect of ketamine infusions on sedation depth, inflammation, and clinical outcomes in mechanically ventilated patients with sars-cov-2. Anaesthesia and Intensive Care, 52(2), 105-112.
https://doi.org/10.1177/0310057x231201184