Incidence and predictors of respiratory adverse events in children undergoing procedural sedation with intramuscular ketamine in a paediatric emergency department

INTRODUCTION@#Although ketamine is one of the commonest medications used in procedural sedation of children, to our knowledge, there is currently no published report on predictors of respiratory adverse events during ketamine sedation in Asian children. We aimed to determine the incidence of and factors associated with respiratory adverse events in children undergoing procedural sedation with intramuscular (IM) ketamine in a paediatric emergency department (ED) in Singapore.@*METHODS@#A retrospective analysis was conducted of all children who underwent procedural sedation with IM ketamine in the paediatric ED between 1 April 2013 and 31 October 2017. Demographics and epidemiological data, including any adverse events and interventions, were extracted electronically from the prospective paediatric sedation database. The site of procedure was determined through reviewing medical records. Descriptive statistics were used for incidence and baseline characteristics. Univariate and multivariate logistic regression analyses were performed to determine significant predictors.@*RESULTS@#Among 5,476 children, 102 (1.9%) developed respiratory adverse events. None required intubation or cardiopulmonary resuscitation. Only one required bag-valve-mask ventilation. The incidence rate was higher in children aged less than three years, at 3.6% compared to 1.0% in older children (odds ratio [OR] 3.524, 95% confidence interval [CI] 2.354-5.276; p < 0.001). Higher initial ketamine dose (adjusted OR 2.061, 95% CI 1.371-3.100; p = 0.001) and the type of procedure (adjusted OR 0.190 (95% CI 0.038-0.953; p = 0.044) were significant independent predictors.@*CONCLUSION@#The overall incidence of respiratory adverse events was 1.9%. Age, initial dose of IM ketamine and type of procedure were significant predictors.

Comparison of the effects of magnesium and ketamine on postoperative pain and morphine consumption. A double-blind randomized controlled clinical study

PURPOSE: To compare the effects of magnesium sulfate and ketamine on postoperative pain and total morphine consumption in a placebo-controlled design. METHODS: One hundred and twenty women scheduled for total abdominal hysterectomy were included in this prospective, randomized, double-blind study. Postoperatively, when the Numeric Pain Rating Scale (NPRS) was four or more, IV-PCA morphine was applied to all patients. The patients were randomized into three groups: Group K ketamine, Group M magnesium, and Group C saline received as infusion. Total morphine consumption for 48h, pain scores, adverse effects, and patients' satisfaction were evaluated. RESULTS: Total morphine consumption was significantly lower in Group K (32.6±9.2 mg) than in Group M (58.9±6.5 mg) and in Group C (65.7±8.2 mg). The satisfaction level of patients in Group K was higher than the other two groups (p<0.05). Pruritus and nausea were observed more frequently in Group C. CONCLUSİON: The addition of ketamine to IV-PCA morphine reduces the total consumption of morphine without psychotic effects; however, magnesium did not influence morphine consumption.

Comparative study between propofol and propofol-ketamine for induction of anesthesia in dogs / Estudo comparativo entre propofol e propofol-cetamina para a indução anestésica em cães

Anesthetic procedures in animals are widely used in hospital for routine surgery. For induction of anesthesia in dogs, propofol has been shown to be the drug of choice. The objectives of this study were the assessment of induction of anesthesia using propofol or propofol-ketamine. Twenty client-owned dogs were randomly assigned to treatment and control groups. All patients were administered acepromazine (0.05 mg kg-1) and fentanyl (5 μg kg-1) for premedication by intramuscular (IM) injection. Dogs in the treatment group were administered ketamine (1 mg kg-1), while dogs in the control group were administered 0.9% saline solution, by intravenous (IV) injection. Induction of anesthesia was done using IV propofol at a rate of 1 mL minute-1. Cardiopulmonary patterns were assessed before application of premedication, 15 minutes after application of premedication and after induction of anesthesia with propofol. Additionally, data regarding tracheal intubation score, presence of adverse effects and dose of propofol necessary for induction of anesthesia were collected. The control group showed significantly more adverse effects and changes in cardiopulmonary patterns when compared to the treatment group. There was a clinically significant reduction in the dose of propofol necessary for induction of anesthesia when associated with ketamine. The association of ketamine for induction of anesthesia in healthy dogs using propofol was able to reduce the dose of the induction agent necessary for tracheal intubation. Moreover, there was a reduction in the occurrence of adverse effects and cardiopulmonary depression, which allowed for a safer procedure for the patients...

Os procedimentos anestésicos em animais são amplamente utilizados em hospitais para cirurgias de rotina. Para a indução anestésica em cães o propofol tem se mostrado o fármaco de escolha. O objetivo deste estudo foi a avaliação da indução anestésica com propofol ou propofol-cetamina. Vinte cães foram divididos de forma aleatória nos grupos com tratamento e controle. Em todos os pacientes administrou-se acepromazina (0,05 mg kg-1) e fentanil (5 µg kg-1) como medicação pré-anestésica por via intramuscular (IM). Nos cães do grupo de tratamento foi administrado cetamina (1 mg kg-1), enquanto que os cães do grupo controle receberam solução salina a 0,9%, pela via intravenosa (IV). A indução da anestesia foi realizada com propofol IV a uma taxa de 1 mL minuto-1. Os padrões cardiopulmonares foram avaliados antes da aplicação da medicação pré-anestésica, 15 minutos após a mesma e após a indução da anestesia. Além disso, avaliou-se o escore de intubação traqueal, a presença de efeitos adversos e a dose de propofol necessária para a indução da anestesia. De forma significativa, o grupo controle apresentou mais efeitos adversos e alterações nos padrões cardiopulmonares quando comparado com o grupo de tratamento. Houve uma redução clinicamente importante da dose de propofol necessária para a indução de anestesia quando associado à cetamina. A associação de cetamina ao propofol para indução de anestesia em cães saudáveis foi capaz de reduzir a dose do anestésico geral necessária para intubação traqueal. Além disso, houve uma redução na ocorrência de efeitos adversos e depressão cardiopulmonar, o que permitiu um procedimento mais seguro para os pacientes...

Avaliação dos valores de troponina I, eletrocardiograma e ecocardiograma em felinos sedados com cetamina e midazolam, suplementados ou não com oxigênio / Troponin I, electrocardiography and echocardiography values in felines sedated with ketamine and midazolam, supplemented or not with oxygen

Lesões no miocárdio, causadas por baixa perfusão e oxigenação cardíaca, podem ser ocasionadas por fármacos anestésicos, como a cetamina. Essas lesões podem ser identificadas por meio de biomarcadores específicos e, dentre estes, destaca-se a troponina I. O objetivo deste estudo foi avaliar as alterações cardiovasculares com base nos valores de troponina I (TnI), eletrocardiograma (ECG) e ecocardiograma em gatos sedados com cetamina e midazolam, suplementados ou não com oxigênio. Utilizaram-se 12 gatos machos, hígidos, nos quais se avaliaram os valores de troponina I, eletro e ecocardiografia, frequência cardíaca (FC) e pressão arterial sistólica (PAS) no momento basal (M0). Na sequência, os animais foram sedados com a associação de 10mg.kg-1 de cetamina e 0,5mg.kg-1 de midazolam pela via intramuscular. Decorridos aproximadamente 10 minutos, os animais foram alocados aleatoriamente em dois grupos: com e sem suplementação de oxigênio via máscara facial (GCO e GSO, respectivamente), sendo submetidos novamente aos exames citados. Foram coletadas amostras sanguíneas, para dosagem de TnI em seis, 12 e 24 horas após a administração dos agentes anestésicos. Não foram observadas alterações significativas na FC, na PAS e no ECG após a administração dos tratamentos em ambos os grupos. Os valores médios de TnI elevaram-se significativamente em T6 quando comparados ao basal em ambos os grupos, com médias de 0,507±0,335ng/mL no GSO e 0,777±0,505ng/mL no GCO. Na ecocardiografia, o débito cardíaco (DC) reduziu em M1 em ambos os grupos, quando comparados aos valores basais, sendo M0 0,472±0,115 e M1 0,234±0,08 no GSO e M0 0,356±0,095 e M1 0,222±0,09 no GCO, expressos em L/min. Conclui-se que a administração de cetamina e midazolam em gatos hígidos não promove alterações eletrocardiográficas, aumenta os valores de troponina I, com pico de seis horas após a administração, reduz o débito cardíaco, e que a suplementação de oxigênio 100% via máscara facial não atenua tais alterações.

Myocardium injuries caused by low myocardial oxygenation and perfusion might be induced by anesthetics agents like ketamine. These injuries can be detected by specific biomarkers and, among them, troponin I. The aim of this study was to evaluate the cardiovascular changes based on troponin I (TnI) values, electrocardiography (ECG) and echocardiography in cats sedated with ketamine and midazolam, supplemented or not with oxygen. Blood samples were collected from 12 intact male healthy cats for troponin I (T0) and they were then submitted to electrocardiographic and echocardiographic evaluation, as well as measurements of heart rate (HR) and systolic blood pressure (SBP) (M0). Subsequently, they were ketamine-midazolam (10mg.kg-1 and 0,5 mg.kg-1 respectively) anesthetized by intramuscular route. After about 10 minutes, the animals were randomly allocated into two groups with or without oxygen supplementation (GCO or GSO, respectively), again being subjected to the tests mentioned. Blood samples for troponin I were collected at 6, 12 and 24 hours after sedation. HR, SBP and ECG did not change among groups. The TnI values rise significantly in T6 comparing to baselines in both groups (0,507±0,335 ng/mL in GSO and 0,777±0,505 ng/mL in GCO). In echocardiography, the cardiac output decreased at M1, in both groups compared to baseline (M0 0,472±0,115 and M1 0,234±0,08 in GSO and M0 0,356±0,095 and 0,222±0,09 in GCO, L/min). We concluded that ketamine and midazolam sedation in healthy cats did not cause changes electrocardiography, increase troponin I values, with an 6 hours peak after administration, reduces cardiac output and oxygen supplementation, via facial mask, did not attenuated these alterations.

Preemptive analgesia effects of Ketamine in patients undergoing surgery. A meta-analysis

PURPOSE: To evaluate the preemptive analgesia effects of ketamine for postoperative pain. METHODS: PubMed, EMBASE and Cochrane Library were searched to identify randomized controlled trials (RCTs) involved in ketamine for preemptive analgesic up to March 2013. The relative risk (RR) or mean difference (MD) as well as the confounding 95% confidence interval (CI) were calculated by the Revman 5.0 software. RESULTS: A total of five studies including 266 patients were included in this meta-analysis. Overall, ketamine could reduce the postoperative morphine consumption and significantly prolong the time to first analgesic (p < 0.00001, MD = 0.91, 95% CI: 0.56 to 1.26). However, there was no significant difference in indicators of nausea and vomiting (p = 0.87, RR = 1.04, 95% CI: 0.67 to 1.60), surgical time (p = 0.41, MD = -2.13, 95% CI: -7.21 to 2.95) and anesthetic time (p = 0.53, MD = -1.54, 95% CI: -6.34 to -3.26) between ketamine and control group. CONCLUSIONS: Ketamine was able to accomplish some preemptive analgesic effects of reducing postoperative morphine consumption and prolonging the time to first analgesic. Meanwhile, ketamine was as safe as physiological saline in side effects of nausea and vomiting. .

Sympathetic activity of S-(+)-ketamine low doses in the epidural space / Atividade simpática de cetamina S-(+) em doses baixas no espaço epidural / Actividad simpática de la ketamina S(+)-en dosis bajas en el espacio epidural

BACKGROUND AND OBJECTIVES: S-(+)-ketamine is an intravenous anaesthetic and sympathomimetic with properties of local anaesthetic. It has an effect of an analgetic and local anaesthetic when administered epidurally, but there are no data whether low doses of S-(+)-ketamine have sympathomimetic effects. The aim of this study was to determine whether low doses of S-(+)-ketamine, given epidurally together with local anaesthetic, have any effect on sympathetic nervous system, both systemic and below the level of anaesthetic block. METHODS: The study was conducted on two groups of patients to whom epidural anaesthesia was administered to. Local anaesthesia (0.5% bupivacaine) was given to one group (control group) while local anaesthesia and S-(+)-ketamine were given to other group. Age, height, weight, systolic, diastolic and mean arterial blood pressure were measured. Non-competitive enzyme immunochemistry method (Cat Combi ELISA) was used to determine the concentrations of catecholamines (adrenaline and noradrenaline). Immunoenzymometric determination with luminescent substrate on a machine called Vitros Eci was used to determine the concentration of cortisol. Pulse transit time was measured using photoplethysmography. Mann-Whitney U-test, Wilcoxon test and Friedman ANOVA were the statistical tests. Blood pressure, pulse, adrenaline, noradrenaline and cortisol concentrations were measured in order to estimate systemic sympathetic effects. RESULTS: 40 patients in the control group were given 0.5% bupivacaine and 40 patients in the test group were given 0.5% bupivacaine with S-(+)-ketamine. Value p < 0.05 has been taken as a limit of statistical significance. CONCLUSIONS: Low dose of S-(+)-ketamine administered epidurally had no sympathomimetic effects; it did not change blood pressure, pulse, serum hormones or pulse transit time. Low dose of S-(+)-ketamine administered epidurally did not deepen sympathetic block. Adding 25 ...

JUSTIFICATIVA E OBJETIVOS: cetamina S-(+) é um anestésico intravenoso e simpaticomimético com propriedades de anestésico local. Tem efeito analgésico e de anestésico local quando administrada por via epidural, mas não há dados que relatem se cetamina S-(+) em doses baixas tem efeitos simpaticomiméticos. O objetivo deste estudo foi determinar se cetamina S-(+) em doses baixas, administrada por via epidural em combinação com anestésico local, tem algum efeito sobre o sistema nervoso simpático, tanto sistêmico quanto abaixo do nível do bloqueio anestésico. MÉTODOS: o estudo foi conduzido com dois grupos de pacientes submetidos à anestesia epidural. Anestesia local (bupivacaína a 0,5) foi administrada a um grupo (controle), enquanto anestesia local em combinação com cetamina S-(+) foi administrada ao outro grupo (teste). Idade, altura, peso, pressão arterial sistólica e diastólica e pressão arterial média foram medidos. O método imunoquímico de inibição enzimática não competitiva (Cat Combi Elisa) foi usado para determinar as concentrações de catecolaminas (adrenalina e noradrenalina). O ensaio imunoenzimométrico com substrato luminescente em uma máquina chamada Vitros Eci foi usado para determinar a concentração de cortisol. O tempo de transição do pulso foi medido com fotopletismografia. Para análise estatística, os testes de Wilcoxon, U de Mann-Whitney e Anova de Friedman foram usados. Pressão arterial, pulso e concentrações de adrenalina, noradrenalina e cortisol foram medidos para estimar os efeitos simpáticos sistêmicos. RESULTADOS: receberam bupivacaína a 5% 40 pacientes do grupo controle e 40 do grupo teste receberam bupivacaína a 0,5% com cetamina S-(+). Um valor de p < 0,05 foi ...

JUSTIFICACIÓN Y OBJETIVOS: la ketamina S(+) es un anestésico intravenoso y simpaticomimético con propiedades de anestésico local. Posee un efecto analgésico y de anestésico local cuando se administra por vía epidural, pero no existen datos que informen si la ketamina S(+) en bajas dosis tiene efectos simpaticomiméticos. El objetivo de este estudio fue determinar si la ketamina S(+) en bajas dosis y administrada por vía epidural en combinación con el anestésico local tiene algún efecto sobre el sistema nervioso simpático, tanto sistémico como por debajo del nivel del bloqueo anestésico. MÉTODOS: el estudio fue realizado con 2 grupos de pacientes sometidos a anestesia epidural. A un grupo (grupo control) se le administró la anestesia local (bupivacaína al 0,5), mientras que a otro se le administró la anestesia local en combinación con la ketamina S(+). La edad, altura, peso, presión arterial sistólica y diastólica y la presión arterial media se midieron. El método inmunoquímico de inhibición enzimática no competitiva (Cat Combi ELISA) se usó para determinar las concentraciones de catecolaminas (adrenalina y noradrenalina). El ensayo inmunoenzimométrico con sustrato lumínico en una máquina llamada Vitros Eci fue usado para determinar la concentración de cortisol. El tiempo de transición del pulso fue medido usando la fotopletismografía. Para el análisis estadístico se usaron los test de Wilcoxon, U de Mann-Whitney y ANOVA de Friedman. La presión arterial, pulso y concentraciones de adrenalina, noradrenalina y cortisol fueron medidos para estimar los efectos simpáticos sistémicos. RESULTADOS: cuarenta pacientes del grupo control recibieron bupivacaína al 5% y 40 pacientes del grupo test recibieron bupivacaína al 0,5% con ketamina ...

Remifentanil-based total intravenous anesthesia for pediatric rigid bronchoscopy: comparison of adjuvant propofol and ketamine

OBJECTIVE: Laryngoscopy and stimuli inside the trachea cause an intense sympatho-adrenal response. Remifentanil seems to be the optimal opioid for rigid bronchoscopy due to its potent and short-acting properties. The purpose of this study was to compare bolus propofol and ketamine as an adjuvant to remifentanil-based total intravenous anesthesia for pediatric rigid bronchoscopy. MATERIALS AND METHODS: Forty children under 12 years of age who had been scheduled for a rigid bronchoscopy were included in this study. After midazolam premedication, a 1 µg/kg/min remifentanil infusion was started, and patients were randomly allocated to receive either propofol (Group P) or ketamine (Group K) as well as mivacurium for muscle relaxation. Anesthesia was maintained with a 1 µg/kg/min remifentanil infusion and bolus doses of propofol or ketamine. After the rigid bronchoscopy, 0.05 µg/kg/min of remifentanil was maintained until extubation. Hemodynamic parameters, emergence characteristics, and adverse events were evaluated. RESULTS: The demographic variables were comparable between the two groups. The decrease in mean arterial pressure from baseline values to the lowest values during rigid bronchoscopy was greater in Group P (p = 0.049), while the reduction in the other parameters and the incidence of adverse events were comparable between the two groups. The need for assisted or controlled mask ventilation after extubation was higher in Group K. CONCLUSION: Remifentanil-based total intravenous anesthesia with propofol or ketamine as an adjuvant drug along with controlled ventilation is a viable technique for pediatric rigid bronchoscopy. Ketamine does not provide a definite advantage over propofol with respect to hemodynamic stability during rigid bronchoscopy, while propofol seems more suitable during the recovery period. .

Efeitos sedativos da associação de Cetamina e Midazolam administrados pela via intranasal ou intramuscular em papagaio (Amazona aestiva e Amazona vinacea) / Sedative effects of the association Ketamine and Midazolam administered intranasally or intramuscular in parrots (Amazona aestiva and Amazona vinacea)

A falta de protocolos de sedação seguros para uso em papagaios na literatura demonstra a necessidade de conhecer os anestésicos que são eficazes nestes animais. Devido a pouca massa muscular desta espécie, notou-se a necessidade de estudar outra via de administração, menos invasiva e dolorosa ao animal, como a via intranasal. O objetivo deste estudo foi avaliar os efeitos sedativos e a viabilidade da administração intranasal, em comparação à via intramuscular, de 15mg/kg de Cetamina e 1mg/kg de Midazolam. Foram utilizados 14 papagaios das espécies Amazona aestiva e Amazona vinacea, de ambos os sexos, adultos, peso médio de 388,5±29,1g. Os animais foram distribuídos aleatoriamente em dois grupos: intramuscular (IM, n=7) e intranasal (IN, n=7). No grupo intramuscular, a administração dos anestésicos foi realizada nos músculos peitorais, utilizando seringas de insulina e no grupo intranasal, com auxílio de uma micropipeta. Avaliou-se o período de latência, tempo de duração, qualidade de sedação, e o tempo de recuperação total. A média para o período de latência no grupo IM foi de 6,13±2,02 minutos e no grupo IN de 4,84±2,37 minutos. Já para o tempo de duração da sedação no grupo IM a média foi de 35,81±29,56 e no grupo IN de 24,52±14,83 minutos. Ambas as vias promoveram sedação adequada, pois a média do escore da qualidade de sedação obtida pelo grupo IM foi 2±1,5 e pelo grupo IN 1,28±1,1. O tempo de recuperação total no grupo IM foi de 27,04±11,69 e no grupo IN de 17,67±11,64 minutos. Apesar do grupo IN ter apresentado os menores tempos de período de latência, duração e de recuperação total e ter obtido melhor escore na qualidade de sedação, não houve diferença estatística significativa entre os grupos. Os resultados obtidos neste estudo indicam que a administração de 15 mg/kg de cetamina e 1mg/kg de midazolam pela via intranasal ou intramuscular em papagaios (Amazona aestiva e Amazona vinacea) produzem sedação adequada para pequenos procedimentos como colocação de anilha, coleta de sangue e radiografias; porém a via intranasal mostrou ser uma alternativa menos invasiva quando comparado à via intramuscular.

The lack of safe sedation protocols for use in parrots in the literature, demonstrate the need to know that the anesthetics are effective in these animals. Due to low muscle mass this bird, it was noted the need to consider other routes of administration, less invasive and painful to the animal, such as intranasal. The aim of this study was to evaluate sedative effects of intranasal administration compared to intramuscular 15mg.kg-1 of Ketamine and Midazolam 1mg.kg-1. We used 14 parrots (Amazona aestiva and Amazona vinacea), adults, and mean weight of 388.5±29.1g. The animals were randomly into two groups: intramuscular (IM, n=7) and intranasal (IN, n=7). In group intramuscular, administration of anesthetics was performed in the pectoral muscles, using insulin syringes and intranasal group with a micropipette. We evaluated the latency period, duration, quality of sedation, and the total recovery time. The average for the period of latency in the IM group was 6.13±2.02 and IN group 4.84±2.37 minutes. As for the duration of sedation in the IM group was 35.81±29.56 and in IN group 24.52±14.83 minutes. Both pathways promoted adequate sedation, the mean score for the quality of sedation obtained by the IM group was 2±1.5 and 1.28±1.1 in the IN group. The total recovery time in the IM group was 27.04±11.69 and 17.67±11.64 minutes in the IN group. Although the IN group the lowest times of onset, duration and full recovery and have better scores on quality of sedation, there was no statistically significant difference between groups. The results of this study indicate that administration of ketamine (15mg.kg-1) and midazolam (1mg.kg-1) intranasal or intramuscular in parrots (Amazona aestiva/Amazona vinacea) produce adequate sedation for minor procedures, but the intranasal route could be an alternative less invasive when compared to intramuscular injection.

Eficiencia de la combinación ketamina-propofol para procedimientos quirúrgicos cortos / Efficiency of ketamine-propofol combination for short surgical procedures

Determinar la eficacia de la anestesia con ketamina-propofol en una mezcla 1:2 (1 miligramo de ketamina por cada 2 miligramos de propofol) para procedimientos quirúrgicos cortos mínimamente invasivos. Metodología: Se realizó un estudio prospectivo, por medio de la aleatorización de 77 pacientes sometidos a procedimientos quirúrgicos cortos en dos grupos de estudio: el primero recibió una mezcla de ketamina-propofol en una proporción 1:1, y el otro la recibió en una proporción 1:2. Resultados: No se obtuvieron diferencias estadísticamente significativas entre los dos grupos de estudio en edad, género o peso. Al grupo que se le administró menos ketamina recibió más frecuentemente otro tipo de medicamentos para suplementar la analgesia. No hubo diferencias en lo referente a estabilidad hemodinámica o incidencia de efectos adversos. Conclusión: La mezcla ketamina-propofol es probablemente eficaz para garantizar condiciones quirúrgicas adecuadas, y segura evitando la inestabilidad hemodinámica de los pacientes. Dosis inferiores de ketamina a 2 mg/kg pueden requerir adición de medicamentos analgésicos...

To determine the efficacy of anaesthesia with ketamine-propofol in a mixture 1:2 (1 milligram of ketamine per each 2 milligrams of propofol) for short surgical procedures minimally invasive. Methodology: A prospective study through randomization of 77 patients undergoing surgical procedures at two study groups: the first received a mixture of ketamine-propofol in a ratio of 1:1, and the other received it in a proportion 1:2. Results: No statistically significant differences between the two groups of study on age, gender or weight were obtained. The group that received less ketamine most frequently received another type of drugs to supplement analgesia. There were no differences in relation to stability and haemodynamics or incidence of adverse effects. Conclusion: The mix ketamine-propofol is probably effective to secure adequate surgical conditions avoiding hemodynamics instability of the patients. Lower doses of 2 mg/kg ketamine may require addition of pain-relieving medications...

The role of pre-induction ketamine in the management of postoperative pain in patients undergoing elective gynaecological surgery at the University Hospital of the West Indies / El papel de la ketamina de pre-inducción en el tratamiento del dolor postoperatorio en pacientes que se someten a cirugía ginecológica electiva en el Hospital Universitario de West Indies

OBJECTIVES: To determine if a single preoperative dose of ketamine hydrochloride reduces the narcotic analgesic requirements and/or pain scores reported by patients in the first 24 hours postoperatively. METHODS: A single-centred, prospective, case-control study was conducted on 84 patients aged 18-65 years, American Society of Anaesthesiologists (ASA) I and II, undergoing elective gynaecological procedures at the University Hospital of the West Indies (UHWI). Patients were randomly assigned to one of two treatment groups: (a) ketamine group, where patients received intravenous ketamine 0.15 mg/kg pre-induction of anaesthesia; and (b) placebo group, patients received normal saline. The anaesthetic technique was standardized. Postoperatively, patients were interviewed at 15-minute intervals for the first hour, then at 2, 4, 6, and 24 hours to determine their pain scores and any side effects. Timing and dose of opioid analgesics were also recorded. RESULTS: The mean cumulative morphine dose over the first 24 hours postoperatively was 29.6 ±10.8 mg for the ketamine group and 31.9 ± 11.2 mg for the placebo group (p = 0.324). There was also no significant difference in pain intensity measured by the visual analogue scale (VAS) between the groups. Patient age and the type of surgery performed were not found to influence pain intensity. The most common adverse effects were nausea and vomiting (32.5%), dizziness (42.2%), drowsiness and sedation (45.8%) with no significant difference between groups. Both groups had an average in-hospital stay of three days postoperatively, however, the patients in the ketamine group reported higher satisfaction scores than those in the placebo group (p = 0.039). CONCLUSION: Despite no significant reduction in postoperative narcotic requirements or pain intensity, more patients who received ketamine reported higher levels of satisfaction with their pain management.

OBJETIVOS: Determinar si una sola dosis preoperativa de hidrocloruro de ketamina reduce los requerimientos de analgésicos narcóticos y/o puntuaciones de dolor reportados por los pacientes en las primeras 24 horas posteriores a la operación. MÉTODOS: Se llevó a cabo un estudio de caso-control, prospectivo, monocéntrico en 84 pacientes de 18-65 anos de edad, sometidas a procedimientos de ginecologia electiva en el Hospital Universitario de West Indies (HUWI). Los pacientes fueron asignados aleatoriamente a uno de dos grupos de tratamiento: (a) grupo ketamina, en el que los pacientes recibieron una preinducción de anestesia de 0.15 mg/kg de ketamina intravenosa; y (b) grupo placebo, en el que los pacientes recibieron una solución salina normal. La técnica anestésica fue estandarizada. Postoperatoriamente, se entrevis-taron los pacientes a intervalos de 15 minutos durante la primera hora, y más tarde a 2, 4, 6, y 24 horas para determinar sus puntuaciones de dolor, y efectos cualesquiera. También se registraron el tiempo y la dosificación de los analgésicos. RESULTADOS: La dosis promedio de morfina cumulativa promedio en las primeras 24 horas posteriores a la operación, fue de 29.6 ± 10.8 mg para el grupo de ketamina; y 31.9 ± 11.2 mg para el grupo placebo (p = 0.324). No hubo tampoco ninguna diferencia significativa entre los grupos, en cuanto la intensidad de dolor medida mediante la escala visual analógica (EVA). No se halló que la edad del paciente y el tipo de cirugia realizada tuvieran influencia en la intensidad de dolor. Los efectos adversos más comúnes fueron náusea y vómito (32.5%), vértigo (42.2%), adormecimiento y sedación (45.8%), sin diferencia significativa entre los grupos. Ambos grupos tuvieron una estancia intra-hospitalaria promedio de tres dias tras la operación. No obstante, los pacientes del grupo de la ketamina reportaron puntuaciones de mayor satisfacción que los del grupo placebo (p = 0.039). CONCLUSIÓN: Si bien no hubo una reducción significativa en cuanto a requerimientos de narcóticos o intensidad de dolor postoperatorios, más pacientes que recibieron ketamina reportaron niveles más altos de satisfacción con el tratamiento del dolor.

Club drugs: review of the ‘rave’ with a note of concern for the Indian scenario.

'Club drugs’ which include Ecstasy, gamma-hydroxybutyrate (GHB), ketamine, and Rohypnol (flunitrazepam) have become popular with participants in ‘raves’, because they are perceived to enhance energy, endurance, sociability and sexual arousal. These drugs vary in their pharmacologic properties, physiological and psychological effects, and potential consequences. The use of club drugs by young people has increased in the last decade, and continue to get modified and evolve, making them very difficult to monitor. Further, these drugs are not picked up by routine drugs screening procedures, thereby making these popular with the criminals. India, which is in a phase of social transition, also faces this rising menace. Despite the nature and extent of this problem, this area has been under-researched. Data from India are sparse barring a few newspaper and police reports. Keeping abreast of current trends in club drug use prepares the clinician to recognize the clinical effects of club drug use, to manage club drug related emergencies, and to generate social awareness.

Estudo hematológico e cardiorrespiratório em cadelas anestesiadas com cetamina-s/xilazina e tiletamina/zolazepam e submetidas a ovário-histerectomia / Hematological and cardio-respiratory study in females dogs anesthetized with cetamine-s/xilazine and tiletamine/zolazepam submitted to ovariohysterectomy

Avaliou-se o efeito de dois protocolos anestésicos dissociativos sobre o perfil do hemograma e cardiorrespiratório utilizando-se 20 cadelas admitidas para o tratamento cirúrgico de ovário-histerectomia. Os animais foram distribuídos em dois grupos (G). Os do GI administraram-se 0,1 mg/kg de acepromazina e 20 minutos após, 10 mg/kg de tiletamina/zolazepam, ambos via intramuscular; no GII, 0,044 mg/kg de sulfato de atropina e, 20 minutos após, 15 mg/kg de cetamina-S e 1 mg /kg de xilazina na mesma seringa, ambos administrados via intramuscular, em estudo duplo-cego. Foi monitorada a pressão arterial sistólica, saturação periférica de hemoglobina, freqüência cardíaca e respiratória e temperatura. Mensuraram-se os parâmetros 30 minutos antes da anestesia, imediatamente antes da anestesia (M0), 15 (M1), 30 (M2), 45 (M3) e 60 (M4) minutos após M0. Para o hemograma coletou-se amostras 30 minutos antes da anestesia, final do estudo (T60) e 24 horas após o término do estudo (T24). Os resultados demostraram que os valores de hematimetria, hemoglobina, hematócrito, volume globular médio e leucócitos totais diminuíram no tempo 60 (T60) e voltaram a normalizarem após 24 horas. Os fármacos em teste não atuaram significativamente sobre os valores de SpO2, pressão arterial sistólica, freqüência cardíaca e respiratória. O emprego de acepromazina, no pré-tratamento à tiletamina/zolazepam promoveu a redução da temperatura corporal. As associações anestésicas em estudo são protocolos viáveis para anestesia em cadelas submetidas a ovário-histerectomia quanto ao perfil hematológico e cardiorrespiratório.

The effect of two dissociative protocols relating to hemogram and cardio-vascular profiles was assessed, using twenty females dogs admitted for surgical treatment of ovariohysterectomy. The animals were divided into two groups (G). To G1, 0.1 mg/kg of acepromazine was administered and twenty minutes later, 10 mg/kg of tiletaminezolazepam, both via intramuscular; to G2, 0.044 mg/kg of atropine sulfate and, twenty minutes later, 15 mg/kg of cetamine-s and 1 mg/kg of xylazine in the same syringe, both via intramuscular, in a double blind study. The arterial systolic blood pressure, peripheral hemoglobin saturation, heart rate, respiratory rate and temperature were monitored. These parameters were measured thirty minutes before the anesthetic, immediately before the anesthetic (M0), 15 (M1), 30 (M2), 45 (M3) and 60 (M4) minutes after M0. For the hemogram, samples were collected 30 minutes before the anesthetic, at the end of the study (T60) and 24 hours after the end of the study (T24). The results showed that the value for the erythrocyte, hemoglobin, hematocritus, mean globular volume and total leucocytes, diminished at the time 60 (T60) and were normalized again after 24 hours. The substances undergoing tests did not react significantly on the SpO2 values, systolic blood pressure, heart beats and respiratory frequency. The use of acepromazine in the pre-treatment for tiletamine/zolazepam led to a diminishment of the body temperature. The anesthetic associations under study are viable protocols for anesthesia in females dogs submitted to ovariohysterectomy, when relating to the hematological and cardiorespiratory profiles.

Dependencia a ketamina y cocaína: reporte de un caso / Ketamine and cocaine dependence: a case report

Presentamos un caso de un paciente varón de 21 años de edad, quien tiene una historia de consumo de sustancias psicoactivas, con criterios de dependencia a cocaína y ketamina, además de probables desórdenes psiquiátricos relacionados. La ketamina es un anestésico considerado dentro de las drogas de club, produce un cuadro de dependencia severo y su uso se ha incrementado en los últimos años.

We report a case of a 21 years old male patient, who has a history of psychoactive substance use, with cocaine and ketamine dependence criteria, and also probable related psychiatric disorders. Ketamine, is an anesthetic considered within the club drugs that produces a frame of severe dependence and its use has increased in recent years.

The correlation between ketamine-induced schizophrenia-like signs in mice and the expressions of NRG1, ErbB4 mRNA / 法医学杂志

OBJECTIVE@#To explore the correlation between signs similar to schizophrenia in mice after ketamine administration and the expressions of NRG1 and ErbB4 mRNA in order to explain the possible pathogenesis of schizophrenia.@*METHODS@#Fifty KM mice were randomly divided into 5 groups which were administered intraperitoneally with saline, clozapine and different dosages ketamine. The ketamine groups were administered intraperitoneally with low dosage (25 mg/kg), middle dosage (50 mg/kg) and high dosage (100 mg/kg) one time every day for 7 days. After administration of 100 mg/kg ketamine for 7 days, the clozapine group was introgastrically administered 20 mg/kg with clozapine one time every day for 7 days. The pathological changes of hippocampus neurons were observed by HE stain. The expressions of the NRG1 and ErbB4 mRNA in hippocampus were detected by reverse transcriptase polymerase chain reaction (RT-PCR).@*RESULTS@#In the group with high dosage of ketamine, the levels of NRG1 and ErbB4 mRNA were significantly lower than that of the group with saline.@*CONCLUSION@#Ketamine may induce signs similar to schizophrenia in KM mice. The mechanism may be involved in the reduction of NRG1 and ErbB4 mRNA expression.

Advances in research of ketamine addiction mechanism / 法医学杂志

Ketamine is a phencyclidine derivative acting primarily as a noncompetitive antagonist of N-methyl-D-aspartate (NMDA) excitatory glutamate receptors. As a common intravenous anaesthetic in clinic, it is also increasingly abused because of its hallucination and addiction effects. Based on the pharmacological and toxicologic characteristics of ketamine and the acknowledged addiction mechanism of other abused drugs, this article reviews the possible addiction mechanism of the ketamine in the aspects of its enhanced effects and reward systems, the anatomic structures, the related receptors and the individual differences.

Ketamina, una antigua droga que renace ante el dolor: parte I / Ketamine, and old drug coming back for pain management: part I

La Ketamina es una antigua droga usada como inductor anestésico, que debido a sus efectos adversos alucinatorios se subutilizó en las últimas décadas, pero debido al avance de las neurociencias y al conocimiento del dolor, renace como un potente medicamento analgésico (antihiperalgésico). Es un bloqueador no competitivo de los receptores NMDA, que son los receptores que se activan cuando el dolor es intenso, se postula que se podría utilizar para disminuir la percepción del dolor. es un neuromodulador del dolor y potenciador de la acción analgésica de los opioides. Los estudios clínicos han evidenciado su uso en el manejo del dolor postoperatorio dentro de una modalidad multimodal, con menor incidencia de náuseas y vómitos que al usar opioides solos y con reacciones adversas de tipo alucinatorias escasas. Las dosis ideales para los distintos tipos de cirugía, actualmente se basan en opiniones de expertos y se requieren mayores estudios. En dolor neuropático y en dolor por cáncer existe evidencia tipo IV, basadas en serie de casos que muestra ser útil. En tolerancia por opioides y en cronificación del dolor postoperatorio existen buenos estudios, pero aún no concluyentes. En conclusión, la ketamina es un fármaco útil, pero se debe conocer muy bien su farmacología para poder usarlo de manera segura y con un buen criterio clínico para el manejo del dolor moderado y/o intenso.

Ketamine is an old drug used in the induction of anesthesia that due to adverse hallucinatory effects has been under utilized during the past decades. However, the advances in neuroscience and a deeper knowledge of pain, ketamine is reborn as a strong analgesic (antihyperalgesic) aid. Ketamine is a non competitive blocker of NMDA receptors that are activated by severe pain and it could be used in pain reduction. Ketamine is a pain neuromodulator and enhancer of the opioids analgesic action. Clinicals trials showed it can be used in post surgery pain management in a number of ways with lessened side effects sunch as nausea and vomiting and scare hallucinatory effects compared to those caused by opioid treatment alone. the ideal dosage for different types of surgery now relies on the opinion of experts, however, further research is required. In neuropathic and cancer pain there is type IV evidence based on a number of cases that proves to be useful. Good trials, but not yet conclusive have been made in matters of tolerance to opioids and post surgery chronic pain. In conclusion, Ketamine is a useful drug, however, a deep knowledge of the same as well as good judgement are required for using it in moderate and/or severe pain management.

Safety profile of parenteral ketamine and lignocaine infiltration in pediatric operations

To study the safety and benefits of parenteral ketamine and lignocaine infiltration among pediatric surgical patients with co-morbidities that would preclude the use of general anesthesia requiring endotracheal intubation/face mask in a developing country. This prospective study was undertaken at the Leadeks Medical Centre, Benin City Edo State, Nigeria between January 2002 and December 2006. Patients requiring surgery were safely operated even in the presence of co-morbidity. A total of 416 children were recruited and they were aged 6 days to 16 years [mean 12 -/+ 2.04 years] with a male/female ratio of 1:1.1. Appendectomy [33.2%], herniotomy [20.2%] and suturing of laceration [15.9%] were the most common indications for surgery. Anemia, upper respiratory tract infections, malnutrition, malaria fever, typhoid fever, and retroviral infections were co-morbidities. Ambulatory surgery was carried out in 48.6% patients. Overall, only 23.3% experienced postoperative pain, which was statistically significant in those that had laparotomy and appendectomy [p<0.0001], and analgesics such as paracetamol were enough to relieve the pain. Complications recorded such as postoperative vomiting, emergence reaction, wound infection, post operative fever, and apnea occurring after ketamine injections were tolerated and no mortality was recorded. The satisfactory anesthesia and analgesia recorded with this combination, and the low complications observed in the presence of co-morbidity showed that these agents have much to offer in a developing country