Case: 77-year-old patient has been in ICU intubated due to severe community-acquired pneumonia for the last 2 weeks. The patient was unable to tolerate propofol, dexmedetomidine, or benzodiazepine infusions either due to exaggerated response or reports of allergy. Finally, ketamine infusion appears to work well with the patient. On the 12th day of infusion, it is noted that the patient has progressively rising alkaline phosphatase and other liver enzymes. What should be your concern?
Answer: Sclerosing cholangitis
Sclerosing cholangitis due to prolonged continuous infusion of Ketamine in the ICU is less recognized. Thanks to the COVID pandemic where ketamine infusion was used liberally and numerous cases were reported highlighting the said issue.
Signs of sclerosing cholangitis during ketamine infusion include jaundice, decompensated cirrhosis, hepatic failure, and liver enzymes consistent with cholangiopathy.
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References:
1. Keta-Cov research group. Electronic address: vincent.mallet@aphp.fr, Keta-Cov research group. Intravenous ketamine and progressive cholangiopathy in COVID-19 patients. J Hepatol 2021; 74:1243.
2. de Tymowski C, Dépret F, Dudoignon E, et al. Ketamine-induced cholangiopathy in ARDS patients. Intensive Care Med 2021; 47:1173.
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