Racemic, S(+)- and R(-)-ketamine do not increase elevated intracranial pressure

Background: There is controversy regarding the influence of ketamine and its enantiomers on cerebral haemodynamics at increased intracranial pressure (ICP). This study was designed to compare cerebrovascular responses, with particular respect to ICP, to bolus injections of racemic, S(+)- and R(-)-ketamine in an experimental model of intracranial hypertension. Methods: Nine pigs were anaesthetised with fentanyl and vecuronium during mechanical normoventilation. The ICP was raised with extradural balloon catheters to 23 mmHg. The intra-arterial xenon clearance technique was used to determine cerebral blood flow (CBF). Three 60-s bolus injections of racemic ketamine (10 mg/kg), S-ketamine (5 mg/kg) and R-ketamine (20 mg/kg) were given in a randomised sequence. Cerebral and systemic haemodynamic responses were evaluated before and at 1, 5, 10, 15, 30 and 45 min after each injection. Results: Racemic ketamine decreased ICP (P = 0.026) by maximally 10.8%, whereas there was no effect on ICP of S- (P = 0.178) or R-ketamine (P = 0.15). All study drugs had similar biphasic effects on CBF, with maximal initial decreases by 25-29%, followed by transient increases by 7-15%, and a reduction of mean arterial pressure by maximally 22-37%. Conclusions: A decrease or a lack of an increase in ICP in response to intravenous bolus injections of racemic, S- or R-ketamine suggests that the administration of racemic or S-ketamine might be safe in patients with intracranial hypertension due to a space-occupying lesion. The ICP-lowering effect indicates that racemic ketamine might offer a therapeutic advantage over S-ketamine.