Kolenda H, Gremmelt A, Rading S, Braun U, Markakis E
Department of Neurosurgery, University Clinic of Göttingen, Federal Republic of Germany.
Acta Neurochir (Wien). 1996;138(10):1193-9. doi: 10.1007/BF01809750.
Ketamine was supposed to be contra-indicated in head injured patients although it possesses numerous advantages over other commonly used analgosedative drugs. Referring to these potential advantages and the lack of definitive data about its effect upon ICP, CPP or neurological development, we conducted a prospective study in which moderate or severely head injured patients (n = 35) were prospectively allocated to receive treatment either with a combination of ketamine or midazolam or fentanyl and midazolam. The initial dose was 6.5 mg/kg/day midazolam, 65 mg/kg/day ketamine or 65 micrograms/kg/day fentanyl and was later adjusted due to clinical requirements for a period of 3 to 14 days. Comparably high dosages of ketamine [corrected] have been found necessary (104 mg/kg/day). Four patients from the ketamine group (n = 17) and 5 from the control group (n = 18) were withdrawn during treatment due to persistent ICP above 25 mm Hg, countermeasured by barbiturate coma. Two more patients were withdrawn due to development of cardiovascular arrest (ketamine group) and multi organ failure. A comparison of the remaining patients revealed a lower requirement of catecholamines (significant on first day, p<0.05), an on average 8 mm Hg higher cerebral perfusion pressure and a 2 mm Hg higher intracranial pressure in the study [corrected] group. Enteral food intake was better in the study group. The outcome was comparable in both groups with or without inclusion of withdrawn patients.
氯胺酮尽管相对于其他常用的镇痛镇静药物具有诸多优势，但曾被认为是头部受伤患者的禁忌药物。鉴于这些潜在优势以及缺乏关于其对颅内压（ICP）、脑灌注压（CPP）或神经发育影响的确切数据，我们进行了一项前瞻性研究，将35例中度或重度头部受伤患者前瞻性地分配为接受氯胺酮与咪达唑仑联合治疗，或芬太尼与咪达唑仑联合治疗。初始剂量为咪达唑仑6.5毫克/千克/天、氯胺酮65毫克/千克/天或芬太尼65微克/千克/天，随后根据临床需求在3至14天内进行调整。已发现需要相当高剂量的氯胺酮（校正后为104毫克/千克/天）。在治疗期间，氯胺酮组（n = 17）有4例患者和对照组（n = 18）有5例患者因持续颅内压高于25毫米汞柱而退出，通过巴比妥类药物昏迷进行对抗处理。另外有2例患者因发生心血管骤停（氯胺酮组）和多器官衰竭而退出。对其余患者的比较显示，研究组儿茶酚胺需求量较低（第一天有显著差异，p<0.05），平均脑灌注压高8毫米汞柱，颅内压高2毫米汞柱。研究组的肠内食物摄入量更好。无论是否纳入退出的患者，两组的结局相当。
