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Query: UMLS:C0085631 (agitation)
 12,064 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Twenty-seven consecutive cases of acute epiglottitis in children were treated by nasotracheal intubation during a 25-month period. The duration of intubation averaged 44.2 hours. No mortality or morbidity occurred. Mean hospitalization was 4.5 days. Anaesthetic techniques are discussed. Ketamine is a somewhat controversial choice for these patients as it can enhance excitement, restlessness, and accidental extubation. This study reconfirms the ease of maintaining an assured airway by nasotracheal intubation in cases of acute epiglottitis.
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PMID:Acute epiglottitis in children: management of 27 consecutive cases with nasotracheal intubation, with special emphasis on anaesthetic considerations. 31 5

An hemodynamic study has been performed in eight patients (age 68 +/- 7) suffering from complete atrioventricular block. They had to undergo the definitive implantation of a cardiac pace maker under general anesthesia. The fixed cardiac frequency may help to understand the effect of the anesthetic agent used on the cardiac muscle function. Ketamine is the only agent used directly at an initial intravenous dose of 3 mg.kg-1 followed by a perfusion in a constant rate of 0.20 mg.kg-1. min-1. Hemodynamic data (arterial pressure, pulmonary pressures, thermodilution cardiac output) are performed before induction, then every 5 minutes after induction for a 20 minute period. The absence of respiratory depression (PaCO2: 38 +/- 3 mm Hg) shows that hemodynamic changes are entirely due to ketamine. The peak of these changes takes place after 5 minutes (significant rise (p < 0.05) in systemic and pulmonary resistances, in systemic arterial pressure and in pulmonary arterial pressure). Stroke index decreases moderately. After 20 minutes all the parameters have returned to control values. Use of ketamine is not desirable for two reasons: 1 degree The rise of the afterload may alter the hemodynamic state which can be previously deteriorated in patients suffering from atrio-ventricular block. 2 degree Post-anesthetic agitation can displace the right ventricular electrode.
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PMID:[Ketamine anesthesia for definitive implantation of a cardiac pace maker (author's transl)]. 55 78

Four pharmacologic actions of intravenous ketamine (30 mg/kg) were studied in the rat. To elucidate the mechanism(s) terminating the pharmacologic effects, animals were pretreated with ketamine and agents anticipated to modify hepatic microsomal metabolism, including phenobarbital and SKF 525A. SKF 525A pretreatment markedly prolonged ataxia, analgesia and agitation, in addition to significantly elevating brain and plasma ketamine levels subsequent to the initial 10 minutes following injection; thus hepatic metabolism appeared to play a prominent role in the termination of the posthypnotic effects of the drug. While significantly shortening the durations of the three posthypnotic events, phenobarbital and ketamine pretreatments also lowered the brain and plasma levels of ketamine. With all pretreatments, brain ketamine levels were almost identical at the cessation of hypnosis (25 mug/g of tissue) and ataxia (8-10 mug/g of tissue). No pretreatment altered either the duration of loss of righting reflex (hypnosis) or brain and plasma ketamine levels during the initial 10 minutes after injection. Approximately 70% of the injected drug was recovered from four tissues, skeletal muscle, gut, skin and liver, at 10 minutes after injection; thus redistribution from brain to other tissues appeared to play a major role in the cessation of hypnosis. Ketamine pretreatment caused a 2-fold increase in the rate of its in vitro hepatic microsomal metabolism. Brain and plasma ketamine levels 30 minutes after injection were nearly identical in rats pretreated with ketamine and phenobarbital, although phenobarbital pretreatment resulted in a 4-fold increase in in vitro ketamine hepatic metabolism.
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PMID:Biodisposition of ketamine in the rat: self-induction of metabolism. 127 Dec 78

Diazepam and droperidol are used clinically with ketamine anesthesia to reduce emergence hallucinations, vivid unpleasant dreams, and hyperexcitability. Also, there are reports that the recovery time from ketamine anesthesia is shortened after administration of physostigmine. The authors investigated the influence of diazepam, droperidol, and physostigmine pretreatment on ketamine anesthesia by measuring the brain local regional activity and behavioral responses in rat. The 2-deoxyglucose brain local metabolic mapping method was used to determine regional brain functional activity. The recovery of tail flick response and righting reflex from ketamine anesthesia were prolonged by diazepam and by droperidol pretreatment, but the duration of agitation was shortened; physostigmine caused no significant change in any of these responses. Ketamine alone caused a statistically significant (P less than 0.05) increase in the rate of glucose utilization along the hippocampal molecular layer (control 87 mumol . 100 g-1 . min-1; ketamine 166 mumol . 100 g-1 . min-1) and a decrease in medial geniculate (25%), inferior colliculus (37%), and lateral habenula (18%). Diazepam, droperidol, and physostigmine pretreatment did not significantly alter any ketamine-induced glucose use changes, except for a decreased activity in hippocampal molecular layer with diazepam pretreatment (20%) and an increased activity in the lateral habenula with droperidol pretreatment (94%, P less than 0.05). These findings corroborate the "epileptogenic" character of ketamine anesthesia and implicate the hippocampus as a major focus. The reduced activity in the hippocampus induced by diazepam retreatment and the increased activity in the lateral habenula induced by droperidol pretreatment may be factors in the clinical reduction of ketamine hyperexcitability and hallucination by these drugs.
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PMID:The influence of droperidol, diazepam, and physostigmine on ketamine-induced behavior and brain regional glucose utilization in rat. 713 16

The behaviour of 48 children ranging from weeks to eight years was observed and compared after four different anaesthesia methods. Either ethrane or halothane was used with or without induction with ketamine i.m. (5 mg/kg bodyweight). Restlessness, the depth of postanaesthetic sleep, shivering, muscle rigidity and vomiting were evaluated every 15 min. up to one hour postoperatively using a graduation from 1--4. Ketamine combined with halothane showed significantly less postoperative restlessness than all other methods. No statistically proven differences were seen in the other criteria, which were noticed more than once. The psychic effects as well as the practical clinical application of this method are discussed.
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PMID:[Steal-induction with ketamine in childhood: comparison of the postanaesthetic period (author's transl)]. 746 56

General anaesthesia is often required for burns dressing. Ketamine was the most common agent for carrying out removal of adherent dressings. Disadvantages are delirium on emergence from anaesthesia and prolonged recovery. We have studied an intravenous combination of propofol and ketamine in 29 burned patients for 39 dressings. After induction with 1 mg.kg-1 of propofol and 0.75 mg.kg-1 of ketamine, the maintenance rate was 2.5 mg.kg-1.h-1 of each agent. Satisfactory intraoperative conditions were obtained in all cases. Mean time of recovery was less than 15 min. Unpleasant dreaming occurred in 3 patients only, without agitation. The technique proved to be simple, effective and should revive interest for ketamine in the management of burned patients.
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PMID:[Propofol and ketamine for dressing in burnt patients]. 767 Oct 53

Several situations arise in the PICU patient that require the administration of drugs for sedation and analgesia. A "cookbook" approach is impossible because of the diversity of patient and clinical scenarios. When amnesia is required, these authors prefer a continuous infusion of a benzodiazepine such as midazolam or lorazepam. Although the majority of clinical experience has been with midazolam, lorazepam either by bolus dose or continuous infusion offers a cost-effective alternative. When analgesia is required, the addition of a continuous infusion of narcotic or the use of a PCA device in the older patient should prove effective. Although fentanyl is frequently chosen, morphine is an effective and cost-effective alternative for patients with stable cardiovascular function. The synthetic narcotics are recommended for neonates, especially following cardiac surgical procedures and those at risk for pulmonary vasospasm. Narcotics may also be used for the treatment of agitation in those situations that do not necessarily require analgesia. Our clinical experience suggests that narcotics may be more effective for sedation than benzodiazepines in children less than 1 year of age. When the above agents fail to be effective or are associated with cardiovascular depression, alternatives may include ketamine or pentobarbital. Ketamine may be useful for the unstable patient or those with a bronchospastic component to their disease process. We have found pentobarbital to be effective when the combination of benzodiazepines and narcotics fails to provide the desired level of sedation. Aside from these techniques, regional anesthesia may offer a more effective means of controlling pain in the PICU patient. These techniques may be effective when parenteral narcotics are inadequate or lead to undesired effects. Although most commonly used for postoperative analgesia, their use in patients with pain from other causes (e.g., multiple trauma) may be indicated, especially when parenteral narcotics may interfere with respiratory function or the ongoing assessment of the patient's mental status.
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PMID:Pain management and sedation in the pediatric intensive care unit. 798 86

Pharmacological praemedication. In patients receiving regional anaesthetics induction of deep sedation prior to the performance of the block should be avoided because during the installation of the nerve block it is an advantage to have a cooperative patient. Adequate anxiolytic effects are achieved by oral administration of chloracepate (0.3-0.5 mg/kg body weight). Intraoperative sedation. Once regional anaesthesia is established deep sedation or even a light sleep might be appropriate to improve the patient's comfort. Short acting i.v. substances are the agents of choice. Propofol (1.5-5 mg/kg per h) and midazolam (0.03-0.09 mg/kg per h) are recommended. Both substances should be titrated as needed. Since respiratory depression or loss of airway patency may occur, close observation and pulse oxymetric monitoring are mandatory. Intraoperative analgesia. Restlessness due to pain is not an indication for sedatives and/or hypnotics. Pain can be caused not only by incomplete regional anaesthesia, but also by a tourniquet or uncomfortable body positions, for example, and it should be treated in different ways according to its cause. In the case of an incomplete block, a catheter technique makes a top-up dose for augmentation possible; additional peripheral nerve blocks can also be used to complete the analgesia. If these attempts are unsuccessful, systemic analgesics (preferable narcotics) or even anaesthetics must be given. Opioids are recommended only in mild to moderate pain or discomfort. The risk of respiratory depression should be considered. The administration of oxygen by mask and pulse oxymetric monitoring are useful. Ketamine is a common drug with a potent analgesic effect, which possesses the advantages of good support for the cardiovascular system, because of its sympathomimetic action, and minimal depression of the ventilatory drive. However, with the exception of a few specific indications, Ketamine is not a drug that is initially an integral part of planned regional anaesthetic procedures. In case of incomplete regional blocks administration of ketamine is more frequently the "ultima ratio" following a number of previous, unsuccessful attempts-primarily with sedatives and/or opioids-to achieve a condition that will permit surgical procedures; as a result, the hypnotic and respiratory depressant effects of subsequently administered drugs are enhanced and potentiated. An important consequence of this complex pharmacodynamic interaction scenario is a potential loss of the advantages that would otherwise be gained by using "subanaesthetic" ketamine doses (< 0.5 mg/kg), namely: a cooperative patient who is breathing spontaneously and has an intact laryngopharyngeal reflex response and, therefore, an uncompromised airway competence. Pulse oxymetric monitoring of the potentially endangered respiratory function is obligatory. The individual transition to general anaesthesia is not easy to determine. Therefore, it is essential that, whenever the need arises, intubation and mechanical ventilation intervention procedures be carried out immediately.
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PMID:[Analgesia and sedation to supplement incomplete regional anesthesia]. 859 70

The effects of intravenous administration of variable-dose midazolam and ketamine (3 mg/kg) were studied in twelve healthy unmedicated cats from time of administration until full recovery. A range of midazolam doses (0.0, 0.05, 0.5, 1.0, 2.0 and 5.0 mg/kg) was chosen, so that beneficial and/or detrimental effects could be documented and the therapeutic window for further study determined. One minute after administration of ketamine, all cats had assumed a lateral position, mostly with head up. Muscle tone was increased (100%), apneustic breathing pattern evident in 92% of cats, chewing without stimulation of the oropharyngeal area was observed in most cats (97%), but most cats did not salivate (87%). At 2.5 min after completion of ketamine injection and 1 min after administration of saline, a similar picture was observed, except that salivation was evident. All cats chewed or swallowed in response to a finger or laryngoscope placed in the oropharyngeal area and, while most cats were not aware of a noxious stimulus to the tail, some cats were aware of a noxious stimulus to the paw. Recovery from ketamine alone was rapid and smooth with cats rolling into sternal recumbency and then cautiously walking with ataxia. Recovery to walking without incoordination was also rapid (< 2 h) and no abnormal behavioural patterns were observed during recovery. Administration of midazolam after ketamine, had beneficial effects and the therapeutic window for midazolam was found to lie between 0.05 mg/kg and 0.5 mg/kg. Administration of any dose of midazolam after ketamine caused a greater proportion of cats to assume a laterally recumbent position with head down compared with ketamine alone, however, the time period of recumbency was only significantly longer with a midazolam dose of 2.0 mg/kg or above. Doses of midazolam of 0.5 mg/kg or above decreased muscle rigidity but did not affect salivation or respiratory pattern observed in cats which received ketamine alone. A significantly greater proportion of cats which received ketamine and midazolam 0.5 mg/kg or above did not swallow in response to a finger or a laryngoscope placed in the mouth compared with that which received ketamine alone. The length of time in which cats did not swallow was only significantly longer at midazolam doses of 1.0 mg/kg and above. At midazolam doses of 0.5 mg/kg or above, the proportion of cats without a nociceptive response to a tail or paw clamp was significantly greater than cats which received ketamine alone. The time period without nociceptive response, however, was not influenced by midazolam administration. The time taken for cats which received ketamine and midazolam 0.05 mg/kg or 0.5 mg/kg to assume sternal position, walk with ataxia, walk without ataxia, behave normally when approached or restrained and recover normal arousal state was not significantly different from cats which received ketamine alone. Ketamine and midazolam 5.0 mg/kg significantly prolonged all recovery times compared with ketamine alone. Unfortunately, a greater proportion of cats which received ketamine and midazolam 0.5 or 5.0 mg/kg exhibited detrimental behavioural effects. These were more likely to be adverse and included restlessness, vocalization and difficulty approaching and restraining cats. In this study, an effect of sex of the cats was found, with male cats taking a significantly longer to recover to sternal recumbency and walk with ataxia, while female cats took longer to recover to a normal arousal state.
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PMID:The effect of intravenous administration of variable-dose midazolam after fixed-dose ketamine in healthy awake cats. 880 80

Intubating the subconscious, struggling patient in a pre-hospital setting can be a difficult task even in experienced hands. We performed a clinical prospective study to evaluate the applicability of ketamine for induction of anaesthesia before intubation in the field. Ketamine was distributed to all air medical rescue teams--trained reserve army volunteers from various medical specialties. Lectures and literature concerning the use of ketamine for anaesthesia induction before intubation were given. The physicians were instructed to administer ketamine, in a dose of 2 mg/kg intravenously, if a single intubation attempt failed. Following the administration of ketamine, a questionnaire was filled in by the physician. Analysis of the data was performed after 24 months. During the study period, intubation was indicated in 161 injured patients evacuated by air in Israel. In 29 patients (18 per cent) the first intubation attempt had failed and they were given ketamine. The reasons for failure of the first intubation attempt were restlessness or trismus in 23 patients and traumatic distortion of the upper airway anatomical landmarks in six. Following ketamine administration, intubation was successful in 19 patients (65.5 per cent) in all of whom the indication for ketamine administration was restlessness or trismus. All patients with upper airway anatomy distortion were given a cricothyroidotomy. There were no complications attributed to ketamine. All patients reached hospital alive. This preliminary study suggests that the use of ketamine in this pre-hospital setting is safe. The drug is effective in cases where the primary reason for failure to intubate is restlessness or trismus. The drug is not effective in cases of anatomical damage to the upper airway. In these cases, cricothyroidotomy should probably be performed as early as possible.
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PMID:Ketamine in the field: the use of ketamine for induction of anaesthesia before intubation in injured patients in the field. 919 25


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