Effectiveness of ketamine in decreasing intracranial pressure in children with intracranial hypertension

Clinical article

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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.

Abbreviations used in this paper: ANOVA = analysis of variance; CBF = cerebral blood flow; CPP = cerebral perfusion pressure; ICP = intracranial pressure; MABP = mean arterial blood pressure; PICU = pediatric intensive care unit; TBI = traumatic brain injury.

Article Information

Address correspondence to: Gad Bar-Joseph, M.D., Pediatric Critical Care, Rambam Medical Center, P.O.B 9602, Haifa, Israel. email: g_barjoseph@rambam.health.gov.il.

© AANS, except where prohibited by US copyright law.

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Figures

  • View in gallery

    Graphs showing ICP (A), CPP (B), and MABP (C; MAP) responses to ketamine administration in the entire study population (30 patients, 82 events). Intracranial pressure decreased by 30% within 2 minutes of ketamine administration. **p < 0.005, ***p < 0.001.

  • View in gallery

    Graphs demonstrating ICP (A), CPP (B), and MABP (C) responses to ketamine administration before a potentially distressing intervention in patients with intracranial hypertension (17 events, Group 1). Intracranial pressure decreased by ~ 20% within 2 minutes of ketamine administration and did not increase during the intervention. **p < 0.005, ***p < 0.001.

  • View in gallery

    Graphs showing ICP (A), CPP (B), and MABP (C) responses to ketamine administration in an attempt to lower markedly elevated ICP (65 events, Group 2). Intracranial pressure decreased by 33% within 2 minutes of ketamine administration. *p < 0.05, ***p < 0.0001.

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