Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA.
Division of Neurosurgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
Neurocrit Care. 2023 Apr;38(2):242-253. doi: 10.1007/s12028-022-01611-2. Epub 2022 Oct 8.
Ketamine has traditionally been avoided as an induction agent for tracheal intubation in patients with neurologic conditions at risk for intracranial hypertension due to conflicting data in the literature. The objective of this study was to evaluate and compare the effects of ketamine versus other medications as the primary induction agent on peri-intubation neurologic, hemodynamic and respiratory associated events in pediatric patients with neurologic conditions at risk for intracranial hypertension.
This retrospective observational study enrolled patients < 18 years of age at risk for intracranial hypertension who were admitted to a quaternary children's hospital between 2015 and 2020. Associated events included neurologic, hemodynamic and respiratory outcomes comparing primary induction agents of ketamine versus non-ketamine for tracheal intubation.
Of 143 children, 70 received ketamine as the primary induction agent prior to tracheal intubation. Subsequently after tracheal intubation, all the patients received adjunct analgesic and sedative medications (fentanyl, midazolam, and/or propofol) at doses that were inadequate to induce general anesthesia but would keep them comfortable for further diagnostic workup. There were no significant differences between associated neurologic events in the ketamine versus non-ketamine groups (p = 0.42). This included obtaining an emergent computed tomography scan (p = 0.28), an emergent trip to the operating room within 5 h of tracheal intubation (p = 0.6), and the need for hypertonic saline administration within 15 min of induction drug administration for tracheal intubation (p = 0.51). There were two patients who had clinical and imaging evidence of herniation, which was not more adversely affected by ketamine compared with other medications (p = 0.49). Of the 143 patients, 23 had pre-intubation and post-intubation intracranial pressure values recorded; 11 received ketamine, and 3 of these patients had intracranial hypertension that resolved or improved, whereas the remaining 8 children had intracranial pressure within the normal range that was not exacerbated by ketamine. There were no significant differences in overall associated hemodynamic or respiratory events during tracheal intubation and no 24-h mortality in either group.
The administration of ketamine as the primary induction agent prior to tracheal intubation in combination with other agents after tracheal intubation in children at risk for intracranial hypertension was not associated with an increased risk of peri-intubation associated neurologic, hemodynamic or respiratory events compared with those who received other induction agents.
由于文献中的数据相互矛盾，对于有颅内高压风险的神经疾病患者，氯胺酮传统上被避免作为气管插管的诱导剂。本研究的目的是评估和比较氯胺酮与其他药物作为主要诱导剂对有颅内高压风险的神经疾病患儿在围插管期神经、血流动力学和呼吸相关事件的影响。
本回顾性观察性研究纳入了 2015 年至 2020 年间在一家四级儿童医院因颅内高压风险入院的<18 岁患儿。相关事件包括比较氯胺酮与非氯胺酮作为气管插管的主要诱导剂的神经、血流动力学和呼吸结果。
143 例患儿中，70 例在气管插管前接受氯胺酮作为主要诱导剂。随后，所有患儿均接受了辅助镇痛和镇静药物（芬太尼、咪达唑仑和/或丙泊酚），剂量不足以诱导全身麻醉，但足以使患儿在进一步诊断性检查过程中感到舒适。在氯胺酮组与非氯胺酮组之间，围插管相关神经事件无显著差异（p=0.42）。这包括获得紧急 CT 扫描（p=0.28）、气管插管后 5 小时内紧急进入手术室（p=0.6）和气管插管诱导药物给药后 15 分钟内需要给予高渗盐水（p=0.51）。有 2 例患儿有疝的临床和影像学证据，氯胺酮对其影响并不比其他药物更不利（p=0.49）。在 143 例患儿中，有 23 例记录了插管前和插管后的颅内压值；11 例患儿接受了氯胺酮，其中 3 例颅内高压得到缓解或改善，而其余 8 例患儿的颅内压在正常范围内，且未因氯胺酮而加重。两组患儿在气管插管期间的总体相关血流动力学或呼吸事件无显著差异，且两组均无 24 小时死亡率。
在有颅内高压风险的儿童中，在气管插管前给予氯胺酮作为主要诱导剂，并在气管插管后与其他药物联合使用，与使用其他诱导剂相比，并未增加围插管期相关神经、血流动力学或呼吸事件的风险。
