Anaesthesia, 1976, Volume 31, pages 1081-1083

CASE REPORT

Recurrent hallucinations following ketamine

A. PEREL AND J. T. D A V I D S O N

Ketamine possesses many unique properties that make it a valuable agent in anaes-
thetic practice. The outstanding disadvantage of this drug is the high incidence of
delirium and unpleasant dreams which are generally restricted to the recovery
period.'-' The case reported here was most unusual in that the emergence reaction
recurred periodically during 5 days following ketamine administration.

Case history
An 1 I-year-old boy, weighing 33.5 kg, previously healthy, began to suffer from fever,
recurrent nausea and vomiting, sore throat and severe temporal headaches accom-
panied by photophobia and loss of appetite. There were no disturbances of equilibrium
or hallucinations. He was admitted to hospital for investigation. The only positive
findings were increased CSF pressure on one occasion (220 mmH,O) and slowing of
electrical activity in the posterior brain areas. During the course of the investigations,
right carotid angiography was performed under general anaesthesia. Premedication
consisted of morphine 5 mg and scopolamine 0-25 mg intramuscularly and induction
was with diazepam 10 mg and ketamine 25 mg intravenously. The procedure lasted
about 1 hour during which time the patient received a further 75 mg of ketamine
and 15 mg of diazepam in three increments. Recovery was uneventful and there was
total amnesia. Ten days later the patient underwent pneumo-encephalography.
Premedication included intramuscular atropine 0.5 mg and phenobarbitone 200 mg,
but this was given only 10 minutes before the patient reached the examination room.
He was very anxious and received immediately ketamine 20 mg and diazepam 5 mg
by intravenous injection. Two minutes later, he was well sedated and 250 mg of
ketamine were given intramuscularly. The examination lasted about 90 minutes and
towards its completion another 15 mg ketamine and 2.5 mg diazepam were adminis-
tered intravenously. At the end of the procedure the patient was transferred to the
recovery room, where half an hour later he woke up screaming. He was sure that his
A. Perel, MD, House Doctor and J. T. Davidson, FFARCS, Associate Professor and Head Depart-
ment of Anaesthesia, Hadassah University Hospital and Hebrew University-Hadassah Medical
School, Jerusalem, Israel.
1081
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1082 A . Perel and J. T. Davidson

grandmother, whom he detests, was standing beside his bed and this terrified him.
During the next 5 days he suffered from recurring visual hallucinations, each of which
lasted from a few seconds to minutes, and which he described very vividly. He saw
'big dark blotches on the ceiling' that took the form of 'terrible threatening creatures'
which he unsuccessfully tried to draw. Several times he sought cover under the blankets
because 'the ceiling was going to fall down'. On the 4th day after the examination he
saw his mother's face becoming distorted, the nose growing longer and the hair
standing up. On the 5th and last day of the hallucinations, he described clouds
moving on the ceiling. During the intervals between hallucinations, he attempted to
discuss the abnormal sensory perceptions in all their details, although it was apparent
that the mere description was causing intense anxiety.
Five months later, the child still suffered from fever and headache and no diagnosis
had been established. The hallucinations had not recurred and the parents, who have
insight and understanding, feel that neither personality nor emotional problems
have been created by the episode.

Discussion
Emergence phenomena from ketamine are very common'-6 and may be divided
into dreams and disturbances of sensory perception^.^ The dreams may be very
pleasant or terrifying. The sensory disturbances described include transient blindness
or double vision, distortion of body image,' colour hallucinations, floating sensation
and depers~nalization.~.~ The delusional type action of ketamine is comparable to
that of LSD, mescaline and phencyclidine" and use of ketamine by addicts as a
hallucinogen has been reported.' Delayed hallucinations outside the immediate
post-operative period are rare. Fine & Finestone4 reported three such cases, out of
1400 patients anaesthetized with ketamine, in whom the hallucinations commenced
1 day-1 week following ketamine administration and recurred within a period of up
to 3 weeks post-anaesthesia. When interviewed a few months later, all of these patients
denied further recurrences. A more serious prolonged effect attributed to ketamine
is that of a psychotic reaction in a 29-year-old woman who suffered from hallucina-
tions for 1 year following ketamine, with 'visions of bright lights and thousands of
faces', depression, and ideas of impending death. Her psychometric testing showed
her to be basically normal. l 2
The case now described and those quoted above, demonstrate the potential of
ketamine to cause delayed emergence reactions. These reactions might occur after
the patient has left the hospital, especially if the drug has been administered on an
ambulatory basis for minor surgical procedures. These delayed hallucinations seem
very similar to 'LSD flashbacks'. Horwitz" defines LSD flashbacks as 'returns of
imagery for extended periods after the immediate effect of hallucinogen has worn
off. The most symptomatic form is recurrent intrusion of the same frightening image
into awareness without volitional control'. Why a drug should have a hallucinatory
effect long after it has disappeared from the blood stream is unknown, although a few
theories for the phenomenon have been postulated.
Different methods of overcoming immediate emergence reactions of ketamine
have been described. These include careful selection of patients, very heavy pre-
m e d i ~ a t i o n , ' ~ sedation
.'~ with intravenous diazepam just prior to the end of opera-
tion,16 and seclusion of the patient from extraneous stimuli during the recovery
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Recurrent hallucinations following ketamine 1083

period." The author's practice is to give diazepam, 1 mg/6 kg intravenously, towards

the end of the operation in addition to that given as premedication or as supplement.
In the case described here the patient was exposed to ketamine on two occasions. In
the first exposure he received diazepam in adequate dosage and recovery was un-
eventful, while in the second he received far less diazepam and hallucinations resulted.
It is of interest that the other reported cases of recurrent hallucinations after ketamine
received no sedation other than the pethidine in the p r e m e d i c a t i ~ n . ~ ~ ' ~

Summary
Recurrent hallucinations appeared in an 1 1-year-old boy during 5 days following
ketamine anaesthesia. Previous anaesthesia with ketamine and adequate diazepam
supplementation did not produce any such effect. The phenomenon of delayed
recurring hallucinations is a rare but dangerous side-effect of ketamine, not unlike
LSD flashbacks. The described case lends support to previous reports on the value
of diazepam in the prevention of post-ketamine perceptual abnormalities.

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