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Chapter 57. Anesthesia for Humanitarian Relief Operations

Which of the following is an advantageous reason to choose ketamine during disaster situations?

A. Extensive surgery is possible, and multiple doses can be given.

B. Its use has been extensively proven in mass-casualty scenarios.

C. Ketamine provides both anesthesia and analgesia; however, it requires a secured airway.

D. Ketamine does not require a secured airway and laryngospasms do not occur during the use of ketamine.

B is correct. The use of ketamine under disaster conditions has been extensively described by Mulvey et al.1,2 During the Haiti earthquake disaster in 2010 and the tsunami in 2004 it has proven its usefulness with a low complication rate associated with the use of the drug.

A is incorrect. Ketamine in repeat doses can cause tachyphylaxis. Surgery requiring more than 1 hour of work should probably not be performed and repeat doses are tricky to calculate.

C is incorrect. Although it is a very potent drug, a secured airway is not necessary. The drug allows for spontaneous breathing in correctly administered doses.

D is incorrect. Ketamine in combination with the placement of a laryngeal mask airway can sometimes produce laryngospasm.3 This could also be because ketamine causes extensive saliva secretion. Atropine may sometimes even be recommended. As seen in the explanation for answer C, it may be more advantageous to let the patient breathe spontaneously without securing the airway at all.

Propofol is advantageous over ketamine because:

A. Anesthetists from high-resource settings are more familiar with giving propofol total intravenous anesthesia (TIVA) than using ketamine.

B. Propofol is much more forgiving of temperature extremes during transport and storage compared to ketamine.

C. Propofol TIVA 2% comes in high concentration and doesn’t require large volumes to be transported to the disaster area.

D. Working alongside local anesthetic nurses and officers who have extensive experience with TIVA propofol improves safety and speeds turnover of cases.

A is correct. Indeed most aid workers who work in modern facilities will be much more familiar with propofol TIVA than with the use of ketamine. However, ketamine has huge advantages; it’s both anesthetic and analgesic, it can be given IV and IM, and can be given while maintaining spontaneous breathing.4

B is incorrect. Ketamine comes in highly concentrated doses, which allow for multiple uses. Storage is much easier and is not influenced by temperatures during transport or storage.

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