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PED-EM-L  July 1995

PED-EM-L July 1995

Subject:

Ketamine Use

From:

CHRIS RITCHEY <[log in to unmask]>

Reply-To:

Pediatric Emergency Medicine Discussion List <[log in to unmask]>

Date:

Thu, 13 Jul 1995 16:27:05 -0700

Content-Type:

text/plain

Parts/Attachments:

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text/plain (160 lines)

I am interested in everyone's opinion about the following protocol
and any experience you have had with this medication.  Thanks
        Chris Ritchey, M.D.
        E-mail -  [log in to unmask]
 
 
 
Ketamine Hcl
 
Ketamine produces a Dissociative Anesthetic State
characterized by the following:
 
1. Dissociation: following administration of ketamine the
patient passes into a fugue state or trance.  The eyes may
remain open but the patient does not respond.
2. Catalepsy: Normal or slightly enhanced muscle tone is
maintained.  On occasion the patient may move or be moved
into a position that is self-maintaining.
3. Analgesia: Produces profound analgesia(particularly
somatic) that is adequate for many surgical procedures.
4. Amnesia: Total lack of recall is routinely affected.
5. Maintenance of reflexes: Upper airway reflexes usually
remain intact and active.  However, these reflexes cannot be
relied upon to prevent aspiration of gastric contents or
other foreign material from oral cavity.
6. Cardiorespiratory Stability.
7. Nystagmus: Vertical nystagmus will be universally noted
in patients in the dissociative anesthetic state.
 
 
 
KETAMINE METHODS OF ADMINISTRATION AND DOSAGES:
 
Forms - 100 mg/ml - 5ml bottle
 
Single Drug Dosing
IM only
2-3 mg/kg
     (this should be adequate for a 15-20 minute procedure)
mix with Robinul
 
P.O.
6 mg/kg in 0.2cc/kg of Cola Drink; do not use grape drink
    Light sedation is expected.  Vomiting is occasional.
 
 
Combination Drug Dosing (e.g.Ketamine & Versed)
IM only
Ketamine - 2-3 mg/kg
Versed   - 0.05 - 0.1 mg/kg   maximum dose - 5mg
Robinul  - 0.005 - 0.01 mg/kg  maximum dose - 0.2mg
    Mix together in same syringe
    (this should be adequate for a 20-25 minute procedure)
 
 
 
Ketamine Hcl
 
Combination Drug Dosing (e.g.Ketamine & Versed)
IM/IV combination
IM Induction dose -   0.5-2.0 mg/kg
IV access obtained
Additional doses every 10 minutes as deemed necessary to
  produce the desired anesthesia.
IV dose -   0.25mg/kg       * slowly over 60 seconds !
Consider combining with Versed and Robinul
 
IV only
Induction dose -  0.25mg/kg   * slowly over 60 seconds !
Additional doses every 10 minutes as deemed necessary to
  produce the desired anesthesia.
Consider combining with Versed and Robinul
 
CONTRAINDICATIONS
Upper Respiratory Infection
Acute Pulmonary Infection
Head Injury associated with loss of consciousness, altered
   mental status, or emesis
CNS mass lesions, hydrocephalus, or other conditions
   associated with intracranial hypertension
Glaucoma or acute global injury
Thyroid disorder or medication
 
 
Ketamine Hcl
POTENTIAL SIDE EFFECTS
Hypersalivation(13%)
Muscle hypertonicity(48%)
Transient clonus(2%)
Transient stridor or Laryngospasm(2%)
     (requiring intervention - 1%)
Emesis while sedated (1%)
Emesis well into recovery(6%)
Transient rash(18%)
Unpleasant agitation(1%)
 
Use of Robinul concomitantly should be considered, routinely
 
 
EMERGENCE PHENOMENON:
Mechanism of action
- animal studies show a depression of the inferior
colliculus and medial geniculate( centers responsible for
auditory transmission)
     - disconnects clinical sensation and proprioception
     - this loss of external stimuli leads to:
       - sense of body detachment
       - psychic reactions- ? "weird trips"
Incidence
     Adults - 0-50%
     Children - 0-8%
 
 
Ketamine Hcl
Risk Factors for Emergence Phenomenon
- older age( usually over 10y/o)
- female sex
- rapid IV administration
- vivid frequent dreams
- excessive noise and stimulation
- psychic and neurotic traits
 
- Using positive psychology in 90 treated adults, there
were no unpleasant reactions.
   Reference - Skiar, GS, etal, Anesthesia, 1981, (38)2
 
Reducing Emergence Phenomenon
- reduce stimuli during recovery
- use appropriate dose
     (there have been some reports of an inverse relationship
       between dose and the risk of emergence phenomenon)
- coadminister benzodiazepines
 
Upsetting/Emergence reactions in children
- rare in children
- almost exclusively in over 10 y/o
- dreams are presen