Editorial

The role of ketamine in addressing the anesthesia gap in low-resource settings

Prior to the COVID-19 pandemic, ketamine's wide safety margin led to its use as a sole anesthetic agent in resource-limited settings when no anesthetist was available. During this time of the pandemic the use of ketamine has increased, however there are few recommendations on approaches to intraoperative challenges associated with ketamine's unique properties. The objective of this study was to gain surgeons' perceptions on performing operations supported by ketamine and to recommend best practices and techniques.

A qualitative study was conducted using semi-structured interviews of surgeons experienced with performing operations supported with ketamine as the sole anesthetic agent. Interviews continued until thematic saturation. Open-response data was analyzed using thematic analysis as well as iterative group discussions about emergent themes.

Sixteen surgeons were interviewed regarding their operative experiences supported by ketamine across 12 countries. Surgeons universally felt that ketamine is safe, saves lives, and that they would administer it to a loved one in support of an operation if no anesthetist was available. Although lack of muscle relaxation with ketamine may require additional strategies to gain exposure, few surgical technical changes are necessary. While ketamine side effects are manageable, a single provider must always be dedicated to ketamine administration and patient monitoring. Surgeons should advocate for global policies, training and access.

Ketamine is safe, can provide increased access to emergency and essential surgery, and requires few operative technical changes. Global standards on ketamine training and use should be established.

Snakebite envenomation is a global health crisis and is classified as a Category A neglected tropical disease by the World Health Organization (WHO). Snakebite envenomations account for a significant amount of morbidity and morbidity in tropical and subtropical regions. Recently, publications have illustrated the potential for snake envenomations causing post-traumatic stress disorder (PTSD) in a significant number of patients. Ketamine is on the WHO's list of essential medications and is used for a variety of pharmacologic applications including anesthesia and acute pain management. To date it has not been assessed for pain control in snakebite envenomations. Twelve patients who presented with severe pain secondary to Bitis, Causus, and Atractaspis envenomations were treated with low-dose intravenous ketamine. The patients included 7 males and 5 females with a median age of 37.5 (range 14–64) and a median presentation time of 5.75 h (range 5 min–96 h) after the initial bite occurred. Ten envenomations were presumed to have been caused by Bitis species resulting in extensive swelling and blistering of the affected extremities. One envenomation was presumedC. maculatus causing local swelling and pain. One envenomation was a presumed Atractaspis species causing significant local pain with minimal swelling. All patients expressed having significant pain but could not express the degree of their pain using an analogue pain scale. An initial median dose of 5 mg of ketamine (range 2.5–15 mg) was administered intravenously for pain control. Every patient expressed decreased pain and felt more comfortable within 1 min after administration of ketamine. Nine of the twelve patients only required a single dose. There were no adverse side effects. Ketamine appears to be an effective means of pain control for those suffering from painful envenomations. With minimal risk of significant side effects at acute pain management doses and the average cost per effective dose averaging between US$0.03–0.06, this may provide a cheap, safe, and effective solution for Sub-saharan Africa and other resource-limited settings. Controlled studies need to be done to critically assess our observations.