The Pre-brief
We all know that ketamine can increase blood pressure. However, in the hemodynamically fragile patient ketamine can induce hypotension. Here we will break down how ketamine can induce hypotension.
The De-brief
- Ketamine is still a strong choice for the induction of a hemodynamically fragile patient.
- Ketamine can increase blood pressure by inhibiting the catecholamine reuptake channels.
- If the catecholamine supplies are exhausted or the receptors are desensitized this inhibition may not matter.
- In this hemodynamically fragile patient we should always anticipate post intubation hypotension regardless of what induction agent we are use.
- Preparation for post intubation hypotension should include obtaining good IV access, resuscitating before intubating, and setting the BP cuff to cycle frequently.
References
Garg K, Grewal G, Grewal A, et al. Hemodynamic responses with different dose of ketamine and propofol in day care gynecological surgeries. J Clin Diagn Res. 2013;7(11):2548-2550. doi:10.7860/JCDR/2013/6860.3607
Suleiman Z, Ik K, Bo B. Evaluation of the cardiovascular stimulation effects after induction of anaesthesia with ketamine. J West Afr Coll Surg. 2012 Jan;2(1):38-52. PMID: 25452977; PMCID: PMC4170283.
Tweed WA, Minuck M, Mymin D. Circulatory response to ketamine anaesthesia. Anesthesiology. 1972;37:612–19.
Mohr NM, Pape SG, Runde D, Kaji AH, Walls RM, Brown CA 3rd. Etomidate Use Is Associated With Less Hypotension Than Ketamine for Emergency Department Sepsis Intubations: A NEAR Cohort Study. Acad Emerg Med. 2020 Nov;27(11):1140-1149. doi: 10.1111/acem.14070. Epub 2020 Jul 20. PMID: 32602974.
April MD, Arana A, Schauer SG, Davis WT, Oliver JJ, Fantegrossi A, Summers SM, Maddry JK, Walls RM, Brown CA 3rd; NEAR Investigators. Ketamine Versus Etomidate and Peri-intubation Hypotension: A National Emergency Airway Registry Study. Acad Emerg Med. 2020 Nov;27(11):1106-1115. doi: 10.1111/acem.14063. Epub 2020 Jul 18. PMID: 32592205.
- Jabre P, Combes X, Lapostolle F, Dhaouadi M, Ricard-Hibon A, Vivien B, Bertrand L, Beltramini A, Gamand P, Albizzati S, Perdrizet D, Lebail G, Chollet-Xemard C, Maxime V, Brun-Buisson C, Lefrant JY, Bollaert PE, Megarbane B, Ricard JD, Anguel N, Vicaut E, Adnet F; KETASED Collaborative Study Group. Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial. Lancet. 2009 Jul 25;374(9686):293-300. doi: 10.1016/S0140-6736(09)60949-1. Epub 2009 Jul 1. PMID: 19573904.
