Ketamine is a strange strange drug…

I saw my first ever Ketamine induction yesterday.

It was for a 6 year old boy undergoing bilateral medial rectus botox injections. Apparently, other general anaesthetic agents attenuate the electromyograph signals needed to locate the extraocular muscles too much, and thus render them unsuitable for this procedure.

The boy was shown a little toy snake as a form of distraction whilst I cannulated him.

Then, the ketamine went in.

His eyes remained open. He continued to blink despite looking a little blank. He continued to breathe. He also continued to move his arms about.

Somehow, I don’t know how, my consultant was able to tell that the child was “ready.” She was able to tell that he had been anaesthetised despite him still looking completely awake.

The procedure took all of 5 minutes. We gave him a small dose of midazolam at the end to “dumb down” any emergence phenomena that may subsequently manifest. Then, we transferred him to the recovery area. We shut the doors, turned down the lights, and kept the area as quiet as possible.

The little boy continued to look around whilst in recovery, occasionally picking at his cannula. Then, he started calling out “snake! snake!” He was very obviously having visual hallucinations of the little snake we (erroneously) showed him before his anaesthetic. He started lifting up his covers, and picking up the snake which seemed to have slithered onto his body. The boy did that repeatedly for a good half an hour. Occasionally he would try and get rid of the snake from his body. Other times, he would lean over the bed rails saying “where has the snake gone?” Throughout this entire time, we just watched him deal with his hallucinations. After all, the teaching is not to disturb the child or engage with them as it worsens their nightmares. But what an awful experience it must have been for him!

I wondered how we would know that the child has recovered from his emergence delirium. My boss said that you would just know, because they will start speaking to you properly. True enough, as though someone had flicked a switch, the little boy suddenly came to and asked “When is the botox going to be done? Where is my daddy?” It was then that our recovery nurse finally said her first words to him “it has already been done,” and he cheered.

Seeing as he had finally recovered from the ketamine, the recovery nurse wanted to give him a sticker for his “bravery.” The boy claimed that he did not really like spiderman. “What do you like then?” she asked.

“Snakes” he answered.

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