Fulminant pulmonary edema after intramuscular ketamine

Abstract

Purpose: To report an unusual case of pulmonary edema following intramuscular ketamine administration. Clinical Features: An eight-year-old, healthy girl presented for dressing of first degree burns on dorsum of hand. Ten minutes after administration of 125 mg ketamine im, she developed laboured breathing, cyanosis, and bilateral crepitations and arterial blood gas analysis showed PaO 2 55 mmHg. There was no evidence of upper airway obstruction. On intubating the trachea, pink frothy fluid emerged from the tube. She was diagnosed as a case of neurogenic pulmonary edema. She was managed with positive pressure ventilation with positive end expiratory pressure, morphine and furosemide. With this treatment she showed a favourable recovery. Conclusion:Ketamine was given im to aid burns dressing in this case because it has distinct advantages above the other anesthetic agents including that of being a good analgesic which is absorbed by im route. Its use led to the development of pulmonary edema.Objectif : Signaler un cas inhabituel d'oedème pulmonaire survenu après l'administration intramusculaire de ké-tamine.Éléments cliniques : Une fillette de 8 ans, en bonne santé, s'est présentée pour un pansement sur des brûlures de premier degré au dos de la main. Dix minutes après l'administration de 125 mg de kétamine im, elle a présen-té une gêne respiratoire, de la cyanose et des crépitations bilatérales. La gazométrie artérielle a montré une PaO 2 de 55 mmHg. Il n'y avait pas d'évidence d'obstruction des voies aériennes supérieures. À l'intubation de la trachée, un liquide rosé spumeux sortait du tube. On a posé le diagnostic d'oedème pulmonaire neurogène. La ventilation à pression positive avec pression positive en fin d'expiration, de la morphine et du furosémide ont constitué le traitement. L'enfant a connu une bonne récupération.Conclusion : La kétamine im a été utilisée pour faciliter le pansement de brûlures à cause de ses avantages particuliers par rapport aux autres anesthésiques. En effet, elle fournit une bonne analgésie absorbée par voie im. Son emploi a provoqué l'apparition d'un oedème pulmonaire.

Ketamine Inhibits Lung Fluid Clearance through Reducing Alveolar Sodium Transport

“…First, several case reports have shown that ketamine is a possible reason for lung edema in patients during intraoperative period [1–3, 5]. If this effect occurred at the level of the alveolar or distal airway epithelium, then the threshold for developing alveolar edema could be downregulated or the resolution of edema, in which active ion transport plays an important role, might be reduced by ketamine [8].…”

“…Intraoperative pulmonary edema has been reported worldwide following intramuscular or intravenous ketamine administration [1–5]. Pulmonary edema is the abnormal fluid accumulation in the interstitial or alveolar spaces of the lung.…”

“…In patients undergoing anaesthesia, higher afterload as in neurogenic causes or other noncardiogenic pulmonary edema are also encountered [1–3]. Ketamine can clinically induce lung edema as well as increase pulmonary vascular permeability and arterial pressure.…”

A single small dose of ketamine prevents lung injury following hepatic ischemia-reperfusion in rabbits

“…19,20 However, Pandey et al have reported that intramuscularly injected large-dose ketamine could cause pulmonary artery hypertension and acute pulmonary edema, indicating a potential unfavorable effect of ketamine despite its favorable effect in inhibiting the production of proinflammatory cytokines. 10 This unfavorable effect limits the use of ketamine in liver surgeries such as the OLT, though ketamine may alleviate hypotension induced by the HIR. Anyway, such adverse effect of ketamine is dosedependent.…”

“…8,9 However, ketamine sometimes causes dramatic hemodynamic changes, which may induce serious pulmonary artery hypertension, provoking or aggravating pulmonary edema. 10 In this study, a single small dose of ketamine was given to rabbits before cross-clamping of the IVC and the HPV, changes in systematic hemodynamics and pulmonary proinflammatory cytokines after hepatic reperfusion were observed to evaluate the effect of ketamine preconditioning on hepatic ischemia-reperfusion (HIR) induced acute lung injury.…”