Elsevier

Injury

Volume 33, Issue 4, May 2002, Pages 323-327
Injury

Ketamine in war/tropical surgery (a final tribute to the racemic mixture)

https://doi.org/10.1016/S0020-1383(01)00209-1Get rights and content

Abstract

A technique of continuous intravenous anaesthesia with ketamine was used successfully during the Somalia civil war in 1994 and in north Uganda in 1999 for 64 operations in 62 patients, aged from 6 weeks to 70 years, undergoing limb and abdominal surgery including caesarian sections and interventions in neonates. Operations lasting up to 2 h could be performed in the absence of sophisticated equipment such as pulse oximeters or ventilators in patients on spontaneous ventilation breathing air/oxygen only.

After premedication with diazepam, glycopyrrolate and local anaesthesia, and induction with standard doses of ketamine, a maintenance dose of 10–20 μg/kg/min of ketamine proved safe and effective. Emphasis was placed on bedside clinical monitoring, relying heavily on the heart rate.

Diazepam, unless contraindicated or risky, remains the only necessary complementary drug to ketamine as it buffers its cardiovascular response and decreases the duration and intensity of operative and postoperative hallucinations. Local anaesthetic blocks were useful in decreasing the requirement for postoperative analgesia. An antisialogue was usually unnecessary in operations lasting up to 2 h, glycopyrrolate being the best choice for its lowest psychotropic and chronotropic effects, especially in a hot climate.

Experience in war/tropical settings suggests this technique could be useful in civilian contexts such as outdoor life-saving emergency surgery or in mass casualties where, e.g. amputation and rapid extrication were required.

Introduction

Ketamine is a very useful parenteral anaesthetic agent in situations where muscle relaxation is not necessary, in casualties where the patient is hypovolaemic or for extrication and transport under anaesthesia or sedation, in short minor procedures on spontaneous ventilation, and in uncooperative patients, e.g. children or psychiatric patients.

It is the systemic agent of choice in developing countries with scarce or no anaesthetic equipment and in war surgery where anaesthetic gases and oxygen cannot be used because of the risk of explosion and the handicap of carrying bulky equipment. All anaesthesia in developing countries, except in a few privileged centres, is done by three types of technique, i.e. draw over anaesthesia, spinal/epidural blocks and total intravenous anaesthesia with ketamine [1], [2]. The main advantages of ketamine are the convenient intramuscular route of administration as well as the intravenous one, the lack of hypotension (blood pressure is maintained or increases) and the maintenance of or increase in upper airway tone, which allows the patient to breathe spontaneously.

Drawbacks are increased salivation and lacrimation, an increase in blood pressure and heart rate, increased intracranial and intraocular pressures, and the high incidence of hallucinations and delirium on awakening. Extrapyramidal effects may appear during anaesthesia with normal or excessive dosages.

The drug is contraindicated in intracranial hypertension, head and eye injuries, glaucoma, thyrotoxicosis, ischaemic heart disease, hypertension and alcoholism.

A beneficial bronchodilator action in asthmatics has been reported [3], [4]. Atropine is often used as antisialogue, but it crosses the blood-brain barrier and the placenta, and it worsens the side-effects of ketamine such as the increase in heart rate and the hallucinations; furthermore, by interfering with pupil size it obscures a potential monitoring sign of the effects of the anaesthesia and by raising the temperature provokes unwanted effects, especially in a tropical environment.

Glycopyrrolate, which does not pass the blood-brain barrier or the placenta, is a preferable antisialogue because of its lesser chronotropic and psychotropic effects [5], [6].

Guidelines and dosages for total intravenous anaesthesia with ketamine have been drawn up but have a far too wide range [1], [2], [3], [4].

Section snippets

Materials and methods

This work was performed at Jowhar Hospital, Jowhar, Somalia, during the civil war in the period March–June 1994 and Kitgum Government Hospital, Kitgum, north Uganda, an area often subjected to attacks by antigovernment rebels in the period February–May 1999.

The two areas were similar in that surgery had to be performed with the real risk of rapid evacuation, scarce equipment and variably trained local staff. Sixty-two patients (age range 6 weeks–70 years, median 25 years) were anaesthetised

Technique

Local anaesthetic blocks were given as premedication when applicable to decrease the requirement for early postoperative analgesia. Lignocaine 1% with or without bupivacaine 0.5% infiltration was used in caesarian sections and herniae, lignocaine 1% plus adrenaline 1:200,000 infiltration in haemorrhoids and lateral sphincterotomies, and lignocaine 2% plus adrenaline 1:200,000 in axillary brachial plexus blocks for forearm amputation. Immediately after the local anaesthetic, in order to obtain

Results

Trismus and ventilatory rate were never a problem. No intraoperative or postoperative vomiting was reported. No gross extrapyramidal movements were observed in any patient.

The respiratory rate was maintained within a normally accepted physiological range of 10–18 breaths/min in all patients. In particular, no case of laryngospasm was observed. Awakening from anaesthesia was swift and smooth in the patients who had received diazepam as premedication, all of whom also went peacefully to sleep

Discussion

The reason for starting the maintenance infusion soon after reaching anaesthesia lies in the facility of monitoring the effect of continuous infusion from a known beginning and not from the unpredictable wearing off of the anaesthetic effect of the induction dose [3]. Furthermore, the overlapping effect between the induction bolus and the initial infusion of the maintenance drip would give better analgesia on the incision stimulus. The absence of sophisticated equipment and professionally

Conclusions

Diazepam is indispensable in decreasing the duration of postoperative hallucinations and is known to buffer the cardiovascular response to ketamine and to decrease the required dose of the anaesthetic [3], [4].

Glycopyrrholate, although useful and safer than atropine [5], [6], is not necessary in procedures lasting up to 2 h. Local anaesthesia is useful in decreasing postoperative requirements for analgesia. Limb and lower abdominal surgery can be performed safely without complications related to

Acknowledgements

I am grateful to the Italian Foreign Ministry for supporting me in acquiring the experience through InterSOS and AVSI NGOs, and to my old instructors at the Wythenshawe Hospital Department of Anaesthesia and Intensive Care, whose teaching has stood the test of time.

References (6)

  • Boulton TB. Anaesthesia beyond a major medical centre: current techniques with ketamine. Oxford: Blackwell,...
  • King M. Dissociative anaesthesia and intravenous analgesia. In: Primary anaesthesia. Oxford: Oxford University Press,...
  • Dundee JW, Wyant GM. Ketamine. In: Intravenous anaesthesia, 2nd ed. Edinburgh: Churcill Livingstone, 1988. p....
There are more references available in the full text version of this article.

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