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Ketamine induced myocardial depression

Ketamine induced myocardial depression. 陳姮文. 個案資料. 67 year, man, CAD, 3-vessel-disease s/p POBAS to RCA (1998) s/p POBA to distal LCx and OM (2003). 2008/10/30, cath LM: mid to distal 90% stenosis LAD long segment stenosis LCX multiple significant stenosis patent LIMA.

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Ketamine induced myocardial depression

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  1. Ketamine induced myocardial depression 陳姮文

  2. 個案資料 • 67 year, man, CAD, 3-vessel-disease • s/p POBAS to RCA (1998) • s/p POBA to distal LCx and OM (2003). • 2008/10/30, cath • LM: mid to distal 90% stenosis • LAD long segment stenosis • LCX multiple significant stenosis • patent LIMA. • Surgical intervention (CABG+MVP) on 11/12.

  3. Post OP • 19:30 admission to 4A2 09-1 (11/12) • 21:55 start bed side reopen • 22:10 pavulon 4mg/2ml IV push, ketamine 1支 for ABP 180/87 mmHg by VS 陳order • 22:10 for ABP 65/51 mmHg. •  Dopamine 160mg/100ml set 1013ml/hr • NTG 50mg/100ml set20 5ml/hr, • Bosmin 1mg/20ml set 0.5 2ml/hr

  4. 問題：Ketamine overdose 導因：1.醫師口頭醫囑開立錯誤 2.護理人員對藥物劑量認知不足

  5. Ketamine Ketalar®: 10 mg/mL (20 mL) 50 mg/mL (10 mL) 100 mg/mL (5 mL)

  6. Ketamine • Ketamine was used as a general anesthetic in the late 1960's • most frequently used for short-term sedation during clinical procedures

  7. Ketamine • 首先抑制丘腦及大腦皮質，之後是網狀與邊緣系統，造成「分離式麻醉」： ＊無意識地接受，產生了感官上的刺激感覺 ＊呈現強直性昏厥狀態(cataleptic condition) ＊可任意被保持固定姿勢 ＊伴有明顯的止痛效果 ＊之後回溯性失憶(amnesia) • 作用迅速 • 保有反射動作和自發性呼吸

  8. 適應症 • 視情況作為麻醉的導入劑與維持劑 • 可重複使用的短暫性麻醉，如燒傷病人、不合作的病人 • 止痛鎮靜療法時，並用鎮靜劑

  9. Side effect • >10%:Cardiovascular: Cardiac output increased, hypertension paradoxical direct myocardial depression, tachycardiaCentral nervous system: Intracranial pressure increased, visual hallucinations, vivid dreamsNeuromuscular & skeletal: Tonic-clonic movements, tremor

  10. Side effect • 1% to 10%:Cardiovascular: Bradycardia, hypotensionDermatologic: Pain at injection site, skin rashGastrointestinal: Anorexia, nausea, vomitingOcular: Diplopia, nystagmusRespiratory: Respiratory depression

  11. 禁忌症 • 血壓升高會導致危險的病人 • 對ketamine過敏者

  12. DOSING ADULTS — • Anesthesia (sedation, analgesia):  I.M.: 3-8 mg/kg  I.V.: Range: 1-4.5 mg/kg Usual induction dosage: 1-2 mg/kg     Maintenance: Supplemental doses of 1/3 to 1/2 of initial dose

  13. Onset & duration • Onset of action: I.V.: General anesthesia: 1-2 minutes; Sedation: 1-2 minutes  I.M.: General anesthesia: 3-8 minutes • Duration: I.V.: 5-15 minutes I.M.: 12-25 minutes • Half-life elimination: 11-17 minutes; Elimination: 2.5-3.1 hours

  14. 代謝 • Hepatic將環己酮環(cyclohexanone)進行去甲基作用(N-demethylation)及水解作用(Hydroxylation)，然後形成水溶性的化合物，經由尿液排出 • 代謝主要由尿液排出(91%)，其餘由糞便排出 • 恢復時間按劑量而定

  15. MONITORING PARAMETERS — Cardiovascular effects Heart rate Blood pressure Respiratory rate O2 saturation

  16. 注意事項 • 咽、喉或氣管之手術或診斷，不宜單獨使用本品：因咽喉反射仍然正常 • 注射時間應超過60秒，因太快速注射會導致呼吸抑制或窒息，以及血壓增高 • 恢復期心理不良反應：約有12%的病人會發生（幻想、瞻妄、愉快的夢、混亂、興奮、無理的行為表現）

  17. 結論 • Overdose時：目前尚無相關解藥，但因onset & duration 時間短，一旦發生，應 keep vital signs stable，待藥物代謝完 • 醫師應開立正確醫囑 • 護理人員應加強對藥物認知及敏感度

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