Oral Ketamine Facilitates Induction in a Combative Retarded Patient
Mentally
Cordell L. Bragg, MD,* Blaine R. Miller, DOJr Department Base,
of Surgery,
Induction of general anesthesia in the agitated or combative mentally retarded patient is challenging. Oral ketamine facilitated the smooth and safe induction of anesthesia in an adult mentally retarded patient with a history of violent behavior toward health care providers. The oral administration of ketamine is an ejfective alternative induction technique in situations where the intravenous (IV), intramuscular (IM), or inhalation approach may be dzfficult or hazardous. Keywords: Anesthesia, ketamine; techniques, induction, oral.
anesthetic
Introduction Ketamine is an effective sedative, analgesic, and anesthetic agent that is usually administered IV or IM.’ *Staff Anesthesiologist tAssistant Chief, Anesthesiology
Section
The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Air Force or the Department of Defense. Address reprint requests to Dr. Bragg at 1506 East Washington St., Thomasville, GA 31792, USA. Received for publication June 13, 1989; revised manuscript cepted for publication September 18, 1989. 0 1990 Butterworth
Publishers
USAF Medical Center, Keesler ,4ir Force
MS.
ac-
The use of oral ketamine as a sedative-analgesic also has been described, both in adult and pediatric patients.2-” This is a report of the use of oral ketamine as an induction agent for general anesthesia in a combative mentally retarded patient.
Case Report A 32-year-old, 52 kg mentally retarded female with an estimated mental age of 3 years presented for dental evaluation and restoration. Medical history was significant for violent behavior during attempted examinations or venipuncture and a seizure disorder controlled with phenytoin. Physical examination showed gingival hyperplasia but an otherwise normalappearing airway. On the morning of surgery, the patient received diazepam 10 mg and sodium citrate 15 ml orally. She walked to the operating room accompanied by her mother, where she was offered an oral solution containing ketamine 3 ml (100 mg/ml) and glycopyrrolate 2 ml (0.2 mg/ml) mixed with 5 ml of simple syrup. She readily accepted and ingested the solution. Within 10 minutes, the patient became noticeably sedated and was assisted onto the operating table. She tolerated application of a face mask, and induction of general anesthesia was completed by inhalation of halothane in nitrous oxide 70% and oxygen 30%. IV access was easily obtained, and anesthesia was maintained with isoflurane in nitrous oxide 60% and oxygen 40%. The l-hour operation proceeded without incident. J. Clin. Anesth., vol. 2, March/April
1990
121
Case Reports
At the conclusion of surgery, the inhalation agents were discontinued, with the patient emerging from anesthesia within 5 minutes. She was easily extubated and transported to a quiet, darkened area of the postanesthesia recovery unit. Recovery was uneventful, without nausea, vomiting, or postanesthesia emergence reactions.
Discussion Anesthetic management of the mentally retarded adult patient is challenging, since behavior may range from docile to violently aggressive.” Separation from parents and the familiar home environment often produces anxiety in the mentally handicapped person. When combined with unpleasant or painful experiences, the presence of hospital personnel may trigger aggressive, combative behavior.? Induction of general anesthesia by the IV, IM, 01 inhalation route of administration can be difficult or impossible in such a patient. The ideal induction agent should rapidly facilitate the smooth, gentle transition from consciousness to unconsciousness without causing pain or excitement.’ The administration of oral ketamine as an analgesic agent was reported in 198 1 by Grant et al.,’ who compared the effects of IM ketamine 0.5 mgikg and oral ketamine 0.5 mgikg in six healthy adult volunteers. The onset of analgesia after the administration of oral ketamine occurred within 30 minutes. Morgan and Dutkiewicz” reported profound analgesia without impairment of consciousness in a 3-year-old patient given oral ketamine 1 mg/kg on multiple occasions for burn dressing changes. Hain” reported the successful induction of general anesthesia by oral ketamine 12..5 mg/kg in a 4-year-old patient; however, this patient reportedly experienced “emergence phenomena” and excessive salivation. Elkins rt al.’ described their success using oral ketamine 2 to 8 mg/kg administered as a sedative during outpatient gynecologic examination of mentally retarded patients. Ketamine does not increase the risk of seizures in patients with seizure disorders.’ Although ketamine does cause thalamic and limbic epileptiform patterns, there is no evidence of cortical seizure activity either clinically, or by electroencephalogram (EEG). ’ The current patient’s history was one of extreme agitation and combativeness when a threat was perceived. Previously, physical force had been required to subdue her after she attempted to strike her dentist. The concern was that when presented with a face mask, IM injection, or IV, she might exhibit similar behavior, placing herself and others at risk of injury. 122
J. Clin. Anesth.,
vol. 2, March/April
1990
The practitioners wished to place the patient in a calm environment with a parent present and “allow” her to orally ingest a sweet-tasting substance. Oral ketamine, in a dose of approximately ti mg/ kg, was chosen to facilitate inhalation induction of general anesthesia. , Delong GR: Developmental and other congenital abnormalities of the nervous system. In: Isselbather KJ, Adams RI), Braunwald E, Peter&or1 KC;, Wilson .JD, eds. Harrison’s Principles of Intrrnal MPdiciw. 9th ed. New York: McGraw-Hill, 1980;2010-2. Way WL, Trevor AJ: Pharmacology of intravenous notinarcotic anesthetics. In: Miller RD, ed. Anesthesia. 2d ed. New York: Churchill Livingstone, 1986;799-833. Mirakhur RK, Dundee JW, Connolly JDR: Studies of drugs given before anaesthesia XVII: anticholinergicpremedicants. BrJ Anaesth 1979;51:339-45. Miller BR, Friesen RH: Oral atropine premeditation in infants attenuates cardiovascular depression during halothane anesthesia. Ane,.rth Analg 1988:67:180-5.
Mentally
Cordell L. Bragg, MD,* Blaine R. Miller, DOJr Department Base,
of Surgery,
Induction of general anesthesia in the agitated or combative mentally retarded patient is challenging. Oral ketamine facilitated the smooth and safe induction of anesthesia in an adult mentally retarded patient with a history of violent behavior toward health care providers. The oral administration of ketamine is an ejfective alternative induction technique in situations where the intravenous (IV), intramuscular (IM), or inhalation approach may be dzfficult or hazardous. Keywords: Anesthesia, ketamine; techniques, induction, oral.
anesthetic
Introduction Ketamine is an effective sedative, analgesic, and anesthetic agent that is usually administered IV or IM.’ *Staff Anesthesiologist tAssistant Chief, Anesthesiology
Section
The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Air Force or the Department of Defense. Address reprint requests to Dr. Bragg at 1506 East Washington St., Thomasville, GA 31792, USA. Received for publication June 13, 1989; revised manuscript cepted for publication September 18, 1989. 0 1990 Butterworth
Publishers
USAF Medical Center, Keesler ,4ir Force
MS.
ac-
The use of oral ketamine as a sedative-analgesic also has been described, both in adult and pediatric patients.2-” This is a report of the use of oral ketamine as an induction agent for general anesthesia in a combative mentally retarded patient.
Case Report A 32-year-old, 52 kg mentally retarded female with an estimated mental age of 3 years presented for dental evaluation and restoration. Medical history was significant for violent behavior during attempted examinations or venipuncture and a seizure disorder controlled with phenytoin. Physical examination showed gingival hyperplasia but an otherwise normalappearing airway. On the morning of surgery, the patient received diazepam 10 mg and sodium citrate 15 ml orally. She walked to the operating room accompanied by her mother, where she was offered an oral solution containing ketamine 3 ml (100 mg/ml) and glycopyrrolate 2 ml (0.2 mg/ml) mixed with 5 ml of simple syrup. She readily accepted and ingested the solution. Within 10 minutes, the patient became noticeably sedated and was assisted onto the operating table. She tolerated application of a face mask, and induction of general anesthesia was completed by inhalation of halothane in nitrous oxide 70% and oxygen 30%. IV access was easily obtained, and anesthesia was maintained with isoflurane in nitrous oxide 60% and oxygen 40%. The l-hour operation proceeded without incident. J. Clin. Anesth., vol. 2, March/April
1990
121
Case Reports
At the conclusion of surgery, the inhalation agents were discontinued, with the patient emerging from anesthesia within 5 minutes. She was easily extubated and transported to a quiet, darkened area of the postanesthesia recovery unit. Recovery was uneventful, without nausea, vomiting, or postanesthesia emergence reactions.
Discussion Anesthetic management of the mentally retarded adult patient is challenging, since behavior may range from docile to violently aggressive.” Separation from parents and the familiar home environment often produces anxiety in the mentally handicapped person. When combined with unpleasant or painful experiences, the presence of hospital personnel may trigger aggressive, combative behavior.? Induction of general anesthesia by the IV, IM, 01 inhalation route of administration can be difficult or impossible in such a patient. The ideal induction agent should rapidly facilitate the smooth, gentle transition from consciousness to unconsciousness without causing pain or excitement.’ The administration of oral ketamine as an analgesic agent was reported in 198 1 by Grant et al.,’ who compared the effects of IM ketamine 0.5 mgikg and oral ketamine 0.5 mgikg in six healthy adult volunteers. The onset of analgesia after the administration of oral ketamine occurred within 30 minutes. Morgan and Dutkiewicz” reported profound analgesia without impairment of consciousness in a 3-year-old patient given oral ketamine 1 mg/kg on multiple occasions for burn dressing changes. Hain” reported the successful induction of general anesthesia by oral ketamine 12..5 mg/kg in a 4-year-old patient; however, this patient reportedly experienced “emergence phenomena” and excessive salivation. Elkins rt al.’ described their success using oral ketamine 2 to 8 mg/kg administered as a sedative during outpatient gynecologic examination of mentally retarded patients. Ketamine does not increase the risk of seizures in patients with seizure disorders.’ Although ketamine does cause thalamic and limbic epileptiform patterns, there is no evidence of cortical seizure activity either clinically, or by electroencephalogram (EEG). ’ The current patient’s history was one of extreme agitation and combativeness when a threat was perceived. Previously, physical force had been required to subdue her after she attempted to strike her dentist. The concern was that when presented with a face mask, IM injection, or IV, she might exhibit similar behavior, placing herself and others at risk of injury. 122
J. Clin. Anesth.,
vol. 2, March/April
1990
The practitioners wished to place the patient in a calm environment with a parent present and “allow” her to orally ingest a sweet-tasting substance. Oral ketamine, in a dose of approximately ti mg/ kg, was chosen to facilitate inhalation induction of general anesthesia. , Delong GR: Developmental and other congenital abnormalities of the nervous system. In: Isselbather KJ, Adams RI), Braunwald E, Peter&or1 KC;, Wilson .JD, eds. Harrison’s Principles of Intrrnal MPdiciw. 9th ed. New York: McGraw-Hill, 1980;2010-2. Way WL, Trevor AJ: Pharmacology of intravenous notinarcotic anesthetics. In: Miller RD, ed. Anesthesia. 2d ed. New York: Churchill Livingstone, 1986;799-833. Mirakhur RK, Dundee JW, Connolly JDR: Studies of drugs given before anaesthesia XVII: anticholinergicpremedicants. BrJ Anaesth 1979;51:339-45. Miller BR, Friesen RH: Oral atropine premeditation in infants attenuates cardiovascular depression during halothane anesthesia. Ane,.rth Analg 1988:67:180-5.
