The edition · Emergency & Critical Care
Low-dose ketamine trims opioid requirement in ventilated adults
A 120-patient double-blind trial reports a 13 microgram per hour fall in fentanyl-equivalent dosing, with a 95% probability of benefit and no signal of harm. Plus atropine vials recalled for particulate contamination, what VExUS actually predicts, transfer time from department to intensive care, and the week before a child is admitted with sepsis.
The edition in brief
A double-blind, placebo-controlled trial in two Melbourne intensive care units randomised 120 mechanically ventilated adults already receiving an opioid infusion to low-dose ketamine at 0.15 mg/kg/hr or placebo. Median hourly opioid dose in fentanyl equivalents was 64 micrograms per hour with ketamine against 77 with placebo, a median difference of -13.0 (95% credible interval -26.6 to 2.4) with a 95.1% probability of benefit; delirium, ventilator-free days and serious adverse events did not differ. The FDA has classified as Class II an ongoing American Regent recall of atropine sulfate injection 1 mg/mL after contamination with hair, glass and paraformaldehyde particulate. A systematic review of 32 studies and 3,142 patients found the venous excess ultrasound grading system moderately to well correlated with raised central venous and right atrial pressure, and predictive of acute kidney injury and mortality in cardiac patients but not in a general critically ill population. A Dutch cohort of 18,798 patients found no consistent relationship between emergency department to intensive care transfer time and mortality: the association in out-of-hospital cardiac arrest ran in opposite directions in academic and non-academic teaching hospitals, and nothing was seen in sepsis, pneumonia, overdose, respiratory failure or intracranial haemorrhage. In 6,928 US paediatric sepsis admissions, 53.5% had a healthcare encounter in the preceding week, and 38.9% of those encounters recorded an infection diagnosis.
Ketamine as an opioid-sparing adjunct in ventilated patients
Low-dose ketamine at 0.15 mg/kg/hr modestly reduced opioid requirement in ventilated adults without increasing delirium, which supports it as an adjunct rather than a routine.
Atropine injection recalled for hair, glass and paraformaldehyde
Sweep resuscitation trolleys and airway kits for the recalled atropine lots — vials contaminated with hair, glass and paraformaldehyde sit exactly where nobody inspects them.
VExUS predicts well in cardiac patients and poorly in everyone else
VExUS reliably indicates raised right-sided filling pressures and predicts kidney injury and death in cardiac patients, but carries no clear prognostic value in general critical illness.
Transfer time to intensive care: no single threshold survives the data
Time from emergency department to intensive care showed no consistent relationship with mortality across diagnoses, and ran in opposite directions by hospital type in cardiac arrest — so treat it as a process measure, not an outcome.
In anaphylaxis, the delay is almost never the diagnosis
Give intramuscular adrenaline into the anterolateral thigh first and repeat at five minutes, keep the patient flat, and leave antihistamines and steroids until afterwards.
Half of children admitted with sepsis were seen in the week before
More than half of children later admitted with sepsis had been seen somewhere in the preceding week, which makes explicit, documented safety-netting at every febrile discharge the practical lever.
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