Efficacy of intraoperative ketamine in attenuating emergence agitation in patients with sexual trauma-related post-traumatic stress disorder

Post-traumatic stress disorder places patients at risk for emergence agitation following surgical procedures under general anaesthesia. Gynaecological procedures, sphincteroplasty, and surgical interventions involving the pelvic floor can involve vulnerable patient positioning in theatre, with inserted catheters and sensory stimulation. Such interventions could contribute to postoperative emergence agitation, especially in those with prior experiences of adult sexual assault or childhood sexual abuse. In the medial pre-frontal cortex of patients with post-traumatic stress disorder, brain imaging reveals altered benzodiazepine receptor binding, compared to patients without this chronic stress condition. Consequently, some patients with post-traumatic stress disorder have been known to display trauma re-enactments, thrashing movements, emergence agitation and signs of pain amplification in early recovery from anaesthesia. The objective of this narrative review is to explore why this is the case and to determine whether ketamine has potential to be beneficial. Evidence already exists in the field of mental health to support how ketamine can provide transient relief for symptoms of depression, post-traumatic stress disorder, even suicidality. Extreme stress (for example, reactivation of a trauma memory during emergence from anaesthesia) can stimulate the release of glutamate and cortisol. In excess, this combination causes cellular damage and amplifies pain sensitivity. Ketamine may attenuate such a response, potentially offering a promising protective anaesthetic adjunct for survivors of sexual trauma with post-traumatic stress disorder.