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ORIGINAL/RESEARCH ARTICLES
ORAL KETAMINE FOR PREMEDICATION IN CHILDREN
JA KULKARNI
Premedication in children with oral promethazine or Diazepam is unsatisfactory. To find out the effectiveness and safety of Oral Ketamine 50 children of (age : 4 to 10 years), ASA status I and II, with weights ranging from 9 to 25 kg were studied. Patients were administered oral ketamine 7 mg/kg, 1/2 an hour before the operation. They were evaluated for acceptance of oral ketamine, reaction to separation from parents, emotional state and emergence phenomenon. It was found that oral ketamine 7 mg/kg is acceptable alternative as a premedication in children without any significant side effects.
INTRODUCTION
Undergoing surgery can be a traumatic experience to children. Also fear of painful or unpleasant procedure and separation from parents may result in nightmares and untoward psychological effects. This study was designed to evaluate the efficacy and safety of oral ketamine as premedication in children and to facilitate the induction of anaesthesia without significant side effects. In children oral route is preferable over intramuscular or rectal route. Ketamine has hypnotic, analgesic and amnestic effects. It produces dissociative anaesthesia.
MATERIAL AND METHODS
With informed consent from parents this study was carried out in 50 patients. All were in ASA physical status I and II undergoing surgery like tonsillectomy, hernia, circumcision, skin grafting, of approx 1-2 hours duration. Patients were 4-10 years old and their weights ranged from 9 to 25 kgs, out of which 30 were male and 20 were female. In all patients routine investigations like CBC, urine
were carried out.
On the day of the operation, in the pre-operation room patients were administered oral ketamine 7 mg/kg in 0.2 ml/kg of rasna syrup 1/2 an hour before operation to counteract the bitterness of ketamine.OBSERVATIONS
I. Acceptance of Drug
Acceptance of drug was noted by the expressions of child or whether it was spat out.
II. Monitoring of the vital parameters
All the children were monitored for pulse, respiratory rate and oxygen saturation, after giving premedication, in pre-operative, intraoperative and post-operative period at interval of 5 minutes.
III. Behaviour in pre-operative room
All children were kept in pre-operative room and were observed for upper airway obstruction and onset of sedation before taking up for surgery. Maximum sedation time in each patient was also recorded.
IV. Response to sepatation from parents
Like crying was also noted.
V. Response to induction of anaesthesia
In sedated children, iv canula insertion and acceptance of mask was noted.
VI. Recovery
All children were observed for any side effects like nausea, vomiting and emergence phenomenon.
RESULTS
I. Ketamine was accepted well by all children.
II. No significant change was noted in cardiovascular and respiratory status and no laryngospasm was noted.
III. All patients allowed calm separation from parents.
IV. Onset of sedation was 11 ± 2 minutes and time to maximum sedation was 20 ± 3 minutes.
V. 94% of patients were well sedated and allowed iv canulation and accepted face mask prior to induction on anaesthesia.
VI. In recovery room, 4% of patients had nausea but none of the patients had vomiting or emergence
phenomenon.
DISCUSSION
There is no still entirely satisfactory way to ensure smooth induction of anaesthesia for children. The ideal premedication would be easily administered, well accepted, act rapidly, not prolong emergence from anaesthesia and has few side effects.
The drugs currently available for pre-anaesthetic pre-medication require either an injection, administering a pill, nasal or rectal route. Any of these methods would be difficult or traumatic for children.2
In addition many of the currently used drugs cause respiratory depression and none provides uniform balance of sedation, amnesia and analgesia before surgery.Only 16% of ketamine is bioavailable orally as opposed to 93% IM or IV.3 It has also been shown that oral ketamine doses equivalent to IM doses produce peak plasma concentration only in 1/5th as high as IM delivered and the time to reach peak plasma concentration is longer.
We decided not to administer oral atropine to decrease secretions because it also has bitter taste, the time to peak decrease in salivation is, significantly slower than the time to peak ketamine effect (15 to 20 minutes).4 Oral atropine also delays gastric emptying.
Although we observed no serious side effect, all these pre-medicated children should be monitored carefully.
CONCLUSION
As per our study oral ketamine in 7 mg/Kg dose has good sedative action, allowed calm separation from parents, appropriate amnesia and good induction conditions and insertion of iv canula prior to induction of anaesthesia. Thus, oral ketamine has been found to be reliable, predictable and acceptable pre-medicant in children without significant side effects in dose of 7 mg/Kg.
REFERENCES
1. Tobias JD, Phipps S, Smith B. Oral ketamine premedication to alleviate the distress of invasive paediatric oncology patients. Paediatrics 1992; 90 : 537-41.
2. Gustein HB, Kirsten LJ, Heard HB. Oral ketamine preanaesthetic medication in children. Anaesthesiology 1992; 76 : 28-33.
3. Grant LS, Nimmo WS, Clement JA. Pharmacokinetic and analgesic effects of IM and oral ketamine (KETMIN). Br J
Anaesth 1981; 53 : 805-9.
4. Slogoft S, Allen GW, Wessels IV, Cherry DE. Clinical experience with subanaesthetic ketamine. Anaesth Analg
1974; 53 : 354-8.
5. Mirkhur RK. Comparative study of the effects of oral and IM atropine in volunteers. Br Journal of Anaethesia 1978;
50 : 591-8.
