This study represents an early milestone in understanding the effects of ketamine in children with severe traumatic brain injury (TBI). Contrary to previous concerns that ketamine could increase intracranial pressure (ICP), the results show that it may be a viable option for reducing intracranial pressure during seizures.
Ketamine, a widely used sedative medication, has acute brain effects that are not yet fully understood, especially in children.
This study sought to explore the immediate impacts of ketamine on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) in pediatric patients with severe traumatic brain injury (TBI).
Intracranial pressure (ICP) refers to the pressure exerted by brain tissue, cerebrospinal fluid (CSF), and blood within the skull. Under normal conditions, ICP is maintained in dynamic balance to ensure proper brain function.
However, injuries, infections, or other conditions can lead to an increase in ICP, which can compress brain tissue and reduce blood flow to the brain, causing damage.
Cerebral perfusion pressure (CPP) is a measurement that reflects the amount of blood actually delivered to the brain, and is calculated by the difference between mean arterial pressure (MAP) and ICP.
CPP is essential for supplying oxygen and nutrients to the brain; low values can cause cerebral ischemia (lack of adequate blood supply), while very high values can increase the risk of damage to brain tissue. Together, ICP and CPP are critical metrics for assessing brain health, especially in situations of trauma or neurological disease.
Ketamine administration times were synchronized with automated recordings of ICP and CPP, performed every minute and stored in the electronic medical record.
ICP and CPP values were analyzed at different time points after ketamine administration and compared with baseline values. CPP was adjusted to account for age-based normal thresholds, and changes over time were assessed using robust statistical methods.
The study included 33 patients ranging in age from 1 month to 16 years. Of these, 22 received a total of 127 doses of ketamine, while 11 patients did not undergo this intervention.
The demographic and clinical characteristics of the two groups were similar, allowing for consistent comparison.
The results showed that when ketamine was administered for sedation purposes alone, there were no significant changes in ICP or CPP levels compared to baseline.
This suggests that under normal conditions, ketamine does not worsen ICP or negatively affect CPP. However, for 11 patients who experienced ICP attacks (18 episodes treated with ketamine), the results were more promising.
After ketamine administration, there was a significant reduction in ICP and an increase in CPP adjusted for age thresholds. These findings indicate that ketamine may help alleviate intracranial hypertension attacks.
This study represents an early milestone in understanding the effects of ketamine in children with severe TBI. Contrary to previous concerns that ketamine could increase ICP, the results show that it may be a viable option for reducing intracranial pressure during seizures.
If these findings are confirmed in larger, more comprehensive studies, ketamine could become an evidence-based treatment for intracranial hypertension in children. This offers new hope for the treatment of a critical condition, potentially improving outcomes for pediatric patients in acute care settings.
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Acute Effects of Ketamine on Intracranial Pressure in Children With Severe Traumatic Brain Injury
Laws, Jennifer; Vance, E. Haley; Betters, Kristina; Anderson, Jessica; Fleishman, Sydney; Bonfield, Christopher; Wellons, John C.; Xu, Meng; Slaughter, James; Giuse, Dario; Patel, Neal; Jordan, Lori; Wolf, Michael S.
Critical Care Medicine 51(5):p 563-572, May 2023.
DOI: 10.1097/CCM.0000000000005806
Abstract:
The acute cerebral physiologic effects of ketamine in children have been incompletely described. We assessed the acute effects of ketamine on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) in children with severe traumatic brain injury (TBI). In this retrospective observational study, patients received bolus doses of ketamine for sedation or as a treatment for ICP crisis (ICP > 20 mm Hg for > 5 min). Administration times were synchronized with ICP and CPP recordings at 1-minute intervals logged in an automated database within the electronic health record. ICP and CPP were each averaged in epochs following drug administration and compared with baseline values. Age-based CPP thresholds were subtracted from CPP recordings and compared with baseline values. Trends in ICP and CPP over time were assessed using generalized least squares regression. A 30-bed tertiary care children’s hospital PICU. Children with severe TBI who underwent ICP monitoring. We analyzed data from 33 patients, ages 1 month to 16 years, 22 of whom received bolus doses of ketamine, with 127 doses analyzed. Demographics, patient, and injury characteristics were similar between patients who did versus did not receive ketamine boluses. In analysis of the subset of ketamine doses used only for sedation, there was no significant difference in ICP or CPP from baseline. Eighteen ketamine doses were given during ICP crises in 11 patients. ICP decreased following these doses and threshold-subtracted CPP rose. In this retrospective, exploratory study, ICP did not increase following ketamine administration. In the setting of a guidelines-based protocol, ketamine was associated with a reduction in ICP during ICP crises. If these findings are reproduced in a larger study, ketamine may warrant consideration as a treatment for intracranial hypertension in children with severe TBI.
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