Ketamine in Severe Traumatic Brain Injury

Traumatic brain injury (TBI) accounts for approximately 2.5 million visits to emergency departments in the United States each year. After decades of research, management strategies for severe TBI (sTBI) patients are still evolving. Optimizing intracranial pressure (ICP) and cerebral perfusion pressure (CPP) are paramount in the management of these patients and placement of these monitors is the current standard-of-care. However, monitoring brain oxygenation (PbtO2) with invasive intraparenchymal monitors is currently under investigation in the management of severe TBI and placement of these monitors is gaining widespread use. This has opened the door for the use of tiered therapy to optimize ICP and PbtO2 simultaneously. Current evidence indicates that correction of ICP, CPP and PbtO2 in sTBI requires optimized analgesia and sedation. Ketamine is one of the few drugs available that has both sedative and analgesic properties and does not commonly compromise respiratory drive like opioids and sedative-hypnotics. However, traditionally, ketamine has been viewed as contraindicated in the setting of TBI due to concerns for elevation in ICP. Yet, new data has cast this long-held assumption into significant doubt. Hence the present pilot study will characterize the neurophysiological response to a single dose of ketamine in critically-ill TBI patient with ICP and PbtO2 monitoring.

Administration of ketamine with subsequent measurement of intracranial pressure and brain tissue oxygenation

Measurement of pressure within the rigid skill, with values greater than 22 mm Hg sustained proven to be injurious in patients with traumatic brain injury

Measurement of the concentration of oxygen within the brain tissue, with values less than 20 mmHg sustained proven to be injurious in patients with traumatic brain injury

Inclusion Criteria: Severe traumatic brain injury Placement of intracranial monitor for measurement of intracranial pressure and brain tissue oxygenation Age greater than or equal to 18 years Exclusion Criteria: Documented allergy to ketamine Sinus tachycardia with sustained heart rate >120 Any episode of non-sinus tachycardia Documented history of schizophrenia Systolic blood pressure > 180, diastolic blood pressure > 120 Documented episode(s) of ICP elevations >25 mm Hg sustained greater than 5 minutes within 24 hours Similar episodes as above of PbtO2 <15 mmHg Positive pregnancy test and/or is currently breast-feeding