Ban Ketamine?.... Just say neigh!

I know I’m pretty opinionated but right now I feel incredibly compelled to be so. On the 9^th of March the UN Commission for Narcotic Drugs holds its 58^th meeting and there will be further attempt to place international restrictions on the use and distributions of ketamine.

It was muted that Special K (ketamine) was about to get super special, or indeed exclusive. No more would it just be known as just the horse tranquilizer but it would be locked away in the cupboard next to the big boys of the opiate world such as Morphine and Diamorphine (Heroin). And why? Because Ketamine is highly addictive and could cause all manner of ills if people start abusing it… apparently… very prevalent in China I believe who brought up the motion originally…. Wait a minute, just like caffeine or alcohol or sugar maybe…. They seem highly addictive and a menace to society. In fact isn’t obesity one of the world’s leading scourge’s currently?! I’m sorry, I can’t help but get a little bit riled at the broad sweeping statements that I have seen and read recently. Thank goodness this has been met with stern opposition from the WHO and also the AAGBI.

But Ketamine is (thankfully) still classed as an essential anaesthetic agent by the WHO and by scheduling it there would be no alternative to deliver an anaesthetic in many a low-income country. In fact the impact on global healthcare would be immeasurably bad. Not to mention the impact on the veterinary world!

  It’s a drug that has become fashionable of late to use in the UK even. I remember seeing it being used first of all by a few rather gung-ho individuals on the South Coast years ago for sedation in trauma of the elderly and then even a bit of use out there amongst pain specialistsfor chronic pain conditions. I have noticed it creeping into vogue more and more of late; starting amongst the intensivists, often influenced by the military’s successful use in trauma and shocked personnel. It’s main ‘putting off’ factor of quite severe hallucinations have sort of faded away or become less consequential with other factors to consider.

 

Ketamine in medicinal form

 For me having worked somewhere where it is a staple anaesthetic drug, especially amongst those who are haemodynamically compromised (shocked) I cannot imagine not having it to hand. In fact today as I travelled through the Southern province of Zambia I met up with a solo anaesthetist working at the border of Zambia and Zimbabwe who told me of his plight with poor equipment and drug supplies. In fact this very month he has run out of Halothane (an inhalational anaesthetic agent and has had to resort to using ketamine to keep people asleep during their anaesthetics. This has been a similar finding throughout the last few weeks of following up anaesthetists in rural Zambia. How are they going to manage without their staple, dependable anaesthetic? In fact I highlight one of many cases that I can think of below where I think the lack or the restriction of ketamine would have resulted almost certainly an anaesthetic catastrophe.

Often the only anaesthetic drugs available are: Ketamine, Thiopentone and Halothane (neither of these are great if the patient is shocked). In fact one can say that the last two can often cause worsening hypotension when given.

I’ve personally used Ketamine both intravenously and intramuscularly to great effect.  However, I had never used it as an oral sedative before. There is always a first time for everything! Paediatric Tuesday’s is a particularly difficult challenge. It consists of two concurrent lists of:

• Plastic surgery – which often has small babies having cleft lips and palates repaired as well as some nasty contracture releases or burns treatments.
• ENT - where the usual tonsils and adenoids are interspersed with severe laryngeal papilloma’s (warty growths in the airway causing severe obstruction).

They’re both pretty full on lists that require maximal concentration and attention to detail.

 This Tuesday, no more so than a little 5 year old boy who has one of the worst burn contractures I have seen. Picture a little 4 year old boy running into the house as his 9 year old brother is carrying out a pan of boiling hot water…. I don’t think I need to say anymore. He has extensive burns to his face, neck, chest and arm. That in itself would be pretty horrific but when the burnt skin heals it contracts and becomes hard and so his head and neck are fixed in a downward right sided gaze. His right arm is attached to his chest almost making it barely functionable. And worst of all his mouth is pulled downwards and there is a severe restriction on his actual mouth opening which means eating, drinking and talking are pretty difficult to do. So the plan was to release these contractures and graft them so that he has some function back and starts the process of rehabilitation.

 Great, fantastic… except, we had to anaesthetize him…. A nightmare scenario.

The important things for anaesthetists are:

• Mouth Opening: he could barely open more than 1.5cm
• Protruding one’s bottom jaw past the top – not a chance here!
• Extension of the head (essentially putting one’s chin on one’s chest – actually he was fixed in that position, but then managing to actually tip your head back) – totally impossible.

So essentially getting a breathing tube into him would be a miraculous event. Maybe in the UK in an adult a form of awake intubation would be possible, or even asleep, but here  in Zambia (in a 5 year old) that is not achievable on any level.  I wont bore you with the planning discussions that we had, but essentially we managed to do him with intravenous ketamine and kept him breathing himself via a face mask, and then once the mouth was released enough (when he  was asleep that is) we managed to just get an LMA in. Phew! So that was great – he went back to the ward and was doing well for a few days. Except, he now had to come back this week for changing the dressing and re-look at the wounds. That feeling of getting out of jail that we’d had previously had now evaporated as he had developed a chest infection and potentially an infection in the skin grafts. He was pretty poorly with oxygen saturations in the low 90’s – not a good starting point before an anaesthetic.

 With some discussion with the surgeon and a bit more planning we decided on a course of action: less is more! The option of postponing him wasn’t really there as he was likely to get worse and if the skin was infected then it would likely develop into full blown sepsis (infection) and then there would be no return. So we had a few options but we decided on using some oral ketamine as sedation.

 

Plastic surgeon Dr Goran getting ready to operate after doing the WHO surgical safety checklist on the wall

 Now neither Dave nor I had used it orally before. The surgeon who has done thousands of ketamine based operations in the rural areas of Zambia has seen its use intravenously and intramuscularly but never orally. But we thought we’d try it. Its meant to be very bitter, so we calculated his dose and then put it into a  slug of Calpol we’d managed to get hold of. Now, most parents know the amazing effect Calpol has on a child – they will gulp it down no problems. Even with the bitter taste of Ketamine he devoured it. As there was no nurse in recovery I had to keep him on a trolley next to his Mum as he got more sleepy – the effect of the drug working well. I put the Lifebox pulse oximeter on him and instructed her to keep a beady eye on the saturations and if they dropped below a certain level she should call us – which she did. Parents out here are often far more diligent at checking their children than an overstreched nurse – not ideal, but pragmatic!

  And so 30 minutes later we took the little fella into theatre in a beautiful dissociated state and gave him the merest whiff of Halothane (inhalational anaesthetic) to breathe through a mask with oxygen to make sure that he was anaesthetically deep enough asleep). It worked beautifully and gave the surgeon a great chance to look at all the graft sites, wash them thoroughly and do what was needed. It was a fantastic result as he breathed himself throughout the anaesthetic, we avoided having to do anything to his airway to irritate the lungs or to potentially cause him harm by failing to do so correctly. He then went back to the watchful eye of his Mum on the trolley and woke up from his trance-like state smiling. I’m not sure if that was the effect of the Ketamine or the lingering taste of the Calpol! But still – a wonderful new sedation approach for my armoury and one I would certainly use again, well in fact am likely to have to as he’ll be back many more times yet! And yet it makes me think if we didn’t have access to Ketamine how radically different this story would have been.

        And so, I make no apologies for standing and shouting from my soap box in this blog...

Ketamine is essential here whether intravenously, intramuscularly or orally. I am convinced, my anaesthetic colleagues are long convinced, the surgeon is convinced, the parents and child are convinced. We hope the rest of the world will also see sense and be convinced!