Case Report: Prolonged Psychosis and PTSD in an Adolescent Following Suspected Ketamine Sedation

Case at a Glance

A 14-year-old female reports a history of a severe, prolonged psychotic reaction and subsequent Post-Traumatic Stress Disorder (PTSD) following oral sedation for a minor urological procedure at age 10. The case explores the likely causative agent, the long-term psychiatric impact, and the importance of accessing medical records for future patient safety.

Patient's Story

The patient, a 14-year-old female, presented seeking information about a traumatic medical event that occurred four years prior. At age 10, she was admitted to a hospital for a urological procedure, described as the placement of a 'tube down my uterus,' likely a urinary catheterization, to manage persistent urinary incontinence. She recalls being given a liquid sedative mixed into a popsicle or a drink prior to the procedure. She experienced a state of conscious sedation, which she described as being in a 'twilight zone.' Her memory of the procedure itself is absent.

Initial Assessment

Upon waking from sedation, the patient did not return to a normal state of consciousness. Approximately 30 minutes post-arousal, she developed an acute and severe psychotic episode. Symptoms included intense paranoia, vivid and terrifying hallucinations, and extreme agitation. The state was so severe that she engaged in dangerous, impulsive behavior, including attempting to jump out of her family's moving vehicle on the way home from the hospital. The patient's family documented some of this episode with video footage.

The Diagnostic Journey

The acute psychotic episode did not resolve within hours or days. The patient reports that this event triggered a prolonged period of psychosis lasting nearly three years, characterized by persistent hallucinations, paranoia, and significant memory loss, which severely impacted her psychosocial development. As the overt psychotic symptoms waned, she was left with debilitating symptoms of PTSD, directly related to the trauma of her hallucinatory experiences. Four years after the initial event, she continues to experience occasional visual disturbances and struggles with the psychological aftermath. The family had not been informed of the specific sedative used, leaving the patient without an explanation for her profound and lasting reaction. The primary diagnostic challenge was identifying the causative agent without access to the original medical records.

Final Diagnosis

While the specific agent was not confirmed at the time of reporting, the clinical presentation is highly suggestive of an adverse emergence reaction to a dissociative anesthetic.

Primary Suspected Diagnosis: Ketamine-Induced Psychosis leading to Post-Traumatic Stress Disorder.

Rationale: Ketamine is a dissociative anesthetic commonly used for pediatric procedural sedation. It can be administered orally and is known to cause a 'twilight' state. A well-documented side effect is emergence delirium or emergence reaction, which can involve vivid dreams, hallucinations, and dysphoria. In some cases, these experiences can be profoundly frightening and traumatic, especially for a child. The patient's description of the onset, symptoms, and severity aligns closely with a severe emergence reaction to ketamine.

Treatment Plan

The immediate recommendation provided to the patient and her family was to formally request her complete medical records from the facility where the procedure was performed. Under US law (HIPAA), a patient or their legal guardian has the right to access these records. Confirming the administered sedative is critical for several reasons:

1. Diagnostic Confirmation: To provide a definitive explanation for the patient's experience.
2. Future Patient Safety: To ensure the patient's medical chart is permanently flagged with an allergy/adverse reaction to the specific drug, preventing accidental re-exposure during future medical or surgical procedures.
3. Informed Psychiatric Care: To allow her mental health team to tailor treatment for PTSD with a clear understanding of its iatrogenic origin.

Continued psychiatric therapy for PTSD was strongly advised.

Outcome and Follow-up

Four years post-event, the patient continues to suffer from PTSD and memory loss stemming from the drug-induced psychotic episode. The critical next step is obtaining the medical records to confirm the suspected agent. This case underscores the potential for severe and lasting psychological trauma resulting from adverse reactions to procedural sedation. It highlights the importance of thorough pre-sedation counseling with parents regarding potential side effects like emergence phenomena and the critical need for vigilant post-procedure monitoring in pediatric patients. Documenting and communicating such adverse events is paramount for ensuring long-term patient safety.