Artikel
Ketamine administration neuroprotective sedation for elevated intracranial pressure might lead to a high incidence of sclerosing cholangitis
Ketamingabe zur neuroprotektiven Sedierung zur Behandlung erhöhten intrakraniellen Drucks kann zu einer hohen Rate sklerosierender Cholangitiden führen
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Veröffentlicht: | 8. Mai 2019 |
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Objective: Secondary sclerosing cholangitis (SC-CIP) might develop after longer periods of intensive care treatment. The development of casts in the intrahepatic bile ducts and pronounced cholestasis are pathognomonic for SC-CIP. In the further course liver cirrhosis with indication for liver transplantation may develop. The aim of this study was to analyze risk factors which are associated with SC – CIP.
Methods: A retrospective observational analysis (01/2010 to 11/2015) was done. Clinical variables were reviewed. The records of 239 patients who underwent neuroprotective sedation were screened. Inclusion criteria were cholestasis (: bilirubin ≥2.4 mg/dl and/or γGT ≥1000 U/l) and validation of diagnosis via ERCP/MRCP. Thirty patients fulfilled the criteria of SC-CIP.
Results: All patients were sedated for treatment of critically increased intracranial pressure, 70% were male. Rate of mechanical ventilation was 100%, all patients developed systemic inflammatory response syndrome (SIRS) or sepsis. 87% continuously received ketamine (≥3 mg x kg body weight-1 x h-1). There was a significant correlation between the beginning of cholestasis and days on mechanical ventilation (R=0.948) as well as the days on anti-infectives (R=0.793). Formerly postulated SC-CIP triggers (mean arterial pressure <65 mmHg, number of transfused erythrocyte concentrates, obesity, prolonged prone position, PEEP >10 mbar and high doses of catecholamines) could be ruled out for this cohort.
Conclusion: This is by far the largest report on patients undergoing neurointensive treatment developing SC-CIP. Sedation with high doses of ketamine appears to be a contributing factor to the development of SC-CIP. Clinicians should be highly aware of this observation and Ketamine use should be re-evaluated with regard to this relevant medical complication. SIRS/sepsis and a low oxygenation index have been confirmed as potential relevant factors.