Ketamine as primary anesthetic for upper limb trauma during war: a case series of 100 surgeries at Rafik Hariri University Hospital, Lebanon’s National War Trauma Referral Center

BACKGROUND: The Beirut pager explosions on September 17, 2024 resulted in mass casualties with severe upper limb trauma admitted to Rafik Hariri University Hospital (RHUH), Lebanon's national war trauma referral center. Initial opioid-based anesthesia was associated with postoperative respiratory complications and high opioid requirements. Ketamine became available the following day through the International Committee of the Red Cross (ICRC). This study evaluates the transition to ketamine as a primary anesthetic and its effects on pain control, hemodynamics, respiration, and opioid use. METHODS: We retrospectively reviewed 100 hand and finger amputation surgeries. Patients initially received fentanyl intraoperatively and opioids postoperatively. Ketamine was subsequently introduced as the primary anesthetic. Pain was assessed using the Visual Analog Scale (VAS), while respiratory and hemodynamic parameters were monitored perioperatively. RESULTS: Ketamine was associated with significantly lower VAS scores (3.2 vs 7.8; p < 0.001), no respiratory complications (0 vs 18 cases), stable mean arterial pressure in 94% of patients, and reduced postoperative opioid use (5% vs 65%). CONCLUSION: Ketamine is a safe, effective, opioid-sparing anesthetic and should be prioritized in conflict and resource-limited trauma settings.