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Disclaimer to the On-line Edition
This Manual has been designed for use in the NICU at London Health Sciences Centre (LHSC), London, Ontario, Canada, and represents clinical practice at this institution. The information contained within the Manual may not be applicable to other centres. If users of this Manual are not familiar with a drug, it is recommended that the official monograph be consulted before it is prescribed and administered. Any user of this information is advised that the contributors, Editor and LHSC are not responsible for any errors or omissions, and / or any consequences arising from the use of the information in this Manual.

KETAMINE

Indication

  • Ketamine is a rapid acting, non-barbiturate general anesthetic which produces profound analgesia and therefore may be useful in certain short procedures (eg. painful dressings, debridement)

Pharmacology

  • Ketamine produces an amnesic state in which the patient may appear to be awake (eyes may remain open, nystagmus may be present) but is immobile and unresponsive to pain. The analgesia may result from interference with afferent signals associated with the perception of pain or binding with opiate receptors.
  • Ketamine produces an increase in systemic blood pressure and an increase in heart rate. This has occurred in approximately 25% of patients who have received Ketamine. This increased blood pressure, in association with cerebral vasodilation caused by Ketamine, is thought to be the primary reason for an increased cerebral blood flow and an increased cerebrospinal fluid (CSF) pressure
  • Pulmonary artery pressure and right ventricular stroke work is markedly elevated secondary to increased pulmonary vascular resistance caused by Ketamine
  • Ketamine also possesses a direct myocardial - depressant effect that is often unrecognized because of the sympathomimetic stimulation

Side Effects

  • temporary (approximately 15 minutes in adults) increase in heart rate and blood pressure
  • transient respiratory depression and apnea may occur (increased incidence with rapid administration)
  • increased salivation
  • enhanced muscular tone (rigidity, athetoid motions of the mouth and tongue, generalized extensor spasm)

Precautions

  • contraindicated in infants with history of intraventricular hemorrhage
  • contraindicated in those infants in whom a significant elevation of blood pressure would constitute a serious hazard

Nursing Implications

  • closely monitor blood pressure and heart rate (every 5 minutes for first 30 minutes, then every 15 minutes for an additional hour)
  • careful mouth care and airway management (because of increased salivation); be aware of possible aspiration

Miscellaneous

  • the Ketamine - induced cardiovascular stimulation may be significantly reduced by premedication with diazepam (0.1 to 0.2 mg/kg IV). Diazepam has been shown to prolong the half-life of Ketamine and to delay recovery from Ketamine anaesthesia
  • chronic administration of Ketamine to laboratory animals has resulted in an increase in activity of hepatic drug-metabolizing enzymes. This could modify responses to repeated administration of the drug; infants who receive repeated doses of the drug could possibly develop tolerance to the analgesic effects of ketamine.

Dose

  • for sedation and analgesia
  • IV:0.5 mg/kg
     :given over 60 seconds, by physician only
     :if response is inadequate this dose may be repeated 30 minutes after initial dose
  • IM:3 mg/kg by physician only
     :if response is inadequate this dose may be repeated 30 minutes after initial dose
  • length of analgesia may range from about 10 to 40 minutes
  • THE INFANT MUST BE ON A CARDIAC MONITOR

Supplied

  • a slightly acid (pH 3.5-5.5) solution for IV or IM injection
  • l0 mg/mL, 20 mL vial; solution contains 0.01% benzethonium chloride as a preservative; it is made isotonic with sodium chloride

References

  1. Roberts, RJ: Drug Therapy in Infants, W.B. Saunders, Toronto, 1984.
  2. Anon, Ketalar(R), Product Insert, Parke-Davis.
  3. White PF, Way WL and Trevor AJ: Ketamine - its pharmacology and therapeutic use, Anaesthesiology 1982; 56: 119-136.
  4. Taketomo CK, Hodding JH and Kraus DM: Pediatric Dosage Handbook, Lexi-Comp Inc., Cleveland, 1992.
  5. Yaffe SJ and Aranda JV (Eds): Pediatric Pharmacology-Therapeutic Principles in Practice, WB Saunders Co, Toronto, Ontario 2nd Edition, 1992.



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