(320) Ketamine as a Component of a Multimodal Approach in Withdrawal of Ventilatory Support at End of Life

Introduction: Terminal ventilator withdrawal, also known as known as Palliative Extubation (PE) has become a common procedure in many hospital units through-out the world. The withdrawal of life-sustaining measures is usually a planned procedure. However, if done ineffectively, may lead to undue patient's suffering from dyspnea, pain, agitation, and other distressing symptoms, furthering unintended emotional and psychosocial stress for families and healthcare staff. Currently, there are no established guidelines with practice parameters for the provision of medication use during terminal withdrawal of ventilatory support and approaches vary from institution to institution. We hypothesized that due to ketamine’s unique properties it could be used as component in a multi-modal approach for symptom management following terminal ventilator withdrawal at end-of-life.

Methods: Single-center observational study of adult patients admitted to our institution over a 15-month period. Patients received ketamine infusions in addition to standard analgesia/comfort care regimens. Patients were assessed prospectively using Behavioral Pain Scale (BPS), Respiratory Distress Observation Scale (RDOS), and Riker Sedation-Agitation Scale (SAS) for 1 hour, 12 hours and 24 hours post ventilatory withdrawal.

Results: Analysis cohort included 25 subjects undergoing PE from March 2022 to June 2023. The median age of patients was 73 (IQR 64, 78) years. Ketamine was given with a median (range) intravenous push dose of 20 (10-20) mg, and infusion of 0.2 (0.05-0.25) mg/kg/hr. The median time to death (TTD) after PE was 7.7 (IQR 0.5, 51.6) hours. The number of patients with a TTD of greater than 1 hour, 12 hours, and 24 hours were 18 (75%), 11 (44%), and 9 (36%), respectively. All patients had a recorded BPS score of 3 (no pain). RDOS scores of less than 3 indicate respiratory comfort; this was recorded in 13 (72%) of patients in 1 hour, 10 (91%) of patients in 12 hours, and 8 (89%) of patients in 24 hours. All patients had a recorded SAS score of less than 4, indicating no agitation during the withdrawal of ventilatory support.

Conclusions: Ketamine is a valuable component of a multi-modal approach for symptom management following withdrawal of ventilatory support at end-of-life.