Ketamine in Acute Brain Injury Patients. (BIKe)

Brain Injury and Ketamine: a Prospective, Randomized Controlled Double Blind Clinical Trial to Study the Effects of Ketamine on Sedative Sparing and Intracranial Pressure in Traumatic Brain Injury Patients.

University of Liege, Centre Hospitalier Régional de la Citadelle, AZ Delta, AZ Sint-Jan AV, AZ Turnhout, Imelda Hospital, Bonheiden

Although, in the past years, an increasing use of ketamine in Traumatic Brain injury (TBI) has been reported as an adjunct to other sedatives, there is no evidence from randomized clinical trial to support this practice. The BIKe (Brain Injury and Ketamine) study is a double-blind placebo controlled randomized multicenter clinical trial to examine the safety and feasibility of using ketamine as an adjunct to a standard sedative strategy in TBI patients.

In this study the effects of ketamine as an adjunct to an standard sedation regime in adult TBI patients will be investigated on the therapy intensity level and intracranial pressure. All patients will receive propofol for sedation to control ICP, to a maximum dose of 4 mg/kg/h. If the ICP is not controlled at the maximum dose of propofol, midazolam will be added, to a maximum dose of 0.3 mg/kg/h, as part of the current standard of care in the Participating Sites. All patients will receive remifentanil, fentanyl or sufentanil infusions for pain relief. The study medication (ketamine or placebo) will be started after randomization. As part of the current standard of care in the Participating Sites, the decision for decompressive craniectomy and/or barbiturate coma will be taken after multidisciplinary consultation between the treating intensivist and neurosurgeon. The decision to stop or reduce sedation, lies with the treating physician, based on the level of ICP control, the absence of clinical or radiological signs of deterioration of the neurologic state. In the case of barbiturate coma, the study drug will be discontinued. During and following decompressive craniectomy, the sedative regime (propofol/midazolam/study drug/ opioids) will be continued. In case of suspected or threatening Propofol-Related Infusion syndrome, propofol will be stopped and switched to midazolam. In case of hypertriglyceridemia >200 mg/dL, propofol will be reduced and if necessary, midazolam will be associated to allow control of sedation. During surgical procedures related to the traumatic brain injury or not, the study drug will not be discontinued. The use of open label administration of ketamine is not allowed during the course of the trial, i.e until hospital discharge.

Racemic ketamine® will be administered by continuous infusion in a prefilled 50 ml syringe at a concentration of 50 mg/ml, undiluted. The ketamine dose is 1 mg/kg/h, to a maximum dose of 120 mg/hour, which corresponds to an infusion rate of 0.02 ml/kg/h to a maximum rate of 2.4 ml/h. Study patients weighing over 120 kg will not exceed the maximum dose of 120mg/kg of ketamine. The study medication will be started within 6 hours after randomization. The IMP, ketamine, will be provided directly to each Participating Site by the official supplier of ketamine for Belgium (Pfizer).

The placebo (NaCl 0.9%) will be provided in the same type syringes and administered at the same infusion rate as the IMP (0.02 ml/kg/h to a maximum rate of 2.4 ml/h).

Racemic ketamine® will be administered by continuous infusion in a prefilled 50 ml syringe at a concentration of 50 mg/ml, undiluted. The ketamine dose is 1 mg/kg/h, to a maximum dose of 120 mg/hour, which corresponds to an infusion rate of 0.02 ml/kg/h to a maximum rate of 2.4 ml/h.

Placebo (NaCl 0.9%) will be provided in the same type syringes and administered at the same infusion rate as the IMP (0.02 ml/kg/h to a maximum rate of 2.4 ml/h).

Change in therapeutic intensity of intracranial pressure (ICP) reducing measures, assessed by the TIL score (Therapy Intensity Level)

The primary efficacy endpoint will be the reduction in daily Therapy Intensity Level (TIL) score, based on the highest score in each item per day until study drug discontinuation (calculated every day on the available data at 7:00 AM). Scales for TIL score range from 0 (minimum) to 38 (maximum). Higher scores are related to worse outcome.

From date of randomization (and start study drug) until study drug discontinuation or date of death from any cause, whichever came first, assessed up to 6 months.

From date of randomization until study drug discontinuation or or date of death from any cause, whichever came first, assessed up to 6 months.

Total duration of the first period of sedative treatments (propofol, midazolam and/or dexmedetomidine)

defined as the start of the first infusion of either propofol, midazolam and/or dexmedetomidine to the cessation of the last uninterrupted infusion of either propofol, midazolam, opioids and/or dexmedetomidine, assessed up to 6 months.

From date of randomization until study drug discontinuation or date of death from any cause, whichever came first, assessed at ICU discharge, assessed up to 6 months.

Total duration of mechanical ventilation, defined as all types of ventilation where positive end expiratory pressure is applied, expressed in cm H2O (5 cm H2O minimum).

From date of randomization until study drug discontinuation or date of death from any cause, whichever came first, assessed up to 6 months.

From date of randomization until study drug discontinuation or date of death from any cause, whichever came first, assessed up to 6 months.

From ICU admission until ICU discharge (end of stay is defined as application for discharge in the hospital computer system, or death), assessed up to 6 months.

From date of randomization until study drug discontinuation or date of death from any cause, whichever came first, assessed up to 6 months.

Number of delirium-free days, assessed 3 times per day with the Intensive Care Delirium Screening Checklist (ICDSC) or Confusion Assessment Method for the ICU (CAM-ICU delirium scale).

From date of randomization until study drug discontinuation or date of death from any cause, whichever came first, assessed up to 6 months.

From date of randomization until study drug discontinuation or date of death from any cause, whichever came first, assessed up to 6 months.

From date of randomization until study drug discontinuation or date of death from any cause, whichever came first, assessed up to 6 months.

From date of randomization until study drug discontinuation or date of death from any cause, whichever came first, assessed up to 6 months, assessed up to 6 months.

Incidence of PRIS documented and diagnosed by the attending physician and defined as: Cardiac manifestations, not explained by a coronary ischemic event: Acute refractory bradycardia leading to asystole, or ECG: widening of QRS-complex, or Brugada-syndrome-like patterns (particularly Type 1: Coved-type ST-segment elevation >2mm in >1 of V1-V3 followed by a negative T-wave), or ventricular tachy-arrhythmias Combined with one or more of the following: Unexplained metabolic acidosis (base deficit > 10 mmol/L) Rhabdomyolysis (Creatinine kinase at least five times the upper limit of normal) Hyperlipidaemia (triglyceride levels > 150 mg/dl) Enlarged or fatty liver, apparent on CT or echography All occurring in patients receiving propofol for > 24h Diagnosed by the attending physician

From date of randomization until study drug discontinuation or date of death from any cause, whichever came first, assessed up to 6 months.

Inclusion Criteria: Traumatic brain injury patients Age >= 18 years Admitted to the ICU Within 72 hours after admission to the initial hospital: ICP monitoring in place (parenchymal probe, ventricular catheter, or both) Requiring sedation Exclusion Criteria: Known pregnancy and/or lactation Imminent or actual brain death upon inclusion Allergy or intolerance to the study medication Pre-existing neurocognitive disorders, pre-existing congenital or non-congenital brain dysfunction. Inability to obtain informed consent Inclusion in an interventional randomised controlled trial of which the PI indicates that co-inclusion specifically in the BIKe study is prohibited. Therapy restriction code upon inclusion. Porphyria Glaucoma