INTRODUCTION: Although ketamine is one of the commonest medications used in procedural sedation of children, to our knowledge, there is currently no published report on predictors of respiratory adverse events during ketamine sedation in Asian children. We aimed to determine the incidence of and factors associated with respiratory adverse events in children undergoing procedural sedation with intramuscular (IM) ketamine in a paediatric emergency department (ED) in Singapore. METHODS: A retrospective analysis was conducted of all children who underwent procedural sedation with IM ketamine in the paediatric ED between 1 April 2013 and 31 October 2017. Demographics and epidemiological data, including any adverse events and interventions, were extracted electronically from the prospective paediatric sedation database. The site of procedure was determined through reviewing medical records. Descriptive statistics were used for incidence and baseline characteristics. Univariate and multivariate logistic regression analyses were performed to determine significant predictors. RESULTS: Among 5,476 children, 102 (1.9%) developed respiratory adverse events. None required intubation or cardiopulmonary resuscitation. Only one required bag-valve-mask ventilation. The incidence rate was higher in children aged less than three years, at 3.6% compared to 1.0% in older children (odds ratio [OR] 3.524, 95% confidence interval [CI] 2.354-5.276; p < 0.001). Higher initial ketamine dose (adjusted OR 2.061, 95% CI 1.371-3.100; p = 0.001) and the type of procedure (adjusted OR 0.190 (95% CI 0.038-0.953; p = 0.044) were significant independent predictors. CONCLUSION The overall incidence of respiratory adverse events was 1.9%. Age, initial dose of IM ketamine and type of procedure were significant predictors.
Child ; Conscious Sedation/methods* ; Emergency Service, Hospital ; Humans ; Incidence ; Ketamine/adverse effects* ; Prospective Studies ; Retrospective Studies

BACKGROUND: This study was conducted to compare the effectiveness of low-dose ketamine versus ketorolac in pain control in patients with acute renal colic presenting to the emergency department (ED). METHODS: This is a double-blind randomized clinical trial. The initial pain severity was assessed using the numerical rating scale (NRS). Then, ketamine or ketorolac was administered intravenously at a dose of 0.6 mg/kg and 30 mg respectively. The pain severity and adverse drug reactions were recorded 5, 15, 30, 60, and 120 min thereafter. RESULTS: The data of 62 subjects in the ketamine group and 64 patients in the ketorolac group were analyzed. The mean age of the patients was 34.2 ± 9.9 and 37.9 ± 10.6 years in the ketamine and ketorolac group, respectively. There was no significant difference in the mean NRS scores at each time point, except for the 5 min, between the two groups. Despite a marked decrease in pain severity in the ketamine group from drug administration at the 5 min, a slight increase in pain was observed from the 5 min to the 15 min. The rate of adverse drug reactions, including dizziness (P = 0.001), agitation (P = 0.002), increased systolic blood pressure (> 140 mmHg), and diastolic blood pressure (> 90 mmHg) was higher in the ketamine group. CONCLUSIONS: Low dose ketamine is as effective as ketorolac in pain management in patients with renal colic presenting to the ED. However, it is associated with a higher rate of adverse drug reactions.
Acute Pain ; Blood Pressure ; Dihydroergotamine ; Dizziness ; Double-Blind Method ; Drug-Related Side Effects and Adverse Reactions ; Emergencies ; Emergency Service, Hospital ; Humans ; Ketamine ; Ketorolac ; Pain Management ; Renal Colic ; Urinary Calculi

The pain following gynecological laparoscopic surgery is less intense than that following open surgery; however, patients often experience visceral pain after the former surgery. The aim of this study was to determine the effects of preemptive ketamine on visceral pain in patients undergoing gynecological laparoscopic surgery. Ninety patients undergoing gynecological laparoscopic surgery were randomly assigned to one of three groups. Group 1 received placebo. Group 2 was intravenously injected with preincisional saline and local infiltration with 20 mL ropivacaine (4 mg/mL) at the end of surgery. Group 3 was intravenously injected with preincisional ketamine (0.3 mg/kg) and local infiltration with 20 mL ropivacaine (4 mg/mL) at the end of surgery. A standard anesthetic was used for all patients, and meperidine was used for postoperative analgesia. The visual analogue scale (VAS) scores for incisional and visceral pain at 2, 6, 12, and 24 h, cumulative analgesic consumption and time until first analgesic medication request, and adverse effects were recorded postoperatively. The VAS scores of visceral pain in group 3 were significantly lower than those in group 2 and group 1 at 2 h and 6 h postoperatively (P<0.05 and P<0.01, respectively). At 2 h and 6 h, the VAS scores of incisional pain did not differ significantly between groups 2 and 3, but they were significantly lower than those in group 1 (P<0.01). Groups 1 and 2 did not show any differences in visceral pain scores at 2 h and 6 h postoperatively. Moreover, the three groups showed no statistically significant differences in visceral and incisional pain scores at 12 h and 24 h postoperatively. The consumption of analgesics was significantly greater in group 1 than in groups 2 and 3, and the time to first request for analgesics was significantly longer in groups 2 and 3 than in group 1, with no statistically significant difference between groups 2 and 3. However, the three groups showed no significant difference in the incidence of shoulder pain or adverse effects. Preemptive ketamine may reduce visceral pain in patients undergoing gynecological laparoscopic surgery.
Adolescent ; Adult ; Analgesics ; administration & dosage ; Female ; Gynecologic Surgical Procedures ; adverse effects ; Humans ; Ketamine ; administration & dosage ; Laparoscopy ; adverse effects ; Male ; Middle Aged ; Pain Measurement ; Pain, Postoperative ; drug therapy ; Postoperative Period

Adult ; Angioedema ; chemically induced ; diagnosis ; Female ; Humans ; Ketamine ; adverse effects ; Succinylcholine ; adverse effects

Ketamine is a short-acting anaesthetic agent that has gained popularity as a 'club drug' due to its hallucinogenic effects. Substance abuse should be considered in young adult patients who present with severe debilitating symptoms such as lower urinary tract symptoms, even though the use of controlled substances is rare in Singapore. Although the natural history of disease varies from person to person, a relationship between symptom severity and frequency/dosage of abuse has been established. It is important to be aware of this condition and have a high degree of clinical suspicion to enable early diagnosis and immediate initiation of multidisciplinary and holistic treatment. A delayed diagnosis can lead to irreversible pathological changes and increased morbidity among ketamine abusers.
Adult ; Cystitis ; drug therapy ; Cystoscopy ; Female ; Fluoroscopy ; Humans ; Ketamine ; adverse effects ; Lower Urinary Tract Symptoms ; chemically induced ; Male ; Singapore ; Substance-Related Disorders ; complications ; Tomography, X-Ray Computed ; Ultrasonography ; Urinary Tract ; drug effects ; physiopathology ; Young Adult

Patients presenting for emergency abdominal procedures often have medical issues that cause both general anaesthesia and central neuraxial blockade to pose significant risks. Regional anaesthetic techniques are often used adjunctively for abdominal procedures under general anaesthesia, but there is limited published data on procedures done under peripheral nerve or plexus blocks. We herein report the case of a patient with recent pulmonary embolism and supraventricular tachycardia who required colostomy refashioning. Ultrasonography-guided regional anaesthesia was administered using a combination of ilioinguinal-iliohypogastric, rectus sheath and transversus abdominis plane blocks. This was supplemented with propofol and dexmedetomidine sedation as well as intermittent fentanyl and ketamine boluses to cover for visceral stimulation. We discuss the anatomical rationale for the choice of blocks and compare the anaesthetic conduct with similar cases that were previously reported.
Abdominal Wall ; surgery ; Aged ; Anesthesia, Conduction ; methods ; Anesthesia, General ; adverse effects ; Colostomy ; adverse effects ; methods ; Conscious Sedation ; methods ; Dexmedetomidine ; administration & dosage ; Fentanyl ; administration & dosage ; Hemodynamics ; Humans ; Ketamine ; administration & dosage ; Laparoscopy ; Male ; Nerve Block ; methods ; Pain, Postoperative ; Postoperative Period ; Propofol ; administration & dosage ; Pulmonary Embolism ; complications ; Reoperation ; methods ; Tachycardia, Supraventricular ; complications ; Ultrasonography, Interventional

Acute Coronary Syndrome ; chemically induced ; Anesthetics, Dissociative ; adverse effects ; Humans ; Ketamine ; adverse effects

Adult ; Female ; Humans ; Ketamine ; adverse effects ; Kidney ; drug effects ; physiopathology ; Kidney Diseases ; chemically induced ; complications ; Substance-Related Disorders ; complications

OBJECTIVETo summarize the imaging features of urinary dysfunction associated with ketamine abuse (KAUD) for imaging diagnosis of KAUD.

METHODSWe analyzed the imaging findings in 45 patients with KAUD, all having a history of ketamine abuse and presenting with severe lower urinary tract symptoms. The patients underwent imaging examinations with ultrasonography (n=45), X-ray (n=38), computed tomography (n=28), magnetic resonance imaging (n=10) or single photon emission computed tomography (n=25), and the results were classified and evaluated to identify the common imaging findings.

RESULTSThe imaging changes of KAUD were found primarily in the urinary and biliary system. The most common imaging characteristics included thickening of the bladder wall, contracture and decreased functional volume of the bladder, dilation of the ureter and hydronephrosis, stricture of the upper ureter, renal impairment, dilation of the biliary system, and inflammation or swelling of the adjacent organs and lymph nodes

CONCLUSIONKAUD presents with typical imaging changes. Radiologists should be aware of KAUD if the typical imaging features are detected, especially in cases with a history of ketamine abuse.

Adolescent ; Adult ; Female ; Humans ; Ketamine ; adverse effects ; Lower Urinary Tract Symptoms ; diagnosis ; diagnostic imaging ; Magnetic Resonance Imaging ; Male ; Retrospective Studies ; Substance-Related Disorders ; diagnosis ; diagnostic imaging ; Tomography, X-Ray Computed ; Young Adult

OBJECTIVETo investigate the expression of protein kinase C (PKC) in the spinal dorsal horn of rats with formalin-induced pain and the effect of intrathecal ketamine on PKC expression.

METHODSThirty-two SD rats were randomly divided into 4 equal groups, namely the control group, intrathecal saline group (NS), 50 µg ketamine group (K1) and 100 µg ketamine group (K2). The rats were anesthetized with 10% chloral hydrate, and a microspinal catheter was inserted intrathecally into the lumbar region. Five days later, the rats in groups, K1 and K2 were subjected to intrathecal administration of 50 and 100 µg ketamine (10 µl), respectively, followed by 10 µl saline, and those in NS group received 20 µl saline only. Thirty minutes later, 5% formalin (50 µl) was subcutaneously injected into the left hindpaw. The pain intensity score (PIS) was utilized to assess antinociceptive behavior within 1 h after formalin injection. Twenty-four hours later, the left hindpaw thickness was measured and the expression of PKC in the spinal dorsal horn in the L5 segment was assayed using immunohistochemistry.

RESULTSCompared to group NS, groups K1 and K2 showed significantly decreased PIS (P<0.01) in the second phase of formalin-induced pain; 24 h later, the left hindpaw thickness of group NS increased obviously in comparison with that in the control group (P<0.01), whereas the thickness was significantly reduced in group K1 and K2 as compared to that in group NS (P<0.05). The number of immunoreactive cells and the immunohistochemical score of PKC in the spinal dorsal horn were significantly higher in group NS than in group C (P<0.01), but significantly lower in groups K1 and K2 than in group NS (P<0.05).

CONCLUSIONIntrathecal ketamine produces obvious antinociception against formalin-induced pain in rats and inhibits the enhanced PKC expression in the spinal dorsal horn in response to formalin-induced pain, suggesting the important role of PKC in nociceptive signal transmission and modulation in the spinal cord.

Animals ; Formaldehyde ; adverse effects ; Injections, Spinal ; Ketamine ; administration & dosage ; pharmacology ; Male ; Pain ; chemically induced ; metabolism ; Pain Measurement ; Posterior Horn Cells ; metabolism ; Protein Kinase C ; metabolism ; Rats ; Rats, Sprague-Dawley ; Spinal Cord ; drug effects ; metabolism