A previously healthy 25-yr-old female developed flaccid areflexic tetraplegia, with intact cranial nerve function, 36 h after the diagnosis of bacterial meningitis. Polymerase chain reaction studies of cerebrospinal fluid and blood were positive for Neisseria meningitidis, serogroup B. Magnetic resonance of the cervicothoracic spine revealed increased signal intensity and expansion in the lower medulla, upper cervical cord and cerebellar tonsils. Neurosurgical consultation recommended hyperventilation, dexamethasone and regular mannitol therapy rather than decompressive intervention. The clinical course over the following 12 days was complicated by the development of progressive central nervous and multisystem organ failure with disseminated intravascular coagulopathy. Autopsy revealed cerebral oedema with cystic infarction extending from the medulla to the upper cervical cord and cerebellar tonsils. Flaccid areflexic tetraplegia with spinal cord infarction has not been reported following bacterial infection in an adult. The clinical implications would suggest complete central nervous system evaluation of patients recovering from meningococcal meningitis, since spinal cord lesions, although uncommon, do occur. In those very rare situations where a patient develops significant peripheral neurological deficits, urgent magnetic resonance imaging is warranted, to rule out an infective focus or an underlying anatomical anomaly.

Providing adequate analgesia during burn wound care is essential to patient-centered care. Both oral and intravenous (IV) ketamine are often used for analgesia and sedation. Ketamine may improve analgesia and decrease opioid requirements for burn wound care. Oral ketamine wafers and tablets have been used as a safe alternative internationally but are unavailable in the United States. The purpose of this study was to compare opioid usage and patient satisfaction scores in patients with and without the use of oral injectable ketamine for burn wound care, with each patient serving as their own control. Ketamine, opioid, and benzodiazepine dosages recorded during dressing changes were compared to dressing changes without ketamine use that occurred before and after ketamine-associated sessions in each patient. Fourteen patients received oral ketamine at a median (interquartile range [IQR]) dose of 2.5 (2.2-2.7) mg/kg. Ketamine use significantly decreased opioid requirements when compared to wound care sessions that did not use ketamine both before (50 [IQR: 30-75] mg vs 75 [IQR: 46–91] mg median IV morphine equivalents, P = .0097) and after (50 [IQR: 30-75] mg vs 63 [IQR: 50-96] mg median IV morphine equivalents, P = .0042) the ketamine-associated sessions. One patient experienced hallucinations, and no adverse events were observed. Hence, oral administration of injectable ketamine was associated with a decrease in opioid requirements during dressing changes. Additionally, ketamine use improved patient satisfaction ( P = .0034). Preliminary data suggest this promising analgesia method is safe and effective for burn wound care.

Little has been published regarding intravenous (IV) ketamine for burn wound care in adult patients. Ketamine may serve as a safe alternative to provide conscious sedation and limit opioid administration to patients. The purpose of this study was to characterize IV ketamine use during burn wound care and establish its potential role as a safe adjunct to opioid and benzodiazepine medications. This is a retrospective review of adult patients admitted to a regional burn center who received IV ketamine for burn wound care. Patient demographics, medications, and ketamine-related side effects including hypertension and dysphoric reactions were recorded. Cardiopulmonary complications were also tracked. Thirty-six patients met inclusion criteria; 50 total cases were performed. The median patient age was 37 [IQR 28 - 55] years with a median burn size of 9.5 [IQR 4.0 - 52] %TBSA. The median ketamine dose administered was 1.2 [IQR 0.8 - 2.1] mg/kg. IV midazolam was administered in almost all cases (98%) at a median dose of 3.0 [IQR 2.0 - 5.0] mg. Opioids were administered in 13 of 50 cases (26%) at a median morphine equivalent dose of 10 [IQR 5.0 - 18] mg. In 46 cases (92%), patients denied unpleasant recall of medication. Dysphoric reactions were observed in 3 cases (6%). Ketamine-induced hypertension occurred in 3 cases (6%) and all immediately responded to IV labetalol. There were no cardiopulmonary complications. These findings suggest IV ketamine provides a safe analgesia and sedative option for burn wound care. Given these findings, IV ketamine for burn wound care warrants further study.

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