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Proper Use of Ketamine and Innovar

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Proper Use of Ketamine and Innovar Proper Use of Ketamine and lnnovar* GUENTER CORSSEN, M.D. Professor and Chairman, Department of Anesthesiology, University of Alabama School of Medicine, Birmingham, Alabama KETAMINE. Success or failure with the use of Use of ketamine predominantly in infants ketamine depends largely on three factors: and children up to 14 years of age. 1. Awareness that ketamine is different from traditional anesthetics. These differences in­ The use of ketamine in adult patients is con­ clude the following: fined to surgical conditions for which keta­ mine has proven to be particularly advan­ Ketamine, unlike traditional anesthetics tageous, safe, and superior to conventional which cause total depression of the central anesthetic agents and methods ( see under 3). nervous system, affects selectively pain con­ duction and perception systems, stimulating Narcotic addicts and patients with a history one area of the brain while simultaneously of chronic alcohol abuse or suffering from depressing another ("dissociation") . acute alcohol intoxication are poor candi­ dates for ketamine anesthesia because in Ketamine stimulates the cardiovascular sys­ these patients even excessive doses of keta­ tem while traditional anesthetics depress car­ mine may fail to control body movements. diovascular function. 3. Limiting the use of ketamine anesthesia to Ketamine has antiarrhythmic properties while the following specific surgical areas and con­ traditional anesthetics do not. They may ditions: even precipitate arrhythmias. Surgical treatment of burns* Ketamine maintains or even exaggerates pro­ tective reflexes while traditional anesthetics Neurodiagnostic procedures such as pneu­ suppress them. moencephalography, ventriculography, mye­ lography, and carotid arteriography. Ketamine ensures airway patency, provided no mechanical airway obstruction is present, Out-patient ophthalmology (tonometry, fun­ while traditional anesthetics require addi­ doscopy, gonioscopy). tional tools and techniques. Out-patient oral surgery (tooth extraction, surgery on the gingiva). Ketamine does not produce the traditional "anesthetized" appearance in the patient, but Out-patient otology ( myringotomy, insertion rather a characteristic "disconnected" ap­ of myringeal tubes, removal of foreign body pearance. from ear canal) . 2. Knowledge of the criteria used for selection Out-patient plastic surgery (removal of nevi, of patients for ketamine anesthesia: suturing of laceration, removal of scars). * Presented at the 25th Annual Stoneburner Lecture Series, February 25, 1972, at the Medical College of Vir­ ginia, Richmond. * Patients of all ages may be included. MCV QUARTERLY 8(2): 85-90, 1972 85 86 CORSSEN : PROPER USE OF KETAMINE & INNOVAR Elective orthopedic surgery (reduction of prior to surgery. Other combinati ons of narcotic congenital hip luxation, spic acast applica­ analgesics, tranquilizers, and ataractics have proven tion) . less effective as compared with the above-mentioned Emergency orthopedic surgery ( closed re­ medication. duction of fr actures). Omitting narcotics or barbiturates in the pre­ anestheti c medicati on will significantly shorten re­ Repeated manipulation under anes thesia (ir­ covery time. No pre-anesthetic medi cati on is given to radiation of inoperable int raocul ar or intra­ patients undergoing ambulatory surgery provided crani al lesions) . that the surgical procedure is limited to 15 minutes. Induction: With the intravenous route, the initial Induction of anesthes ia in high-risk pa­ dose of ketamine ranges fr om 1 to 2 mg per kg de­ tients, including asthmatics, prior to the use pending on the physical state of the pati ent. It is of the principle anesthetic. Ketamine-in­ recommended that ketamine be administered slowly, duced cardiovascular stimulation and its re­ over a peri od of 30 to 60 seconds. More rapid ad­ laxant effect on bronchial muscul ature offer ministration may result in respiratory depression. significant advantages over conventional an­ With the intramuscular route, the initial dose of esthetic agents. * ketamine ranges from 6 to 12 mg per kg. Main tenance: Supplemental in crements of 1/ 2 Cardiac catheteri zation. to 1/ 3 of the full induction dose may be administered intravenously every 8 to 10 minutes or intramuscu­ Open heart surgery, particul arly in volving larly every 20 to 30 minutes, or when movements of patients with minimal or no cardiac reserve. head or extremities indicate lightening of anesthesia. Cardiovascular stimulati on and antiarrhyth­ Complications. The foll owing complications may mic affe cts of ketamine offer prime advan­ be encountered : tages over traditional anesthetics.* Temporary augmentation of pulse rate and blood pressure beginning shortly aft er injection of the Emergency surge ry in pati ents suffering drug. This cardiovascul ar-stimulating effect of keta­ from hypovolemia or shock-like conditions. mine may prove benefi cial in certain circumstances, Ketamine may be used fo r induction or to for example, in the presence of hypotension or shock­ enhance minimal conventional anesthesia. It like states. In hypertensive individuals, however, offers the advantage of ensuring cardiovas­ stimulati on may be considered undesirable or unsafe. cul ar support until conventional measures to T ransient depression of respiration in res ponse control hypovolemi a and shock can be in­ to rapid intravenous injection or in connection with stituted and become effecti ve.* an overdose of ketamine. Contraindications. Ketamine is contraindicated Paroxysmal coughing in the presence of upper with hypertension, history of cerebrovascul ar acci­ respiratory infection, occurring immediately follow­ dent, upper respiratory infection, increased cerebro­ ing the initial injection of ketamine and recurring spinal fluid pressure, abdominal surge ry, and other with supplemental increments. surgery in volving vi sceral pain ( unless supplemented Vivid dreaming, with or without psychomotor with conventional anesthetics). activity, confusion, and irrational behavior occurring Technique of Administration of Ketamine. during emergence from anesthesia. This complication Pre-anesthetic medication: Infa nts and children is more often observed in adults th an in children and receive scopolamine 0.1 to 0.4 mg, depending on age infa nts. and weight, given intramuscularly 1/2 to 1 hour prior Tonic and clonic muscle movements resembling to surgery to counteract ketamine-induced hypersali­ convulsive seizures occurring in certain patients with­ vati on. Pentobarbital or secobarbital (0.5 to 1 mg out el ectroencephalographic evidence of seizure ac­ per pound) may be given fo r additional sedation. tivity. Adult patients receive a tranquilizer with anti­ Eryth ema or morbillifo rm rash occurring subse­ psychotic properties, preferably droperidol ( 1 to 2 ml) quent to the initial injecti on of ketamine. The skin or Innovar® ( 1 to 2 ml ) combined with 0.4 mg of eruption is transient and usually confi ned to face, atropine administered intramuscularly 1/2 to 1 hour neck, and upper chest. CORSSEN: PROPER USE OF KETAMINE & INNOVAR 87 Treatment of Complications. Proper pre-anes­ Properly administered and with due regard for thetic medication as outlined above may signficantly its specific advantages as well as its possible disad­ suppress or even eliminate most adverse reactions. vantages, ketamine may prove superior to conven­ This holds particularly true with regard to post-anes­ tional anesthetic agents and methods in a variety of thetic emergence delirium reactions. The incidence specific surgical procedures. and degree of these psychic disturbances can be fur­ INNOVAR . Innovar is a mixture of two drugs : ther minimized by avoiding premature verbal or droperidol, a butyrophenone derivative, with strong tactile stimulation of the patient ( "sensory depriva­ tranquilizing, antiemetic, and adrenergic-blocking tion") . properties; and fen/any/, a powerful narcotic analgesic Post-anesthetic emergence delirium reactions, related to meperidine which differs from conven­ should they occur in spite of proper pre-anesthetic tional narcotics by its high potency and its fast onset medication, may be successfully treated with intra­ and short duration of action. The two drugs are venous droperidol-1 to 2 ml. Also recommended mixed in a ratio of 50 to I. When administered in­ are ultra short-acting barbiturates such as pentothal travenously in appropriate doses, a state of neuro­ or surital administered intravenously at doses of 75 leptanalgesia is produced in which the patient is to 100 mg. rendered immobile and insensitive to pain. His face Tonic and clonic movements during anesthesia being expressionless, the patient appears detached may be effectively treated with small intravenous from his surroundings, yet he remains alert and co­ doses (2 to 5 mg) of diazepam (Valium®). operative. Respiratory function is depressed and it Ketamine does not provide adequate control of may be necessary to assist or control the respiration pain originating from the viscera. Therefore, the via a face mask or endotracheal tube. If nitrous drug is not recommended for use as a sole anesthetic oxide-oxygen mixtures are added to produce sleep in abdominal or thoracic surgery or where visceral and memory deficit, the state of neuroleptanesthesia pain is expected to occur. In order to control visceral is established. pain, ketamine may be supplemented with other gen­ Innovar or its separate component drugs, drop­ eral anesthetic agents. eridol and fentanyl, can and
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