managing emergent phenomena with ketamine

battlefields ( Dickey et al., 2012), developing countries ( Morgan & Curran, 2012), and endoscopy and radiology suites (Mason et al., 2002). It is equally the sedative of choice in situations where airway management equipment is not readily available e.g. In addition, it has sympathomimetic (increase heart rate, blood pressure and cardiac output) and bronchodilatory effects, which makes it is the preferred anesthetic in patients with hemodynamic instability such as hypovolemia, cardiogenic shock and constrictive cardiac disorders ( Aroni et al., 2009) and severe asthma (Lau & Zed, 2001). Unlike other anesthetics such as propofol, patients under ketamine-induced loss of consciousness maintain spontaneous respiration and protective airway reflexes. Ketamine is a unique anesthetic that exerts most of its effects by non-competitive antagonism of the NMDAR. Ketamine is essential in any basic health care system ( World Health Organization, October 2013), and has been used in various settings from battlefields ( Dickey, Jenkins, & Butler, 2012), developing countries ( Morgan & Curran, 2012) to critical care units in tertiary care centers ( Mohrien, Jones, MacDermott, & Murphy, 2014). As a result, most clinicians avoid using ketamine despite its diverse clinical profile.Ĭlinical uses of ketamine include induction of anesthesia, procedural sedation, acute and chronic pain management, treatment of depression ( Aroni, Iacovidou, Dontas, Pourzitaki, & Xanthos, 2009 Mion & Villevieille, 2013 Zarate, Brutsche, Ibrahim, et al., 2012 Zarate, Brutsche, Laje, et al., 2012), and modulation of inflammation ( D’Alonzo et al., 2011 Dale, Somogyi, Li, Sullivan, & Shavit, 2012. While several medications such as midazolam ( Sener, Eken, Schultz, Serinken & Ozsarac, 2011) and propofol ( Andolfatto & Willman, 2011) have been used to manage EP, to date there is no definitive treatment or predictive tools to identify patients who will develop EP. Beside increasing healthcare cost ( Franco, Litaker, Locala, & Bronson, 2001), EP increases patients’ risk of injury, length of hospital stay, requires more nursing care, and contributes to patient’s lower satisfaction with care ( Hudek, 2009 O’Malley, 2014 Stoelting & Hillier, 2006). Thus, EP may be related to NMDAR function, and rate of ketamine metabolism. Single-photon emission tomographic studies revealed that ketamine produces negative psychotic symptoms by direct inhibition of the N-methyl-D-aspartate receptor (NMDAR) ( Stone et al., 2008), while positive symptoms correlated with blood ketamine levels and glutamate release from the anterior cingulated cortex ( Stone et al., 2012 Stone et al., 2008). EP has equally been described as floating sensation with distortions in body images and objects, which correlate with positive and negative psychotic symptoms of schizophrenia ( Pomarol-Clotet et al., 2006 Xu et al., 2015). It is characterized by euphoria, vivid dreams, illusions, delirium, and hallucinations ( Aroni et al., 2009 Pomarol-Clotet et al., 2006 Powers Iii, Gancsos, Finn, Morgan, & Corlett, 2015 Xu & Lipsky, 2014).

Ketamine-induced emergence phenomena (EP) occur in up to 55 percent of patients treated with ketamine ( Kumar, Bajaj, Sarkar, & Grover, 1992 Strayer & Nelson, 2008).

Managing emergent phenomena with ketamine