ketamine

Various medications are used for intravenous (IV) sedation in pediatric dentistry. This study evaluated the efficacy of IV midazolam/ketamine (MK) versus propofol/ketamine (PK) for dental sedation of uncooperative children.   

This double-blind, randomized controlled clinical trial was carried out on 22 healthy, uncooperative children aged 2-6 years requiring two similar dental treatment sessions. Children were randomly assigned to two groups. Group A received PK in their first, and MK in their second visit. Group B received the same combinations in a reverse order. Oxygen saturation rate (SPO2) and heart rate (HR) were recorded at baseline, at the time of IV administration, local anesthetic injection, 15 and 30 minutes later, and at the time of discharge. Two independent calibrated pedodontists scored the sedation level using the Houpt scale during treatment. Data were analyzed by t-test, Wilcoxon, Mann-Whitney, and one-sample Kolmogorov-Smirnov tests.   

The mean age of the participants was 3.6 years with a mean weight of 15.68 kg. SPO2 was not significantly different between the two groups (P=0.609). However, the HR was significantly higher in the MK combination (P=0.001). No significant difference was detected between the two combinations for sleepiness (P=0.283), movement (P=0.180), crying (P=0.093), or overall behavior (P=0.364). The recovery time in the PK group was significantly shorter than that in the MK group (P=0.03).

Both sedation regimens are effective for dental treatment of uncooperative children. PK combination provided a more acceptable hemodynamic stability and shorter recovery.

Shivering is prevalent in 65% of patients undergoing spinal anesthesia, resulting in adverse outcomes and increased healthcare expenses. Ketamine, an N-methyl-D-aspartate receptor antagonist, and tramadol exhibit analgesic properties, potentially mitigating post-spinal shivering. This scoping review aims to explore the existing literature on the intravenously administered ketamine and tramadol in reducing the incidence of shivering subsequent to spinal anesthesia.

This scoping review, conducted from April to June 2024, examined studies on intravenous ketamine and tramadol for shivering post-spinal anesthesia. Using MeSH terms, researchers searched Scopus, Web of Science, PubMed, Cochrane, Google Scholar, Iran SID, and Iran ISC. After excluding duplicates and irrelevant studies, six pertinent studies were included.

The search strategy identified 1316 articles, with 1258 remaining after removing 58 duplicates. Title and abstract screening excluded 6 conference papers, 42 systematic reviews, 94 book chapters or animal studies, and 2 theses. A full-text review of 97 studies resulted in excluding 78 unrelated cases, 1 language discrepancy, and 11 without full-text availability. Ultimately, 6 studies (5 randomized controlled trials and 1 prospective cohort) from Iran, Pakistan, India, Egypt, and Ethiopia found ketamine more effective than tramadol in preventing shivering.

Ketamine is more effective than tramadol in preventing post-spinal anesthesia shivering, with fewer adverse effects like nausea, vomiting, and bradycardia. These findings support its use for shivering management. Future research should optimize dosing to reduce hallucinations, explore other side effects, and prioritize diverse study parameters and safety evaluations.

Traumatic brain injury (TBI) is a significant cause of mortality and disability worldwide. TBI has been associated with factors such as oxidative stress, neuroinflammation, and apoptosis, which are believed to be mediated by the N-methyl-D-aspartate (NMDA)-type glutamate receptor. Two NMDA receptor antagonists, ketamine and memantine, have shown potential in mitigating the pathophysiological effects of TBI.

To conduct the study, a controlled cortical impact model was used to induce TBI in rats. The rats with TBI were then divided into three groups: a group receiving only TBI, a group receiving TBI along with memantine, and a group receiving TBI along with ketamine. After 24 hr, the levels of oxidative stress markers (such as SOD, MDA, and total thiol) in the brain tissue were measured. Immunohistochemical staining was also performed seven days after TBI to assess the activation of glial cells and the TLR-4/NF-κB neuroinflammatory pathway.

The results indicated that treatment with memantine led to a reduction in MDA levels and an increase in SOD and total thiol levels. Memantine also decreased astrogliosis and down-regulated the TLR-4/NF-κB pathway. On the other hand, ketamine increased the levels of anti-oxidant markers but did not significantly affect the MDA level. Additionally, ketamine decreased the expression of NF-κB seven days after TBI.

The findings suggest that NMDA receptor antagonists, such as ketamine and memantine, may have therapeutic effects on TBI by inhibiting oxidative stress and inflammatory responses.

Sedation is recommended during flexible fiberoptic bronchoscopy (FFB) to aid in airway evaluation, minimize patient mobility, and enhance patient safety. This study was conducted to compare the impact of different sub-dissociative ketamine (SDK) doses on the quality of sedation within FFB.

This research utilized randomized clinical trial design involving three cohorts, each consisting of 30 participants. The cohorts were administered varying doses of ketamine: 0.2 mg/kg (SDK1), 0.4 mg/kg (SDK2), and 0.5 mg/kg (SDK3). After receiving ketamine, all participants received propofol in bolus dose 0.4 mg/kg followed by infusion 50-100 µg/kg.
FFB started when sedation level 4 was reached, according to Ramsey's sedation score.

Regarding demographic variables revealed no statistically notable discrepancy among the cohorts (P>0.05). The SDK3 cohort exhibited a higher average sedation score and longer duration of sedation compared to the SDK2, with both metrics also surpassing those of the SDK1 cohort. (P>0.001). Furthermore, the satisfaction levels reported by the bronchoscopist (P=0.78) and the participants (P=0.019) were notably greater in the SDK3 cohort than in the other groups. Additionally, the amount of propofol administered to the SDK3 cohort was less than that given to the SDK2, and both cohort received lower doses than the SDK1 cohort (P>0.001).

Elevating the SDK from 0.2 mg/kg to 0.5 mg/kg when administered alongside propofol correlates with a rise in the score of sedation, increasing patient and bronchoscopist satisfaction, and decreasing propofol consumption in FFB in adults. A dosage of 0.5 mg/kg might be more advantageous compared to alternative dosages for FFB in adult patients.

Reflex cough is a common complication after fentanyl injection during anesthesia. Several studies have tried different medications to control fentanyl-induced cough (FIC).

Our study evaluated the effect of different ketamine dosage on preventing fentanyl induced cough.

We randomly assigned 80 participants into four groups. Group 1 was administered 0.15 mg/kg, Group 2 received 0.2 mg/kg, Group 3 was given 0.25 mg/kg of intravenous ketamine one minute prior to fentanyl injections, while Group 4 received an equivalent volume of 0.9% normal saline.

The incidence and severity of cough was evaluated by FIC score. The incident of cough was significantly lower in Groups 3, 2 and 1 in comparison to Group 4 (0, 5, 30 respectively vs 85, p<0.001). The cough severity was significantly lower in Groups 3, 2 and 1 in comparison to Group 4 (p<0.001).

Intravenous ketamine 0.25 mg/kg, significantly decreased the severity and frequency of cough compared with 0.20 and 0.15 mg/kg IV ketamine.

The use of opioids for pain relief after cesarean section (C/S) can result in adverse maternal and neonatal outcomes. Therefore, it is important to consider non-opioid analgesics as an alternative. This study examined the effect of intravenous ketamine on analgesic requirement after spinal anesthesia in C/S.

This double-blind randomized clinical trial 80 pregnant women under spinal anesthesia during a planned C/S were recruited from trainig hospitals of Mashhad, Iran between February and August 2022. The participants were selected using convenience sampling and assigned to two intervention (40) and control (40) groups through random allocation. The intervention group received intravenous ketamine (0.5 mg/kg) and midazolam (0.02 mg/kg) immediately after umbilical cord clamping, while the control group received midazolam alone (0.02 mg/kg). Pain scores were recorded at the 0th, 6th, 12th, and 24th hours after elective C/S using the Visual Analog Score (VAS), along with the amount of requiremen to analgesics. Data analysis was performed by SPSS software (version 16) using Chi-square, T-test and repeated measure ANOVA test.

A significant difference in pain scores between the two groups at different hours and over time (P=0.009). The intervention group reported significantly lower levels of pain than the control group (P=0.002) and a significantly lower need for painkillers during the first hour (P=0.04).

Administration of intravenous ketamine in elective C/S with spinal anesthesia in the first hour has a significant effect on reducing pain. Therefore, it can be considered the drug of choice for alleviating pain.

Nausea While elderly patients are at an increased risk of perioperative morbidity and mortality; old age alone is not a contraindication for surgery. General factors that should be considered in preoperative risk assessments include age, functional status, cognition, nutritional status, and comorbidities, such as cardiac, pulmonary, renal, and endocrine disorders. Induction of anesthesia is a critical step in surgery, particularly for elderly patients and those with a high physical status. Commonly used drugs for this purpose include etomidate and propofol. Therefore, this study aimed to compare the impact of Ketofol versus etomidate alone on the hemodynamic status of patients who fall under the ASA class II or higher.

The study was a prospective randomized double-blind clinical trial, with a study population of age of ≥65 years, ASA physical status class II or higher, that were randomized into two groups. Ketofol (n=45) and, Etomidate (n=45) groups. Patients followed for clinical outcomes including their hemodynamic status during the induction period.

The present study showed that, the examination of hemodynamic parameters up to 10 minute after laryngoscopy showed that none of these parameters were significantly different between the two groups, while immediately after anesthesia induction, heart rate and blood pressure were found to be significantly different. However, there was no significant difference in terms of SPO2 among the two groups in any given interval.

The results of the present study revealed that Ketofol resulted in better regulation and stability of blood pressure and heart rate in patients undergoing endotracheal intubation, compared to etomidate alone.

This study compared the effects of rosemary and ketamine gargling on voice hoarseness and sore throat after tracheal intubation.

This clinical trial was conducted on 116 patients who required general anesthesia and were randomly divided into intervention (30 drops of rosemary extract and 40mg of ketamine) and control (30 mL distilled water) groups using Randomize Allocation software. The measurement methods for obtaining information in the current study included the Visual Analogue Scale (VAS) for pain, GRBAS (Grade of Hoarseness; Roughness, Breathiness, Asthenia, and Strain), the auditory scale for the severity of voice hoarseness, and a questionnaire to evaluate the patient’s level of satisfaction. Then, the data was imported into SPSS V. 25 after data gathering.

The results revealed that patients of the three groups did not indicate significant hemodynamic changes, including the parameters systolic blood pressure (P = 0.73), diastolic blood pressure (P = 0.97), SpO 2 level (P = 0.6), and heart rate (P = 0.31). However, the sore throat pain intensity of the rosemary group was significantly lower (P = 0.0008). The difference in time of the first pain sensation significantly differed among the three groups (P = 0.011). However, the mean pethidine administration of the control group (P = 0.003) was significantly higher, and the control group's satisfaction level (P = 0.02) was significantly lower.

Gargling rosemary solution and ketamine did not affect the voice hoarseness after tracheal intubation, but the rosemary group had lower sore throat pain intensity.

Pain is a common cause of patients referred to the emergency department (ED). The current study was performed to compare the efficacy of ketamine and lidocaine administration instead of intravenous morphine to alleviate acute limb pain in patients.

In the current triple-blind clinical trial, 40 included patients were divided into two separate groups. The intervention group received ketamine (5mg/kg), lidocaine (2mg/kg), and normal saline (0.1 ml/kg) intravenously (IV), while the control group received 0.1 mg/kg of morphine and nebulizer normal saline. A 10-point pain scale was performed to measure the pain level and its effects before and after treatment. At intervals of 5-60 minutes, the pain was evaluated.

The average pain relief between the two groups was not statistically different.  For the first 5-10 minutes after the drug administration, similar pain relief was observed in both groups. In the first 15 minutes, ketamine and lidocaine nebulizer pain relief was better than morphine. The reaction to pain-relieving medication in both groups was more extensive than the three numerical pain assessments. There was no noticeable adverse effect in the studied groups.

The ketamine and lidocaine nebulizers in emergency departments can be used as a practical and simple approach to managing acute limb pain. Given that lidocaine was utilized in this investigation to boost ketamine mucosal absorption and prevent probable adverse effects, more trials lacking lidocaine could be conducted to remove lidocaine's effect and better evaluate ketamine's effect. Ketamine can also be used at a higher dose to evaluate its effects and possible side effects.

Vital parameters must be monitored during sedation. This study aimed to evaluate the effects of ketamine-midazolam (KM) and ketamine-propofol (KP) combinations on the heart rate (HR) and oxygen saturation (SPO2) of non-cooperative children. The model parameters were estimated using the Bayesian approach. The data were collected in a double-masked crossover study with repeated measurements (CSWRM). Twenty-two non-cooperative children 3–6 years old were included, and the linear mixed model was adopted for data analysis. The Bayesian estimation of the parameters and their 95% credible interval were calculated in SAS 9.4. The mean heart rate of KM recipients compared to KP recipients was significantly different by 4.47 beats per minute (bpm). The mean HR in KP was lower than KM's, but oxygen saturation (SPO2) was not significantly different. Although the two drug combinations did not differ in SPO2, they differed in HR. As such, the KP combination is recommended.

Combining multiple drugs for intubation raises concerns such as increased side effects, medication er-rors, nursing workload, and costs. Ketamine, with its anesthetic and analgesic properties, shows promise as a sedativeagent for post-intubation care. This study aimed to evaluate the efficacy and safety of ketamine infusion as the sole seda-tive for critically ill intubated patients.

Following PRISMA 2020 guidelines, we conducted a systematic reviewby searching Ovid MEDLINE, Cochrane Central Register of Controlled Trials, and Google Scholar up to May 10, 2024.We included studies assessing ketamine use for post-intubation sedation in critically ill adults or children. Study qualitywas assessed using the Newcastle–Ottawa scale, and meta-analysis was performed using a random-effects model.

The systematic review included 7 studies, with 4 studies included in the meta-analysis. There was no significantdifference in mortality (OR = 1.52; 95% CI: 0.49–4.70, p = 0.46; I2 = 83%) or length of hospital stay (MD = 6.42; 95% CI:-1.42-14.26, p = 0.11; I2 = 84%) between the ketamine only and other groups. The most common adverse events in theketamine infusion group were atrial fibrillation and agitation.

Single-agent ketamine infusion is effectiveand safe for critically ill intubated patients. No significant differences were found in mortality or hospital stay betweenketamine only and other groups. Atrial fibrillation and agitation were the most common adverse effects

Midazolam and ketamine, either alone or in combination, are safe and effective in intranasal application among dental sedation routes. 

This randomized clinical trial compares higher and lower-dose intranasal ketamine/midazolam cocktails in pediatric dentistry. 

This double-blind randomized clinical trial was conducted on 20 uncooperative children aged 3-6 years with a definitely negative Frankel scale. The participants were divided into two groups. Group A received 0.4 mg/kg midazolam and 4 mg/kg ketamine nasally 20 min before initiating dental treatment in the first session while receiving 0.5 mg/kg midazolam/ 3 mg/kg ketamine in the second session. Meanwhile, group B received the opposite drug sequence to assess any sequence effect. Dental treatment was initiated with local anesthesia administration. The sedation score was recorded using the Houpt scale. Vital signs were recorded at every 10-min intervals along with potential side effects. The data were analyzed using variance analysis and Wilcoxon and McNemar tests.

No significant differences were noted in vital signs between groups at recording intervals (anesthetic injecting [P=0.719], 10 min [P=0.317] and 20 min [P=0.480]). No reports were received on post-treatment nausea (P=0.289). 

There was no indication of a significant difference between groups tested with different drug doses, in support of lower ketamine dose as an effective yet safer approach to treat children. The parents were satisfied with their child’s calmness through both episodes of treatment.

Dystrophic Epidermolysis Bullosa (DEB) poses major challenges, especially for anesthetic management. The main challenge faced is a pediatric patient with a difficult airway requiring general anesthesia. Any airway manipulation leads to immediate and significant trauma with bullae formation, thereby necessitating the need for postoperative ventilation and prolonged hospital stay. It is advisable to avoid any airway interventions, if possible.

An 11-year-old male child (weighing 15 kg) presented with non-bilious vomiting for 3 - 4 days and dysphagia for solids for 2 - 3 months. Personal history revealed the diagnosis to be a case of DEB at the age of 10 years (genetic testing) with persistent iron deficiency anemia. The patient underwent esophageal dilatation 6 months ago under general anesthesia (propofol, fentanyl on spontaneous respiration), requiring blood transfusion and an intensive care unit (ICU) stay for a day after the procedure. Dexmedetomidine (Dex) injection was started as a low-dose infusion (0.2 µg/kg) 10 minutes before the start of the procedure, followed by (0.2 µg/kg/hour). Before upper gastrointestinal (GI) scope insertion, ketamine injection (0.66 mg/kg) 10 mg intravenous (IV) bolus was given. Upper GI endoscopy and esophageal dilatation were performed in half an hour without any complications. Dexmedetomidine infusion was stopped after the removal of the scope, and the patient awakened within 3 - 4 minutes. He remained hemodynamically stable throughout the entire procedure. Recovery was uneventful, and the patient was obeying commands with no signs of respiratory depression, postoperative nausea/vomiting (PONV), or pain. Vital signs remained stable in the post-anesthesia care unit (PACU), and then the patient was moved to the ward.

To date, there is no reported case of DEB being successfully managed with only two drugs, dexmedetomidine infusion and a single dose of ketamine for maintaining spontaneous ventilation (opioid-free anesthesia/OFA) with no airway intervention/manipulation, especially in non-operating room anesthesia (NORA) setting.