Ketamine, structurally derived from the street drug phencyclidine, was introduced into the clinical setting the 1970’s. It produces a rapid profound sedation described as trance-like within 5 minutes of an IM (intramuscular) injection. This can be especially useful in a combative or uncooperative child. Ketamine produces a dissociative state and maintenance of spontaneous respiration and protective airway reflexes without the generalized relaxation and respiratory depression that is associated with other agents such as narcotics or barbiturates. It is contraindicated in infants younger than 3 months of age and in the presence of active respiratory infection or disease, hydrocephalus or other conditions with associated increased intracranial pressure, glaucoma or globe injury, cardiovascular disease, and thyroid dysfunction.
The side effects of ketamine include hyper-salivation, this can be reduced by the use of Atropine in the same syringe as the ketamine. Other side effects can be an increase in pulse and blood pressure, increased intraocular and intracranial pressure due to cerebral vasodilation, and increased cerebral oxygen consumption.
Ketamine is quickly metabolized in children, with a half-life of 1 to 2 hours. Dissociative effects usually last for 15 to 30 minutes. Valium and barbiturates also have been shown to prolong recovery when used concurrently with ketamine.
According to Green and Johnson, risk of aspiration appears minimal. After more than 20 years in use, there have been only two case reports of nonneonatal aspiration associated with the use of ketamine. The unfavorable emergence reactions associated with the use of ketamine in adults such as hallucinations or frightening dreams are less common in children 10 to 15 years old and are rare in children younger than 10 years old. Reaction also appears to be less common with IM administration as opposed to IV administration. Reducing stimuli during recovery also may decrease the incidence of unpleasant emergence reaction; however this has not been proven in controlled studies. Adjunctive use of valium or narcotics also may inhibit the reaction, but as stated previously their usage may delay the metabolism of ketamine as well as contribute to prolongation of the recovery phase.
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