|Year : 2010 | Volume
| Issue : 1 | Page : 28-30
An unusual reaction to ketamine in a child
EO Nwasor1, PM Mshelbwala2
1 Department of Anesthesia, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
2 Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
|Date of Web Publication||17-Dec-2010|
E O Nwasor
Department of Anaesthesia, Ahmadu Bello University Teaching Hospital, Zaria HO - 810 001
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Ketamine, a phencyclidine derivative, is a very popular and commonly used parenteral anesthetic agent. It is a safe drug in unskilled hands and a drug of choice in high-risk patients. We report an unusual allergic reaction to Ketamine in a 2.5-year-old child with bilateral congenital inguinal hernia. This is to alert all practitioners to some of the rare but potentially fatal side effects of Ketamine. Anaphylactic reactions to Ketamine are a rare but potentially fatal occurrence. Management includes treatment of acute reactions and avoidance of future reactions. There is no known antidote or reversal agent to Ketamine. So, once it is administered, one must be ready for it to complete full duration of its action. Facilities for resuscitation must be available any time an anesthetic is being administered, no matter how short or minor the surgery is.
Keywords: Allergic, child, Ketamine, reaction
|How to cite this article:|
Nwasor E O, Mshelbwala P M. An unusual reaction to ketamine in a child. Ann Nigerian Med 2010;4:28-30
| Introduction|| |
The incidence of generalized anaphylactic reactions during anesthesia has been reported to range from 1 in 4000 to 1 in 25,000.  In Australia, it is between 1:5000 and 1:25,000, with a 3.4% mortality rate,  and in France, the incidence was found to be 1:4500.  Ketamine, a phencyclidine derivative, has rarely been reported to cause reactions.  Ketamine, with its ease of administration and documented safety profile in the hands of non-anesthetists, has been found to be a useful drug. ,, Kolawole  in Ilorin, Nigeria, reported two cases of misuse of Ketamine in the hands of non-anesthetists. Irabor,  in a study in Ibadan, concluded that hernia surgery can be safely performed with intravenous Ketamine in children and emergency adult surgery.
We report an unusual allergic reaction to Ketamine in a healthy 2.5-year-old child with bilateral congenital inguinal hernia. This is to alert all the practitioners alike to the rare but potentially fatal side effects of Ketamine, a drug, which is said to be very "safe". ,,,
| Case Report|| |
A 2.5-year-old girl was referred from the University Health Services Clinic, with bilateral inguinal swellings. A diagnosis of bilateral inguinal hernia was made after surgical evaluation, and she was slated for elective bilateral herniotomy. She was the second child born to a 40-year-old mother and 42-year-old father, in a consanguineous marriage with no family history of any congenital anomalies. Her past medical history was nil of note. Clinical findings revealed no sign of respiratory tract infection or any abnormality apart from the bilateral inguinal hernia. The patient weighed 10 kg. The serum biochemistry was within normal limits, the packed cell volume (PCV) was 33%, the genotype was AA. She had a temperature of 36.5C, pulse rate of 110 beats per minute and respiratory rate of 32 cycles per minute. The SpO 2 was 98% breathing room air.
Pre-oxygenation with 100% oxygen was done for 3 minutes, and oxygen by face mask was continued using Ayre's T-piece (Jackson-Ree's modification). At induction, the child was given intramuscular (IM) Ketamine 70 mg stat. IV atropine 0.2 mg stat was then given to minimize secretions, followed by IV Ketamine 25 mg after 20 minutes interval. The child suddenly developed difficulty in breathing, substernal recession and urticarial rashes over the upper limbs and trunk, especially along superficial veins where the drug was administered. The SpO 2 dropped to 90%. This necessitated endotracheal intubation, which was facilitated by IV suxamethonium 12.5 mg stat, administration of 100% oxygen, IV atropine 0.2 mg stat, IV hydrocortisone 50 mg stat, and then 10 ml of 50% dextrose in double dilutions. The child was later extubated when her vital signs stabilized and was kept on oxygen via facemask, until she became fully conscious.
Further inquiry revealed history of upper respiratory tract infection the night before surgery and the child had been starved unduly for more than 12 hours. The surgery was suspended and she was discharged a few hours later to the pediatric surgical clinic for follow-up. Parents declined further surgical intervention.
| Discussion|| |
Determining the incidence of drug reactions during anesthesia and in the postoperative period is difficult because they are often attributed to toxic, pharmacologic, or anesthetic effects rather than allergy. Urticaria and hypotension can be produced by rapid administration of opioids, muscle relaxants, or vancomycin and other drugs commonly given during anesthesia.
Ketamine, an intravenous anesthetic agent and a phencyclidine derivative, has rarely been reported to cause reactions.  Onset of anesthesia and analgesia is extremely rapid (as little as 30 seconds) and duration ranges from 15 to 30 minutes. No reversal agent exists for Ketamine. Once it is given, one must be prepared to confront the consequences. 
During the perioperative period, the only feature of anaphylaxis may be cardiovascular collapse or airway obstruction.  Sudden bronchoconstriction is recognized by increased airway pressures during positive pressure ventilation. Cyanosis with oxygen desaturation may be noted. In 100 cases of generalized reactions during anesthesia, 68% had circulatory collapse, 55% had widespread flush, 26% had skin edema, 23% had bronchial obstruction, and 11% had cardiac arrest. IgE-dependent sensitization was found in 42% of cases.  In 20% of cases, edema appeared only at the end of the anesthesia. 
During an anesthetic-related reaction, numerous factors make the assessment difficult. Medications are generally given in quick succession. Draping may prevent detection of early signs such as urticaria or angioedema. Features of the reaction can be delayed such that temporal relationships between drugs administered and the clinical reaction are unhelpful. Reactions caused by mast cell-mediator release can be confused with other causes of hypotension or increased resistance to airflow, such as myocardial infarction; cardiac dysrhythmia; drug overdose; pulmonary embolus; irritant-induced bronchospasm; misplaced, blocked, or kinked endotracheal tube; pulmonary edema; aspiration of gastric contents or foreign body; seizure disorder; hypoglycemia; and stroke. The differential diagnoses in this case may include an allergic reaction or drug overdose. Although an overdose of Ketamine may have been a cause, in this patient the normal pharmacological dose was administered.
Other drugs that could cause anaphylactic reaction during anesthesia include thiopental,  muscle relaxants (e.g., pancuronium), opioids, antibiotics (e.g., penicillin, vancomycin), protamine,  latex  and ethylene oxide.  Blood transfusions may elicit reactions; plasma proteins and synthetic substitutes such as dextran, gelatin, and hydroxyethyl starch solution rarely cause direct release of histamine. Mannitol or other hyperosmotic agents and methylmethacrylate (bone cement), used during orthopedic surgery, have been associated with reactions.
Skin tests with general anesthesia drugs are difficult to interpret because many of these agents cause direct histamine release. In vitro tests have been developed for some neuromuscular blocking agents, thiopental, protamine, ethylene oxide, and latex. As yet, we do not have facilities in our center to perform these skin tests. This would have enabled us to confirm the diagnosis.
Management includes treatment of acute reactions and avoidance of future reactions. Once a reaction is noted, the anesthetic should be stopped as soon as possible. Ventilation should be maintained and adequate oxygenation ensured with the administration of 100% oxygen. Adrenaline may be administered to reduce the allergic response. H1 and H2 antihistamines can be effective in reducing histamine-related manifestations.  In the medical history of a patient, there must be a careful inquiry about possible predisposing factors, including known allergy or intolerance to drugs.
| Conclusion|| |
Allergic reactions to Ketamine are a rare but potentially fatal occurrence. Though Ketamine is said to be safe in unskilled hands,  the potential hazards relating to its use must not be underestimated.
| Acknowledgment|| |
I wish to acknowledge the contribution Dr. S.T. Mohammed to this case report.
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