Midazolam premedication for Ketamine-induced emergence phenomenon: A prospective observational study

Abstract

Objective:Ketamine administration is known to induce hemodynamic pressor response and psychomimetic effects which could be attenuated by appropriate premedication. The present study was designed to evaluate the effect of midazolam on hemodynamic stability and postoperative emergence phenomenon following ketamine anesthesia.Methods:This was a prospective observational study including 30 adult patients with American Society of Anesthesiologists physical grades I and II scheduled for elective short surgeries under ketamine anesthesia. Patients were premedicated with midazolam (0.02 mg/kg intravenously) before the ketamine induction (1 mg/kg intravenously). Demographic data and hemodynamic variables were observed during the perioperative period. Pain score by visual analog scale score and psychomimetic effects were recorded postoperatively.Findings:The mean ± standard deviation of heart rate, systolic blood pressure, diastolic blood pressure, and respiratory rate were decreased postoperatively (85.3 ± 11.4, 120.7 ± 8.2, 79.2 ± 5.5, 13.5 ± 1.8, respectively) compared to intraoperative period (88.53 ± 14.1, 123.83 ± 13.8, 83 ± 9.1, 14.13 ± 2.0, respectively). There was statistically significant decrease in systolic (P = 0.03) and diastolic (P = 0.002) blood pressure, but not with heart rate and respiratory rate. Eighty percent of patients had no pain at ½ hour and 1 hour, while this increased to 90% at 2 hours postoperatively. Mild emergence delirium was noted in 13.3% and 16.7% at ½ hour and 1 hour, respectively, which decreased to 13.3% at 2 hours. Dreams were noticed in 20%, 27% and 10% of patients at ½ hour, 1 and 2 hours after surgery, respectively.Conclusion:Midazolam premedication in ketamine anesthesia effectively attenuated the hemodynamic pressor response and postoperative emergence phenomenon. Hence, the combination of midazolam with ketamine can be safely used for short surgical painful procedures in adults.

Ketamine and Ketamine Metabolite Pharmacology: Insights into Therapeutic Mechanisms

“…In addition, ketamine-associated delirium occurring at anesthetic doses (1-2 mg/kg, i.v. infusion) is effectively minimized via pretreatment with benzodiazepines (positive allosteric modulators of GABA A receptors; Dundee and Lilburn, 1978;Perumal et al, 2015). In contrast, Irifune et al (2000) showed that both muscimol and the benzodiazepine receptor agonist diazepam augment ketamine-induced anesthesia, whereas the GABA A receptor antagonist bicuculline antagonizes ketamineinduced anesthesia in mice.…”

Ketamine: 50 Years of Modulating the Mind

“…IM administration has made it an especially popular choice for sedation in children who may otherwise be uncooperative. Although not as frequently used in adults for this purpose due to an increased likelihood of emergence delirium (1–2% in children vs. 10–20% in adults; Strayer and Nelson, 2008), this can effectively be reduced with benzodiazepine administration (Dundee and Lilburn, 1978; Perumal et al, 2015) or with the co-administration of propofol (Willman and Andolfatto, 2007; Andolfatto and Willman, 2010). …”

Ketamine for the Acute Management of Excited Delirium and Agitation in the Prehospital Setting

“…Following the administration of ketamine, it is important to obtain IV or IO access, monitor oxygen saturations, and ensure an uncompromised airway with consideration for any underlying respiratory comorbidities. Although unlikely during transport, if an emergence reaction occurs following the metabolism of ketamine, administration of midazolam by any route is warranted . Emergency medical service responders have extensive experience with IM midazolam because it is the preferred IM agent in the management of status epilepticus and has a rapid onset of action and short duration of action when compared with other benzodiazepines .…”

“…Although unlikely during transport, if an emergence reaction occurs following the metabolism of ketamine, administration of midazolam by any route is warranted. 34 Emergency medical service responders have extensive experience with IM midazolam because it is the preferred IM agent in the management of status epilepticus and has a rapid onset of action and short duration of action when compared with other benzodiazepines. 35 Although some studies utilized midazolam as adjunct sedation, there is potential concern that such a practice may compound the risk of respiratory compromise.…”