Drug-assisted airway management

[wook]

One recent article discussing Ketamine and IOP...


Am J Ophthalmol. 2007 Mar;143(3):494-9. Epub 2007 Jan 2.

The effects of sevoflurane and ketamine on intraocular pressure in children during examination under anesthesia.
Blumberg D, Congdon N, Jampel H, Gilbert D, Elliott R, Rivers R, Munoz B, Quigley H.

Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. dana.blumberg@duke.edu

Abstract
PURPOSE: We studied the effects on intraocular pressure (IOP) of anesthesia administered during examination under anesthesia (EUA) in children.

DESIGN: Randomized clinical trial.

METHODS: This randomized trial compared IOP after inhaled sevoflurane gas to that after intramuscular ketamine hydrochloride in children undergoing EUA. IOP was measured in 30 eyes with TonoPen XL (Mentor, Inc, Norwell, Massachusetts, USA) as soon as possible after anesthesia induction (T1) and two, four, six, and eight minutes thereafter. At the same times, we recorded systolic and diastolic blood pressure (SBP, DBP) and heart rate (HR).

RESULTS: Compared with the mean IOP at T1, IOP in the sevoflurane group was significantly lower for all measurements from two to eight minutes thereafter (mean decrease in IOP: two minutes = 12%, four minutes = 19%; six minutes = 19%; eight minutes = 17%, all P < or = .01). In the ketamine group, mean IOP was not significantly changed from T1 through six minutes, whereas at eight minutes, it was 7% lower (P = .03). SBP and DBP were significantly lower for sevoflurane than for ketamine at all measurements from two minutes onward, and HR was lower for sevoflurane than for ketamine at two, four, and six minutes.

CONCLUSIONS: IOP measured after ketamine sedation is more likely to represent the awake IOP than that after sevoflurane anesthesia. Changes in SBP, DBP, and HR caused by sevoflurane suggest that hemodynamic alterations may underlie its effects on IOP.

[wook]

I think ketamine has been underutilized in the USA and has alot of dogma surrounding its usage. There has been recent discussion about ketamine decreasing Intracranial Pressure (ICP), not raising it.



J Neurosurg Pediatr. 2009 Jul;4(1):40-6.

Effectiveness of ketamine in decreasing intracranial pressure in children with intracranial hypertension.
Bar-Joseph G, Guilburd Y, Tamir A, Guilburd JN.

Paediatric Critical Care, Meyer Children's Hospital, Rambam Medical Center, Haifa, Israel. g_barjoseph@rambam.health.gov.il

Comment in:

J Neurosurg Pediatr. 2009 Jul;4(1):37-8; discussion 38-9.

Abstract
OBJECT: Deepening sedation is often needed in patients with intracranial hypertension. All widely used sedative and anesthetic agents (opioids, benzodiazepines, propofol, and barbiturates) decrease blood pressure and may therefore decrease cerebral perfusion pressure (CPP). Ketamine is a potent, safe, rapid-onset anesthetic agent that does not decrease blood pressure. However, ketamine's use in patients with traumatic brain injury and intracranial hypertension is precluded because it is widely stated that it increases intracranial pressure (ICP). Based on anecdotal clinical experience, the authors hypothesized that ketamine does not increase-but may rather decrease-ICP.

METHODS: The authors conducted a prospective, controlled, clinical trial of data obtained in a pediatric intensive care unit of a regional trauma center. All patients were sedated and mechanically ventilated prior to inclusion in the study. Children with sustained, elevated ICP (> 18 mm Hg) resistant to first-tier therapies received a single ketamine dose (1-1.5 mg/kg) either to prevent further ICP increase during a potentially distressing intervention (Group 1) or as an additional measure to lower ICP (Group 2). Hemodynamic, ICP, and CPP values were recorded before ketamine administration, and repeated-measures analysis of variance was used to compare these values with those recorded every minute for 10 minutes following ketamine administration.

RESULTS: The results of 82 ketamine administrations in 30 patients were analyzed. Overall, following ketamine administration, ICP decreased by 30% (from 25.8 +/- 8.4 to 18.0 +/- 8.5 mm Hg) (p < 0.001) and CPP increased from 54.4 +/- 11.7 to 58.3 +/- 13.4 mm Hg (p < 0.005). In Group 1, ICP decreased significantly following ketamine administration and increased by > 2 mm Hg during the distressing intervention in only 1 of 17 events. In Group 2, when ketamine was administered to lower persistent intracranial hypertension, ICP decreased by 33% (from 26.0 +/- 9.1 to 17.5 +/- 9.1 mm Hg) (p < 0.0001) following ketamine administration.

CONCLUSIONS: In ventilation-treated patients with intracranial hypertension, ketamine effectively decreased ICP and prevented untoward ICP elevations during potentially distressing interventions, without lowering blood pressure and CPP. These results refute the notion that ketamine increases ICP. Ketamine is a safe and effective drug for patients with traumatic brain injury and intracranial hypertension, and it can possibly be used safely in trauma emergency situations.

[Retiredfire]

My servive would use a non depolarizing.(vec) folowed by a depolarizing(suc). both of these were preceded by an benzo(versed). so you got ver-vec-succed. If you are looking for reversibility try roc, but imho once you commit you need to be prepared for a diffucult airway and poss of a cric