2006 Annual Scientific Meeting - CLICK FOR PROGRAMME

Ketamine/S Ketamine - how and why

JK Orton, Consultant Anaesthetist, Pennine Acute Hospitals, Oldham

This lecture has its origins in a thread on the SIVA UK website discussion board between Chris Pollock, Barrie Friedberg and others. Dr Barrie Friedburg is an anesthesiologist based in California who practices propofol – ketamine anaesthesia for office based plastic surgery. His website is at

 http://www.doctorfriedberg.com/index.htm

Here he promotes the technique and provides a home grown bibliography, the most important reference being Aesth. Plast. Surg. 23:70–75, 1999, which is a 5 year review of 1264 cases. This is downloadable from his website.

There is also a plug for a book he has edited (‘Anesthesia in Cosmetic Surgery’, out in March ’07) which interestingly has a chapter on the UK perspective by Chris Pollock.

The technique is principally a low level propofol infusion augmented by a sub anaesthetic dose of ketamine (typically 0.5mg/kg), administered shortly after the start of the infusion. The surgical stimulus is catered for by local anaesthetic infiltration. The ketamine provides sufficient depth of anaesthesia to cover the stimulus of local infiltration while countering the respiratory, cardiovascular and airway depressant effects of propofol. The patient breathes room air with added oxygen. Formal airway management is avoided.

When I was asked to provide anaesthetic support for the insertion of implantable defibrillators, this technique seemed to possess many desirable features, namely cardiovascular stability, the capacity to avoid formal airway management, devised to cover what is primarily a local anaesthetic procedure and rapid offset with a reputedly low incidence of nausea and vomiting and minimal psychological sequelae.

During this lecture I will describe the strengths and weaknesses of this technique from personal experience and refer to published research on propofol – ketamine anaesthesia and its applicability to other surgical scenarios.

I will also run through the relevant pharmacology of ketamine and its use in unusual situations.

Finally I will give an account of S – (+) Ketamine, where its advantages lie, what the punters think of it and if it is really what we’re all waiting for.