Oxford Meeting - November 2002

KETAMINE

 Stefan Schraag MD, Department of Anaesthesiology, University of Ulm, Germany

Ketamine has been in clinical use for more than 35 years for emergency cases and field surgery. However, there still remains much to discover about this compound and the clinical applications of ketamine have expanded considerably from its initial use as a dissociative anaesthetic. Presently the analgesic and immunologic properties are continuously being explored, as well as its use for total intravenous anaesthesia.

Until recently the use of ketamine has mainly been restricted to induction of anaesthesia in hypovolaemic or cardiovascularly compromised patients, in paediatric anaesthesia or as a simple, almost complete general anaesthetic for anaesthesia under primitive or poorly equipped conditions. Recent research, however, seems to open the door for a wider use of this interesting and unique drug. The discovery of the role of the NMDA receptor in analgesia, wind-up phenomena and possible opioid tolerance is one major possible application for ketamine. The immunomodulating property is another exciting area of research, which may yield results of importance during septicaenria and hypoxic injury of the brain, heart and other organs. The development of S+-ketamine as a drug with improved clinical properties and potency, less side effects and higher clearance compared with the previously used racemic ketamine is a third area of interest, which looks especially promising in neurosurgery and surgery of patients with cardiac disease as well as a sedative component for critically ill intensive care patients. Its potential role in inflammatory pain modulation on the basis of inhibiting NMDA associated wind-up of nociceptive C-fibers is subject of an increasing number of studies.

The general picture of ketamine side effects such as increased intracranial pressure, increased cardiac risk, high rate of nausea and increased salivation needs to be greatly modified. In particular, S+-Ketamine is now understood as a drug of considerable benefit when used in brain trauma or neuroanaesthesia. Whereas concerns about dose-related psychomimetic effects and rare cases of hallucinations are still valid, the risks of these side effects may be greatly reduced by concomitant use of propofol, midazolam and other anaesthetic drugs. Ketamine anaesthesia has some unique characteristics. One major disadvantage is the lack to reliably monitor or titrate the drug using EEG derived parameters, such as the bispectral index (BIS). In fact, in some patients ketamine may paradoxically increase the BIS value due to its distinct effect on the EEG pattern.

However, ketamine is still, after more than 35 years, a safe and very useful anaesthetic, preserving haemodynamic and respiratory functions and improving the quality of acute and chronic pain control.

 Selected recommended references:

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