Importance of ketamine in Anesthesia

1. KETAMINE
• Presented by :-
• Dr. Vishal kr. Kandhway

2. Introduction :
• Ketamine is a phencyclidine derivative that produces dissociative
anesthesia characterised by evidence on the EEG of dissociation
between the thalamocortical and limbic system.
• Ketamine is frequently described as a "unique drug" because it has
hypnotic, analgesic and amnesic effects - no other drug used in clinical
practice combines these three important features.
• It was first used clinically in 1970, and because of these combined
effects it was thought that it might be the perfect anesthetic agent.
• Ketamine has advantages over propofol & etomidate in not requiring a
lipid emulsion vehicle.

3. • Ketamine is water soluble molecule that structurally
resembles phencyclidine.
Mechanism of Action :-
• The mechanism of action of ketamine induced
analgesia & dissociative anesthesia is unknown.
• It interacts with multiple CNS receptors.
• Ketamine binds non-competetively to the
phencyclidine recognision site on N-methyl-D-
aspartate(NMDA) receptors.
• In addition ketamine exerts effect at other sites
including opioid receptor & muscarinic receptors &
nicotinic acetylcholine receptors.

4. Pharmacokinetics
• Rapid onset of action, relatively short duration
of action & high lipid solubility.
• Peak plasma concentrations of ketamine occur
within 1 min after IV administration & within 5
mins after IM injection.
• Initially ketamine is distributed to highly
perfused tissues such as brain & extreme lipid
solubility ensures its rapid transfer across the
BBB.
• Ketamine has high hepatic clearance rate(1
L/min).

5. Actions of Ketamine on the Body:
Central Nervous System (CNS):
After an i/v injection the effects of ketamine on the CNS begin
slowly than other anaesthetic induction agents (1-5 minutes for
ketamine compared with 30 -60 seconds for Thiopentone).
• The anesthetic state produced is frequently called "dissociative
anesthesia" which implies that the patient is detached from the
environment and self.
• The patient's eyes often remain open and constantly move from
side to side.

6. • The duration of action depends on the route of administration.
• In contrast to the smooth induction of anaesthesia, the patient
may be agitated on recovery from ketamine.
• This is often called "emergence delirium", during which the
patient may be disorientated, restless, and crying.
• Patients may continue to experience unpleasant dreams up to
24 hours after the drug has been given.
• Ketamine is potent cerebral vasodilator & capable of
increasing cerebral blood flow by 60% in normal indivisual &
causes a rise in intracranial pressure and should not be used
in patients who have sustained a recent head injury

7. Cardiovascular System (CVS):
• Ketamine causes mild stimulation of the CVS.
• The systolic blood pressure rises about 20 to 40 mmhg & small
increase in diastolic. The heart rate is increased by about 20% - the
overall effect is therefore to increase the workload of the heart.
• In the majority of patients the blood pressure rises steadily over 3-5
minutes and then returns to normal 10-20 minutes after injection.
• There is wide individual variation in cardiovascular responses.
• These increases do not seem to be dose-related when more than 1
mg/kg is given and larger doses do not necessarily cause a greater
increase in pressure.
• There is no evidence to suggest that patients with a high
preoperative blood pressure are at greater risk of developing a rise
in blood pressure following ketamine administration when
compared with normotensive patients.

8.  Premedication with midazolam may reduces this rise in
blood pressure.
 As the cardiovascular stimulation following ketamine is
mediated through the sympathetic nervous system it would
seem appropriate to give alpha or beta blockers to patients
who develop excessively high blood pressures.
 However, the effects of these drugs are unpredictable, and
they are probably best avoided in otherwise normal
patients as there is no evidence of damage occurring from
these short episodes of elevated blood pressure.

9. Respiratory system:
• If Ketamine is administered rapidly by intravenous injection
it often causes the patient to stop breathing for a short
time (up to one minute).
• After a slow intravenous induction, breathing is well
maintained and may even increase slightly.
• The airway is usually well maintained during Ketamine
anesthesia and there is some preservation of pharyngeal
and laryngeal reflexes in comparison with other
intravenous agents.
• However this cannot be guaranteed, and normal airway
care must be maintained to prevent obstruction or
aspiration

10. • Recent research using a pulse oximeter has shown that
following an intravenous induction with ketamine (2
mg/kg) the oxygen saturation falls
• A simple oxygen mask or nasal prongs may be used.
• Ketamine produces some bronchodilation making it a
useful anaesthetic drug for patients with asthma

11. Skeletal muscle
Muscle tone is often increased.
Spontaneous movements may occur during
anesthesia but reflex response to surgery is
uncommon if the patient is adequately
anaesthetised.
Placenta
Ketamine crosses the placenta easily .
Secretions
Salivation is increased.

12. The Eyes
• The intra-ocular pressure rises for a short time
following administration.
• Eye movements may continue throughout
surgery.
• It is not suitable for use in patients with a
perforated eye injury or for ophthalmic
surgery where a still eye is required.
• Pupils are moderately dilated.

13. Routes of Administration:
• Ketamine can be given by either the intravenous
route 1-2 mg/kg or intramuscular route 4-8 mg/kg
to provide anesthesia.

14. Indications for Use:
• Analgesia :
- Intense analgesia can be achieved with sub-
anesthetic doses of 0.2 – 0.5 mg/kg IV.
- Analgesia is thought to be greater for somatic
than
for visceral pain
- Analgesia can be produced during labor without
associated depression of the neonate.
- Ketamine is useful as an analgesic adjuvant in
patients with pre-existing chronic pain syndromes
who require surgery

15. Induction of Anesthesia :
• Induction of anesthesia is produced by administration of
ketamine 1-2 mg/kg or intramuscular 4-8 mg/kg to provide
anesthesia.
• Consciousness is lost in 30-60 seconds after IV administration
& 2-4 mins after IM administration.
• Return of consciousness usually occurs in 10-20 mins after an
injected induction dose of ketamine but return of full
orientation may require additional 60-90 mins.
• Amnesia persists for about 60-90 mins after recovery of
consciousness.
• Because of its rapid onset of action ketamine has been used
as an IM induction drug in children and been used extensively
for burn patients, debridement & skin grafting procedures.
• Induction of anesthesia in acute hypovolemic patients is often
accomplished with ketamine.

16. Reversal of Opioid Tolerance :
• Administration of sub-anesthetic doses of ketamine i.e. 0.3
mg/kg/hr improves analgesia and may reduce the likelihood of
opioid tolerance.
Improvement of Psychiatric Disorders :
• Ketamine in small doses improves the post-operative
depressive state in patients with mental depression.
• Intermittent treatment with low dose ketamine also results in
long-term suppression of obsessions & compulsions in patients
with obsessive compulsive disorder.

17. Short term side effects of Ketamine are:
• Increase in heart rate
• Slurred speech
• Confusion, disorientation
• Out-of-body experience
• Shifts in perception of
reality
• Nausea
• Sedation
• Hypertension
• Euphoria
• Distortion or loss of
sensory perceptions
(common)
• Open- and closed-eye
visuals (common)
• Dissociation of mind from
body
• Numbness
• Ataxia (loss of motor
coordination)
• Significant change in
perception of time
• Double-vision

18. References
• Stoelting’s Phramacology & Physiology.

19. THANK YOU