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Mion G, Himmelseher S. Esketamine: Less Drowsiness, More Analgesia. Anesth Analg 2024; 139:78-91. [PMID: 38295061 DOI: 10.1213/ane.0000000000006851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
Racemic ketamine is a 1:1 mixture of 2 enantiomers that turn light in opposite direction: Dextrorotatory esketamine is approximately 4 times more affine for the N-methyl-D-aspartate (NMDA) receptor than levorotatory arketamine, which may explain why esketamine is about twice as potent as an analgesic and anesthetic as the racemate. Esketamine has attracted renewed interest in view of the opioid crisis, racemic ketamine's abuse, and esketamine's approval for expanded use. We evaluated the anesthesia literature concerning mental, cardiovascular, cerebral, and antinociceptive effects of esketamine published in English between 1980 and 2022. The review shows that esketamine and racemic ketamine are not "the same" at clinically equivalent analgesic and anesthetic dose: Psychomimetic effects seem to be essentially related to NMDA receptor blockade and esketamine is not devoid of unwanted mental impact. However, it probably involves less cholinergic inhibition. Cognitive disturbances during arousal, awakening, and recovery from the drug are less, and less pronounced with esketamine. The drug allows for an approximately 50% dose reduction in anesthesia and analgesia which goes along with a higher clearance and shorter recovery time as compared to racemic ketamine. In comparison of esketamine with placebo, esketamine shows cardiocirculatory stabilizing and neuroprotective effects which can be seen in anesthesia induction, cardiac surgery, and analgesia and sedation in brain injury. Evidence of esketamine's antinociceptive efficacy is inconsistent, although a recent meta-analysis reports improved pain relief after surgery in a study with short observation time. To better define esketamine's place, direct head-to-head comparison with the racemate at equi-analgesic/anesthetic dose is warranted.
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Affiliation(s)
- Georges Mion
- From the Department of Anesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP Centre, Université Paris - Cité, Cochin Hospital, Paris, France
| | - Sabine Himmelseher
- Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
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Wang LQ, Liu SZ, Wen X, Wu D, Yin L, Fan Y, Wang Y, Chen WR, Chen P, Liu Y, Lu XL, Sun HL, Shou W, Qiao GF, Li BY. Ketamine-mediated afferent-specific presynaptic transmission blocks in low-threshold and sex-specific subpopulation of myelinated Ah-type baroreceptor neurons of rats. Oncotarget 2016; 6:44108-22. [PMID: 26675761 PMCID: PMC4792545 DOI: 10.18632/oncotarget.6586] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 11/29/2015] [Indexed: 01/19/2023] Open
Abstract
Background Ketamine enhances autonomic activity, and unmyelinated C-type baroreceptor afferents are more susceptible to be blocked by ketamine than myelinated A-types. However, the presynaptic transmission block in low-threshold and sex-specific myelinated Ah-type baroreceptor neurons (BRNs) is not elucidated. Methods Action potentials (APs) and excitatory post-synaptic currents (EPSCs) were investigated in BRNs/barosensitive neurons identified by conduction velocity (CV), capsaicin-conjugated with Iberiotoxin-sensitivity and fluorescent dye using intact nodose slice and brainstem slice in adult female rats. The expression of mRNA and targeted protein for NMDAR1 was also evaluated. Results Ketamine time-dependently blocked afferent CV in Ah-types in nodose slice with significant changes in AP discharge. The concentration-dependent inhibition of ketamine on AP discharge profiles were also assessed and observed using isolated Ah-type BRNs with dramatic reduction in neuroexcitability. In brainstem slice, the 2nd-order capsaicin-resistant EPSCs were identified and ∼50% of them were blocked by ketamine concentration-dependently with IC50 estimated at 84.4 μM compared with the rest (708.2 μM). Interestingly, the peak, decay time constant, and area under curve of EPSCs were significantly enhanced by 100 nM iberiotoxin in ketamine-more sensitive myelinated NTS neurons (most likely Ah-types), rather than ketamine-less sensitive ones (A-types). Conclusions These data have demonstrated, for the first time, that low-threshold and sex-specific myelinated Ah-type BRNs in nodose and Ah-type barosensitive neurons in NTS are more susceptible to ketamine and may play crucial roles in not only mean blood pressure regulation but also buffering dynamic changes in pressure, as well as the ketamine-mediated cardiovascular dysfunction through sexual-dimorphic baroreflex afferent pathway.
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Affiliation(s)
- Lu-Qi Wang
- Department of Pharmacology, Harbin Medical University, Harbin, China.,Key Laboratory of Cardiovascular Medicine Research of Ministry of Education, Harbin Medical University, Harbin, China
| | - Sheng-Zhi Liu
- Department of Pharmacology, Harbin Medical University, Harbin, China
| | - Xin Wen
- Department of Pharmacology, Harbin Medical University, Harbin, China
| | - Di Wu
- Key Laboratory of Cardiovascular Medicine Research of Ministry of Education, Harbin Medical University, Harbin, China
| | - Lei Yin
- Key Laboratory of Cardiovascular Medicine Research of Ministry of Education, Harbin Medical University, Harbin, China
| | - Yao Fan
- Department of Pharmacology, Harbin Medical University, Harbin, China
| | - Ye Wang
- Department of Pharmacology, Daqing Campus of Harbin Medical University, Daqing, China
| | - Wei-Ran Chen
- Department of Pharmacology, Harbin Medical University, Harbin, China
| | - Pei Chen
- Key Laboratory of Cardiovascular Medicine Research of Ministry of Education, Harbin Medical University, Harbin, China
| | - Yang Liu
- Department of Pharmacology, Harbin Medical University, Harbin, China
| | - Xiao-Long Lu
- Department of Pharmacology, Harbin Medical University, Harbin, China
| | - Hong-Li Sun
- Department of Pharmacology, Daqing Campus of Harbin Medical University, Daqing, China
| | - Weinian Shou
- Riley Heart Research Center, Division of Pediatric Cardiology, Herman B. Wells Center for Pediatric Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Guo-Fen Qiao
- Department of Pharmacology, Harbin Medical University, Harbin, China.,Key Laboratory of Cardiovascular Medicine Research of Ministry of Education, Harbin Medical University, Harbin, China
| | - Bai-Yan Li
- Department of Pharmacology, Harbin Medical University, Harbin, China
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Jung I, Jung SH. Vasorelaxant mechanisms of ketamine in rabbit renal artery. Korean J Anesthesiol 2012; 63:533-9. [PMID: 23277815 PMCID: PMC3531533 DOI: 10.4097/kjae.2012.63.6.533] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Revised: 09/04/2012] [Accepted: 09/04/2012] [Indexed: 11/10/2022] Open
Abstract
Background Ketamine is a non-barbiturate anesthetic agent which has various effects on the cardiovascular system. Among them, ketamine is known for its hypotensive properties. The hypotension is thought to be mediated by a direct effect on vascular smooth muscles. This study is designed to examine the effects of ketamine on KCl- and histamine-induced contraction in isolated rabbit renal arteries. Methods Endothelium-intact or -denuded smooth muscle rings were prepared and mounted in myographs for isometric tension measurements. The inhibitory effect of ketamine were investigated in smooth muscle rings precontracted with either 50 mM KCl- or 10 µM histamine. Results Ketamine (0.1-100 µg/ml) produced similar concentration-dependent inhibition of contractile responses induced by either 50 mM KCl or 10 µM histamine. The respective IC50 values measured for ketamine following precontractions by 50 mM KCl and 10 µM histamine were 28.9 µg/ml (105.5 µM) and 26.7 µg/ml (97.5 µM). The inhibitory effect of 30 µg/ml ketamine were similarly observed after removal of endothelium or pretreatment with NG-Nitroarginine Methyl Ester (0.1 mM). The inhibitory effect of 30 µg/ml ketamine on histamine-evoked contraction was reduced by either tetraethylammonium (10 mM) or iberiotoxin, a large conductance Ca2+-activated K+ channel blocker. However, depletion of intracellular Ca2+ stores by ryanodine (10 µM) or thapsigargin (10 µM) showed no significant effect on 30 µg/ml ketamine-induced relaxation. Pre-incubation with 30 µg/ml ketamine significantly inhibited CaCl2-induced contraction at almost all ranges of concentration. Conclusions Ketamine-induced relaxation of rabbit renal arteries is mediated by both the activation of large conductance Ca2+-activated K+ channel and the inhibition of Ca2+ influx.
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Affiliation(s)
- Il Jung
- Department of Anesthesiology and Pain Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
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Jakobsen CJ, Torp P, Vester AE, Folkersen L, Thougaard A, Sloth E. Ketamine reduce left ventricular systolic and diastolic function in patients with ischaemic heart disease. Acta Anaesthesiol Scand 2010; 54:1137-44. [PMID: 20712843 DOI: 10.1111/j.1399-6576.2010.02283.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Ketamine may be followed by a general increase in haemodynamics and oxygen consumption, which may be of concern in patients with ischaemic heart disease. The purpose of this study was to evaluate the effect of ketamine on left ventricular (LV) systolic and diastolic function by different modalities of echocardiography and tissue Doppler imaging in patients with ischaemic heart disease. METHODS AND RESULTS Prospective observational study of 11 patients acting as own control based on echocardiographic imaging before and after bolus ketamine 0.5 mg/kg. Simpson's 2 D-volumetric method was used to quantify left ventricular volume and ejection fraction. General global LV deformation was assessed by Speckle tracking ultrasound, systolic LV longitudinal displacement was assessed by Tissue Tracking score index and the diastolic function was evaluated from changes in early-(E') and atrial (A') peak velocities during diastole. Average heart rate (34%) and blood pressure (35%) increased significantly after ketamine (P<0.0001). Mean tissue tracking score index decreased from 11.2 ± 2.3 to 8.3 ± 2.6 (P=0.005) and Global Speckle tracking 2D strain from 17.7 ± 2.7 to 13.7 ± 3.6 (P=0.0014) indicating a decrease in LV global systolic function. The E'/A' ratio decreased from 1.11 ± 0.43 to 0.81 ± 0.46 (P=0.044) indicating impaired relaxation. CONCLUSION Different modalities of echocardiography in combination with tissue Doppler indicate both diminished systolic and diastolic function after ketamine administration in patients with ischaemic heart disease.
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Affiliation(s)
- C-J Jakobsen
- Department of Anaesthesia & Intensive Care, Aarhus University Hospital, Aarhus, Denmark.
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Neuhäuser C, Preiss V, Feurer MK, Müller M, Scholz S, Kwapisz M, Mogk M, Welters I. Comparison of S-(+)-ketamine- with sufentanil-based anaesthesia for elective coronary artery bypass graft surgery: effect on troponin T levels. Br J Anaesth 2008; 100:765-71. [DOI: 10.1093/bja/aen095] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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