Operations Supported by Ketamine Anesthesia in Resource-Limited Settings: Surgeons’ Perceptions and Recommendations – Qualitative Study

ABSTRACT Background: 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. Methods: 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. Results: 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. Conclusion: 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. Highlights