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Ketamine

Ketamine is a general dissociative anaesthetic for human and veterinary use. Its hydrochloride salt is sold as Ketanest®, Ketaset®, and Ketalar®. Pharmacologically it is very similar to other dissociative anesthetics such as tiletamine and phencyclidine (PCP). more...

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History

Ketamine was first synthesized in 1962 in an attempt to find a safer anaesthetic alternative to PCP, which was more likely to cause hallucinations and seizures. The drug was first used on American soldiers during the Vietnam War, but is often avoided now because it can cause unpleasant out-of-body experiences. It is still used widely in veterinary medicine, and for select human applications.

Ketamine's "unpleasant" side effects prompted its first psychedelic use in 1965. The drug was used in psychiatric and other academic research through the 1970s, culminating in 1978 with the publishing of John Lilly's The Scientist, a book documenting the author's ketamine, LSD, and isolation tank experiments. The incidence of recreational ketamine use increased through the end of the century, especially in the context of raves and other parties. The increase in illicit use prompted ketamine's placement in Schedule III of the United States Controlled Substance Act in August 1999. In the United Kingdom, it became outlawed and labelled a Class C drug on January 1, 2006.

Medical use

Given that it suppresses breathing much less so than most other available anaesthetics, ketamine is still used in human medicine as a first-choice anaesthetic for victims with unknown medical history (e.g. from traffic accidents), in podiatry and other minor surgery, and occasionally for the treatment of migraine. There is ongoing research into the drug's usefulness in pain therapy and for the treatment of alcoholism and heroin addiction.

In veterinary medicine, ketamine is often used for its anaesthetic and analgesic effects on cats, dogs, rabbits, rats, and other small animals. Veterinarians often use ketamine with sedative drugs to produce balanced anaesthesia and analgesia, and as a constant rate infusion to help prevent pain wind-up. Ketamine is used to manage pain among horses and other large animals, though it has less effect on bovines.

Ketamine may be used in small doses (0.1–0.5 mg/kg/hr) as an analgesic, particularly for the treatment of pain associated with movement and neuropathic pain. It has the added benefit of counter-acting spinal sensitization or wind-up phenomena experienced with chronic pain. At these doses, the psychotropic side effects are less apparent and well managed with benzodiazepines. Ketamine is a co-analgesic, requiring a concomitant low-dose opioid to be effective.

The effect of Ketamine as a depressant on the respiratory and circulatory systems is less than that of other anaesthetics. When used at anaesthetic doses, it will sometimes stimulate rather than depress the circulatory system. It is sometimes possible to perform ketamine anaesthesia without protective measures to the airways. Ketamine is also a potent analgesic and can be used in sub-anaesthetic doses to relieve acute pain; however, its psychotropic properties must be taken into account. Patients have reported going into other worlds or seeing God while anaesthetized, and these unwanted psychological side-effects have marginalized the use of ketamine in human medicine.

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Use Of Ketamine In Status Asthmaticus
From CHEST, 10/1/00 by Toni Petrillo

Toni Petrillo, MD(*); James Fortenberry, MD; Jeffery Linzer, MD and Harold Simon, MD. Pediatric Critical Care, Emory University, Atlanta, GA; Pediatric Critical Care, Children's Healthcare of Atlanta, Atlanta, GA and Pediatric Emergency Medicine, Emory University, Atlanta, GA.

PURPOSE: To evaluate the effects of adding ketamine to standard therapy in pediatric patients with acute refractory status asthmaticus.

METHODS: 10 patients with asthma were enrolled. Children continued to receive standard therapy. In addition, patients received ketamine at a loading dose of 1 mg/kg IV followed by a continuous infusion of 0.75 mg/kg/hr (12.5 mcg/kg/min) for one hour. CAS, vital signs, and PEFR measurements were obtained prior to ketamine, immediately following ketamine and one hour after infusion.

RESULTS: Median CAS on arrival was 15 (range 7 to 23) and did not significantly change prior to ketamine (median 14, range 8 to 21). Median CAS decreased significantly to 10.5 (range 4 to 12) immediately after infusion and 9.5 (range 4 to 12) one hour post ketamine infusion (37% reduction, p [is less than] .05 by ANOVA vs. pre-ketamine CAS). Median RR also decreased from 39 prior to ketamine to 30 immediately following (25% decrease vs. pre-ketamine (p [is less than] .05). Median PEFR increased, but the change was not statistically significant. Four patients experienced mild side effects: two experienced hallucinations, one experienced diffuse flushing and one patient had moderate hypertension. Side effects resolved with benzodiazepines or with discontinuation of the infusion.

CONCLUSION: Addition of ketamine to standard therapy was associated with improved indices of acute asthma severity. Side effects were transitory, and comparable to previous studies. However, a double-blinded randomized controlled trial needs to be conducted to determine if these benefits were attributable to adding ketamine.

CLINICAL IMPLICATIONS: If proven beneficial, cost savings could accrue by reducing length of stay or hospital admission rates.

COPYRIGHT 2000 American College of Chest Physicians
COPYRIGHT 2001 Gale Group

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