Journal of the American College of Emergency Physicians Open (Aug 2022)

Effect of ketamine on transcranial Doppler Gosling pulsatility index in children undergoing procedural sedation: A pilot study

  • Christopher T. Stem,
  • Sriram Ramgopal,
  • Robert W. Hickey,
  • Mioara D. Manole,
  • Jeffrey R. Balzer

DOI
https://doi.org/10.1002/emp2.12760
Journal volume & issue
Vol. 3, no. 4
pp. n/a – n/a

Abstract

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Abstract Objectives There has been controversy over whether ketamine affects intracranial pressure (ICP) in children. Transcranial Doppler ultrasound (TCD) is a validated technique used to assess ICP changes noninvasively. Gosling pulsatility index (PI) directly correlates with ICP changes. The objective of this study was to quantify PI changes as a surrogate marker for ICP changes in previously healthy children receiving intravenous ketamine for procedural sedation. Methods We performed a prospective, observational study of patients 5–18 years old who underwent sedation with intravenous ketamine as monotherapy. ICP changes were assessed by surrogate PI at baseline, immediately after ketamine administration, and every 5 minutes until completion of the procedure. The primary outcome measure was PI change after ketamine administration compared to baseline (denoted ΔPI). Results We enrolled 15 participants. Mean age was 9.9 ± 3.4 years. Most participants underwent sedation for fracture reduction (87%). Mean initial ketamine dose was 1.4 ± 0.3 mg/kg. PI decreased at all time points after ketamine administration. Mean ΔPI at sedation onset was –0.23 (95% confidence interval [CI] = –0.30 to –0.15), at 5 minutes was –0.23 (95% CI = –0.28 to –0.18), at 10 minutes was –0.14 (95% CI = –0.21 to –0.08), at 15 minutes was –0.18 (95% CI = –0.25 to –0.12), and at 20 minutes was –0.19 (95% CI = –0.26 to –0.12). Using a clinically relevant threshold of ΔPI set at +1 (+8 cm H2O), no elevation in ICP, based on the PI surrogate marker, was demonstrated with 95% confidence at all time points after ketamine administration. Conclusions Ketamine did not significantly increase PI, which was used as a surrogate marker for ICP in this sample of previously healthy children. This pilot study demonstrates a model for evaluating ICP changes noninvasively in the emergency department.

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