FWIW, notes and references I have on this topic from a variety of sources suggest this is a misattribution of cause and effect and that the rise in ICP, IF it occurs, may be a consequence of hypercarbia due to hypoventilation. Excerpts follow:
The ICP issue is debatable and is based on a Japanese study done in around 1974 [that article MIGHT be Sari A, Okuda Y, Takeshita H. The effect of ketamine on cerebrospinal fluid pressure. Anesth Analg 1972;51(4):560-5 (July-August). They were using ketamine to induce people with known brain tumours for resection who already had their ICP measured. Ketamine caused a rise in ICP but it was abolished by IPPV.]
This drug is used for trauma ETI in Africa and other countries.
Refs: Emergency Medicine Australasia 2006;18:37-44. ACEP NEWS, 21(10), Oct 2002. Ann Emerg Med. 2004;44:460-471.
Ketamine use in total IV anesthesia: Grathwohl KW, Black IH, Spinella PC, Sweeney J, Robalino J, Helminiak J, Grimes J, Gullick R, Wade CE. Total intravenous anesthesia including ketamine versus volatile gas anesthesia for combat-related operative traumatic brain injury. Anesthesiology. 2008 Jul;109(1):44-53. There seems to be no difference and certainly no adverse outcome with ketamine.
More importantly, a good study recently was designed to address the problem in neurosurgical patients and found that there was NO evidence that ketamine (admittedly S+, not the usual recemic mix we all use) caused a rise in ICP: Schmittner MD, Vajkoczy SL, Horn P, Bertsch T, Quintel M, Vajkoczy P, Muench E.Effects of fentanyl and S(+)-ketamine on cerebral hemodynamics, gastrointestinal motility, and need of vasopressors in patients with intracranial pathologies: a pilot study.J Neurosurg Anesthesiol. 2007 Oct;19(4):257-62.
On Oct 18, 2013, at 12:02 PM, Jay Pershad wrote:
> Hello Marc et al,
> If you have not, I suggest you review this recent guideline from SCCM. It addresses your question with an evidence based approach to severe TBI. Ehud covered a lot of the key aspects of medical management of elevated ICP.
> Pediatr Crit Care Med. 2012 Jan;13 Suppl 1:S1-82. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents
> Tom, I had an opportunity to hear Peter Kochanek from Pittsburgh, the lead author of the working group that published these guidelines. He was a guest speaker at our institution earlier this year. In general, the peds. intensivists disapprove of our use of etomidate. Their concern surrounds the issue of adrenal suppression, particularly since these patients are at high risk for sepsis. Ketamine or propofol (if hemodynamics are normal) may be better options for sedation in these patients.
> Go Cards!!
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