In this episode I’ll:

1. Discuss an article about delayed sequence intubation.

2. Answer the drug information question “Can posaconazole cause hypokalemia?”

3. Share a resource for the Board Certified Critical Care Pharmacy (BCCCP) exam.

My on-line Critical Care Pharmacy Academy will open December 2016. The Academy will be the premier place for hospital pharmacists to develop their critical care skills. Go to pharmacyjoe.com/academy to sign up to be notified when the Academy opens.

Article

Apnea After Low-Dose Ketamine Sedation During Attempted Delayed Sequence Intubation

Lead author: Brian E. Driver

Published online in Annals of Emergency Medicine September 2016

Background

A minority of patients who require endotracheal intubation are too agitated to comply with the pre-oxygenation required to ensure sufficient safe apnea time. The best way to manage these patients is unknown. Some experts advocate proceeding with rapid sequence intubation despite inadequate pre-oxygenation. Other experts advocate a technique described as Delayed Sequence Intubation (DSI).

DSI is essentially procedural sedation so that the patient can tolerate the “procedure” of preoxygenation. RSI then proceeds when preoxygenation is complete. Ketamine is often chosen because the patient will be sedated but maintain respirations with this medication.

Case Report

The authors describe a 60-year-old woman who presented to an emergency department with acute hypoxic respiratory failure. She was given high-flow oxygen at 60 L/min via a non-rebreather face mask however her oxygen saturation did not increase beyond 93%. The patient refused a noninvasive positive-pressure ventilation mask, and the decision was made to sedate her with ketamine to allow for adequate preoxygenation with noninvasive positive-pressure ventilation.

She received a relatively low dose of 25 mg ketamine IV (0.31mg/kg) and within 1 minute became apneic. She was subsequently intubated without difficulty.

Conclusion

The authors concluded:

Apnea can occur in critically ill patients who receive ketamine to facilitate preoxygenation. Sedation remains a valuable technique to enable optimal preoxygenation in agitated patients; however, clinicians should not perform this technique lightly and should be prepared to secure the patient’s airway immediately.

Discussion

Ketamine is often advocated as a sedative that can be used without the risk of apnea. An important lesson from this case report for pharmacists involved in procedural sedation using ketamine is to not let your guard down with respect to the possibility that apnea may occur in patients given ketamine.

Drug information question

Q: Can posaconazole cause hypokalemia?

A: Yes!

Shout out to “Infectious Disease Anita” for asking this drug information question. Anita had encountered a patient with profound hypokalemia – less than 2 mEq/L – a few weeks after starting posaconazole.

Hypokalemia can occur in up to 30% of patients who take systemic posaconazole. There is a dearth of specific electrolyte monitoring guidelines for posaconazole. Given that treatment with posaconazole is typically 6-12 weeks for aspergillosis, I would check a serum potassium at least at 2 and 4 weeks after starting therapy.

Resource

If you are thinking of taking the Board Certified Critical Care Pharmacy Exam, take the time to review the content outline. The content outline contains the domains, tasks and knowledge statements that were delineated and validated by the BPS Critical Care Practice Analysis Taskforce. Reviewing the content outline will give you a solid understanding of the type of studying you will need to do in order to pass the exam.

If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.

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