Vanessa Mazandi, MD
Childrens Hospital of Philadelphia
Philadelphia, Pennsylvania
Disclosure information not submitted.
Shih-shan Lang, MD
Attending Neurosurgeon
Children's Hospital of Philadelphia, United States
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Akira Nishisaki, MD, MSCE
Associate Professor of Anesthesia and Critical Care Medicine
The Children's Hospital of Philadelphia, United States
Disclosure information not submitted.
Forrest Beaulieu, MD
Pediatrics Resident
Children's Hospital of Philadelphia, United States
Disclosure information not submitted.
Avi Gajjar
Research assistant
Children's Hospital of Philadelphia, United States
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Alexander Tucker, MD
Attending Neurosurgeon
Children's Hospital of Philadelphia, United States
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Phillip Storm, MD
Attending Neurosurgeon
Children's Hospital of Philadelphia, United States
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Greg Heuer, MD, PhD
Attending Neurosurgeon
Children's Hospital of Philadelphia, United States
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Bingqing Zhang, MPH
Biostatistician
Children's Hospital of Philadelphia, United States
Disclosure information not submitted.
Heather Griffis, PhD
Director of Data Science and Biostatistics
Children's Hospital of Philadelphia, United States
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Steve Ampah, PhD
Biostatistician Supervisor
Children's Hospital of Philadelphia, United States
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Matthew Kirschen, MD, PhD
Assistant Professor of Anesthesia and Critical Care Medicine, Pediatrics, and Neurology
Childrens Hospital of Philadelphia
Philadelphia, Pennsylvania, United States
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Alexis Topjian, MD, MSCE, FCCM
Associate Professor of Anesthesiology, Critical Care, and Pediatrics
Children's Hospital of Philadelphia, United States
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Ian Yuan, MD
Assistant Professor of Anesthesia, Critical Care and Pediatrics
Children's Hospital of Philadelphia, United States
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Todd Kilbaugh, MD
Associate Professor of Anesthesia, Critical Care, & Pediatrics
Childrens Hospital of Philadelphia, United States
Disclosure information not submitted.
Jimmy Huh, MD
Associate Professor of Anesthesia, Critical Care and Pediatrics
Children's Hospital of Philadelphia, United States
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Title: Ketamine for tracheal intubation in pediatric patients at risk for intracranial hypertension
Introduction: Ketamine [K] has traditionally been avoided as an induction agent for tracheal intubation [TI] in patients at risk for intracranial hypertension [IH]. However published data are conflicting. We hypothesized that children at risk for IH who received K would not have increased peri-intubation neurologic or hemodynamic adverse events compared to those who received other induction medications [NK].
Methods: This was a single-center retrospective study from 2015-2020 of TI in pediatric patients at a children's hospital at risk for elevated ICP (e.g. traumatic brain injury, brain tumor, ventricular shunt malfunction/infection, intracranial hemorrhage, hydrocephalus, and meningitis). Patients who received K were compared to patients who received NK for peri-intubation adverse events. NK drugs included propofol, fentanyl and midazolam. Adverse neurologic events were classified as ICP >20mmHg within 1 hour of TI, need for emergent CT scan, emergent neurosurgery or herniation within 24 hours of TI. Adverse hemodynamic events were classified within 1 hour of TI.
Results: Of 162 patients, 44.7% received K. GCS did not differ between patients who received K vs. NK (p=0.476). In the K group, 18.1% had emergent CT scan vs. 19.1% in the NK group (p=1.000); 12.5% of the patients who received K had emergent neurosurgery within 24 hours vs. 21.3% in the NK group (p=0.206). No patients herniated immediately after TI; 1 child (1.4%) with K vs. 5 children (5.6%) with NK had clinical signs of herniation within 24 hours after TI (p=0.226). Of the 44 children with ICP monitoring, 10 received K and none had ICP >20mmHg. No cardiac arrest or deaths occurred immediately after TI; there was no 24-hour mortality in either group. Tachyarrhythmia or bradycardia occurred in 5.6% with K vs. 10.1% with NK (p=0.445); hypotension requiring intervention occurred in 4.2% with K vs. 3.4% with NK (p=1.000); hypertension requiring intervention occurred in 2.8% with K vs. 7.9% with NK (p=0.293).
Conclusions: In our cohort, the administration of K for TI in children at risk for IH was not associated with an increased risk of peri-intubation adverse neurologic or hemodynamic events compared to those in the NK group for TI. Future randomized, prospective multicenter trials on induction agents for TI in patients at risk for IH are needed.