Effect of Ketamine on Cardiovascular Function During Procedural Sedation of Adults

Abstract

Introduction: Ketamine is commonly used in emergency department procedural sedation. Mild to moderate transient increases in blood pressure, heart rate, and cardiac output are common due to ketamine causing an increase in sympathetic activity. There is a concern that these physiological changes could result in an increased myocardial oxygen demand that may exacerbate underlying cardiac disease. Methods: Convenience sample of patients older than 50 years receiving ketamine for procedural sedation in the emergency department was used (n = 31). Patients were selected to receive ketamine based on provider discretion. Primary outcome was incidence of new myocardial ischemia apparent on an electrocardiogram (ECG). ECGs were obtained prior to sedation and during the sedation approximately one minute after administration of ketamine. ECGs were reviewed by a board-certified emergency medicine physician and a board-certified cardiologist. Results: New onset ischemia was found in 9.7% (3/31) of ECGs. Of these, one was in a patient who had previously received ketamine without evidence of ischemia on the repeat ECG. There were no statistically significant differences between the groups. Evidence of ischemia on ECG did not impact patient disposition. Conclusions: Ketamine is a useful medication in procedural sedation; however, careful attention should be made in patient selection when ketamine is the desired agent. Consideration might be made in using the lowest possible dose of ketamine to obtain adequate sedation in order to hopefully lessen the occurrence of ECG changes suggestive of myocardial ischemia. Based on this small sample, single-site study, no evidence of statistically or clinically significant ischemia was seen with the use of ketamine for procedural sedation. Ketamine remains a safe medication option in adults undergoing procedural sedation.

Music as an Intervention to Improve the Hemodynamic Response of Ketamine in Depression

“…Beyond psychiatric contexts, the stimulatory hemodynamic effects of ketamine have received extensive study, both as desirable (eg, in surgical contexts) and as potentially harmful (eg, in procedural sedation), 5 but never in relation to music, to our knowledge. The magnitude of the hemodynamic effects observed in this study suggests that ketamine research should consider potential influences of contextual factors, including auditory stimuli.…”

Age-related changes in “cortical” 1/f dynamics are linked to cardiac activity

“…This theory is (in part) based on research showing that GABAergic drugs like propofol (Gao et al, 2017) and Glutamatergic drugs like ketamine (Waschke et al, 2021) modulate the spectral exponent of electrophysiologically measured power spectra. However, propofol and ketamine not only influence neural activity, but also influence heart rate variability (a core component of the ECG; (Goddard et al, 2021; Kanaya et al, 2003)). So are drug induced effects on the spectral exponent of the power spectrum (measured using surface electrodes) conflated by cardiac artifacts?…”

Time of day influences stress hormone response to ketamine

“…42 Importantly, stressors can stimulate the sympathetic nervous system to rapidly activate the HPA axis, release noradrenaline from the locus coeruleus, and increase heart rate. 43,44 A large body of work has studied the effects of ketamine on the sympathetic nervous system, 45,46 suggesting that ketamine's action on corticosterone secretion may also be mediated via sympathetic nervous action, although in these studies anaesthetic doses of ketamine were used. Dissociating the actions of subanesthetic doses of ketamine on sympathetic action and its influence on HPA axis function warrants further investigation.…”