J Int Med Res (1978) 6, 61

Further Experience with 2100 Consecutive Ketamine Administrations: Newer Indications and Restrictions A 0 Lotfy, MD, Professor ofAnaesthesiology, Pahlavi University, and ChiefAnaesthesiologist, Nemazee Hospital, Shiraz, Iran M Sami, MD, Instructor in Anaesthesiology, Pahlavi University, Shiraz, Iran A K Amir-Jahed, MD, MSc, FRCS(C), FACS, Professor of Surgery, Pahlavi University, Shiraz, Iran Two thousand one hundred consecutive administrations of ketamine as an anaesthetic agent are reviewed. On the basis of the experience described, the authors assess that this agent could be used with safety in the averagepatient presenting for surgery and that it would be likely to suffice as the sole anaesthetic agent in 40% ofsuch cases but would require supplementation by other anaesthetic agents in the remaining 60% of cases. They recommend it as being particularly useful in children submitting to dental surgery as it can be used without sedative premedication and permits ofrapid recovery.

Introduction In our earlier experience with ketamine (Lotfy, Amir-Jahed & Moarefi 1970) we have largely outlined indications, advantages and shortcomings of this anaesthetic agent. This report is concerned with our subsequent experience over the last five years involving 2100 consecutive ketamine administrations and evaluates some of the points raised and discussed in our initial work. Emphasis is placed on the newer indications of this agent, its clinical applicability and safety and its limitations as observed in the present series. Materials and Methods Following our initial observations we designed the present study based on a protocol which included all data concerned with ketamine administration, namely dosage, route and number of administrations, supplemental

agents, their time of administration, duration of anaesthesia, observable additive effect and all data concerned with patients status evaluated at the time of anaesthesia, during operations, in the recovery room and in the ward. Thus, 2100 ketamine anaesthesics were studied in 1972 patients consecutively from August 1, 1970 to June 9, 1975. Patients could be separated into two groups; the first group receiving ketamine alone and the second receiving ketamine and additional agents. The latter group could be further divided in two; first, those patients to whom ketamine was administered only for induction and who necessarily received other agents for maintenance; and second, those in whom ketamine was used with the idea of carrying on the anaesthesia either with ketamine or with whatever other agent might seem at the time to be more appropriate.

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The Journal ofInternational Medical Research

Intravenous administration of 2 mg/kg was used in 1616 cases and 0·3 to 1·0 mg/kg in 100 cases. Intramuscular injections numbered 384 with a dose of 4 mg/kg. The 100 patients receiving the smaller intravenous doses formed a special study group which has been reported elsewhere (Khorramzadeh & Lotfy 1973). These patients, therefore, do not figure in the present study except for completing our number of cases and total ketamine administrations. Excluding these cases, 1872 patients who received ketamine as an anaesthetic agent ranged in age from 4 days to 95 years with a mean of 17·51 ± 16·22 years. Distribution of the age range per decade and in the.first decade of life is shown in Tables 1 and 2. The first decade of life included 847 patients totalling 45·25% of the whole series. A total of 632 patients were aged 6 years or younger. They comprised 33·76% of all cases and 74·62% of patients below 10 years of age. Male patients numbered 1107 (59·13%) and females 765 (40·87%).

Table 1 Age distribution per decade Number ofpatients

Age in years

847 341 283 186 109 50 37 15 3 1

0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99 Total

1872*

*Does not include cases of schizoanalysis

Table 2 Age distribution in the first decade Age in years

Number ofpatients

0-1 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9

112 93 112 90 136 89 96 77 42

Results

Table 3 shows the breakdown of ketamine anaesthetics given for different procedures. The greatest field of application was general surgery which included paediatric, thoracic and ano-rectal procedures. Orthopaedic surgery was next in using ketamine, in the majority of cases for closed fracture reduction, cast applications and changes, and for manipulations. Urologists used it essentially in

Total

847

Table 3 Number ofketamine anaesthetics

Procedures General surgery" Orthopaedic surgery Urologic surgery Gynaecology and obstetrics Schizoanalysis** Neurosurgery ENT Dental surgery Total diagnostic and surgical procedures

697 495 362 359 100 33 28 26 2100

*Includes paediatrics, thoracic and ano-rectal cases **These cases have been eliminated in the subsequent calculations of anaesthesia time and dose/patient ratios

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A 0 Lotfy, M Sami and A K A mir-Jahed

63

cystoscopies and for circumcisions and supplementation by other agents. Total urethral and meatal dilatations. In duration of anaesthesia varied from 5 to 154 gynaecology and obstetrics, ketamine was minutes. The mean duration was 29·31 ± 9·96 mainly used for dilatation and curettage, minutes. Gynaecological and obstetrical proepisiotomy and forceps deliveries. The neuro- cedures presented the greatest standard surgical cases were mainly ventriculographies, deviation. This group was, in fact, not homotrephinations and cerebral angiographies and geneous with three samples each presenting the ENT cases were mostly tonsillectomies. quite a distinct mean. However, contrary to our general observations The shortest mean duration of anaesthesia, in other cases, in tonsillectomies relaxation 20·35 ± 9·15 minutes, was seen in 40 was not adequate and appropriate opening of dilatations and curettages of non-gravid uteri. the mouth remained a problem together with The next sample, also dilatations and persistent gag reflex. Fifty-two patients curettages, was made up of 14 cases of received a total of 128 ketamine anaesthetics incomplete abortion and therapeutic abortion during their hospitalization. Thirty-two of with a mean duration of anaesthesia of 28·93 these patients had two, sixteen patients had ± 25· 13 minutes and the third sample three and four patients had four ketamine comprised 34 cases of episiotomies with a administrations with 3 to 11 days interval mean duration of anaesthesia of 38·30 ± between anaesthetics. Most of these patients 24· 65 minutes. Urological operations had repeated debridment of burns and skin presented a mean closely similar to the mean grafting. Some had minor stage procedures. duration of anaesthesia for the whole group They all had ketamine without supplements but neurosurgical procedures showed the and showed no signs of habituation or other longest mean duration of anaesthesia with considerable difference from the mean for the untoward effects. Two new applications were encouraged and total group. A total of 1215 supplements were given in practiced increasingly. The first, named schizoanalysis in this paper, was purely of an addition to initial ketamine as shown in Table investigative nature (Khorramzadeh & Lotfy 5. Total duration of anaesthesia with 1973). The second, of a more practical nature, supplements varied considerably ranging from was the use of ketamine in dental surgery, 51 to 193 minutes with a mean duration of namely tooth extraction, and this was 95·14 ± 25·57. These cases included 383 practiced with great ease and safety especially anaesthetics in which ketamine was only used in children and adolescents in whom ketamine for induction. Table 6 summarizes data concerning was used intramuscularly without atropine or ketamine administrations alone and with any other premedication. Table 4 shows the mean duration of supplements. In the former group intravenous anaesthesia for each category in 660 ketamine gave the shortest mean duration, intravenous ketarnine administrations without 29·31 ± 9·96 minutes, which was significantly

Table 4

Surgical procedures

Number oft.v. ketamine administrations

Duration ofanaesthesia in minutes (mean ± S.D.)

General surgery Orthopaedics Gynaecology and obstetrics Urology Neurosurgery ENT Dental

278 193 88 75 10 9 7

32·77 ± 18·26 25·47 ± 13·49 28· 55 ± 20· 70 29· 77 ± 14·28 39·00± 17·92 36·67 ± 20·62 26·43 ± 16·76

Total

660

29·31 ± 9·96

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The Journal ofInternational Medical Research Table 5 Supplemental agents used with ketamine

Number ofadministrations

Agents

311 294 190 176 72 62 58 28

Nitrous oxide Ketamine Succinylcholine chloride Sodium thiopental Gallamine thri-iodoethylate Halothane Pethidine Diazepam Local anaesthesia (Xylocain 1% without adrenaline) Morphine sulphate Ether (open drop)

11 8 5

Total

-1215

Table 6 '

Anaesthetic and route ofadministration

Number ofadministrations

Dose mg/patient (mean ± S.D.)

660 125

81·60 ± 17·25 102·58 ± 38·12

29·31 ± 9·96 46·72 ± 11·32

315 68

102·60 ± 16·31 202·82 ± 31·99

92·12 + 24·23 98·16 ± 26·44

641 191

87·31 ± 21·43 192·81 ± 27·14

102·35 ± 27·13 87·93 + 21·41

..

Duration in minutes

Ketamine alone

i.v, i.m, Ketamine with supplements for induction

i.v, i.m, For induction and maintenance i.v, i.m,

shorter than the mean duration for intramuscular ketamine, 46·72 ± 11·32 minutes (p

Further experience with 2100 consecutive ketamine administrations: newer indications and restrictions.

J Int Med Res (1978) 6, 61 Further Experience with 2100 Consecutive Ketamine Administrations: Newer Indications and Restrictions A 0 Lotfy, MD, Profe...
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