Ketamine: Difference between revisions

No edit summary
(Changed to Drug template format - will need further citation and clean-up)
Line 1: Line 1:
== Contraindications  ==
==General==
*Type:
*Dosage Forms:
*Common Trade Names:


=== Absolute ===
==Adult Dosing==
===Procedural Sedation or Induction===
*1 mg/kg IV, followed by 0.5-1 mg/kg IV PRN
''or''
*4-5 mg/kg IM → repeat 2-4 mg/kg IM after 10 min if first dose unsuccessful
 
===Analgesia===
*0.1-0.5 mg/kg IV PRN<ref>Morton NS. Ketamine for procedural sedation and analgesia in pediatric emergency medicine: a UK perspective. Paediatr Anaesth. 2008;18:25-29</ref>
 
==Pediatric Dosing==
===Procedural Sedation or Induction===
*1.5-2 mg/kg IV
''or''
*4-5 mg/kg IM<ref>Green S. et al. What is the optimal dose of intramuscular ketamine for pediatric sedation?. Acad Emerg Med. 1999 Jan;6(1):21-6</ref>
''or''
*3-6 mg/kg IN<ref>Hall, D, et al. Intranasal ketamine for procedural sedation. Emerg Med J. 2014; 31:789-90.</ref>
 
==Special Populations==
*[[Drug Ratings in Pregnancy|Pregnancy Rating]]:
*[[Lactation risk categories|Lactation risk]]:
*Renal Dosing
**Adult
**Pediatric
*Hepatic Dosing
**Adult
**Pediatric
 
==Contraindications==
*Allergy to class/drug
 
===Absolute===
*<3 month old  
*<3 month old  
*Known or suspected schizophrenia, even if currently stable or controlled with medications
*Known or suspected schizophrenia, even if currently stable or controlled with medications


=== Relative ===
===Relative===
 
*Major procedures involving posterior pharynx (e.g. endoscopy)  
*Major procedures involving posterior pharynx (e.g. endoscopy)  
**Typical minor ED oropharyngeal procedures are okay  
**Typical minor ED oropharyngeal procedures are okay  
Line 16: Line 48:
*Thyroid disorder or on thyroid medication
*Thyroid disorder or on thyroid medication


== Preparation  ==
==Adverse Reactions==
*Monitor
*BVM (ready)
*Suction
*[[Atropine]]
**Only recommended for patients with impaired ability to mobilize secretions
**0.01 mg/kg IVP; min 0.1mg, max 0.5mg
*[[Versed]]
**Pretreatment is nonmandatory in both adults and children
**Consider 0.03mg/kg IVP if pt has unpleasant recovery reaction
*"Happy Place"
 
== Administration  ==
*Given as a slow push bolus.
**Rapid bolus increases risk for apnea.
*IV preferred over IM (faster recovery, less emesis)
*Nystagmus is seen as an effect of the medication
 
===Procedural Sedation or Induction===
'''IV'''
*Children: 1.5-2 mg/kg (over 30-60sec)
*Adults: 1 mg/kg (over 30-60sec)
*Repeat dose 0.5-1 mg/kg q5-15 PRN
'''IM'''
*Children: 4-5 mg/kg <ref>Green S. et al. What is the optimal dose of intramuscular ketamine for pediatric sedation?. Acad Emerg Med. 1999 Jan;6(1):21-6</ref>
*Adult: 4-5 mg/kg
*Repeat dose 2-4 mg/kg if sedation inadequate 10min after initial dose
'''Intranasal'''
*Children: 3-6 mg/kg<ref>Hall, D, et al. Intranasal ketamine for procedural sedation. Emerg Med J. 2014; 31:789-90.</ref>
 
===Analgesia===
'''IV'''
*Intermittent dosing at 0.1-0.5 mg/kg<ref>Morton NS. Ketamine for procedural sedation and analgesia in pediatric emergency medicine: a UK perspective. Paediatr Anaesth. 2008;18:25-29</ref>
 
====Ketamine "Dart" (IM) for Sedation====
*May be an option for combative special needs patients; originally studied in pediatric pts with facial trauma in ED
*IM ketamine (3 mg/kg), midazolam (0.05 mg/kg), glycopyrrolate (0.005 mg/kg)<ref>Pruitt JW,  Goldwasser MS, Sabol SR, Prstojevich SJ. Intramuscular ketamine, midazolam, and glycopyrrolate for pediatric sedation in the emergency department. J Oral Maxillofac Surg. 1995 Jan;53(1):13-7.</ref>
 
== Side Effects  ==
*Airway misalignment requiring re-positioning of head (occasional)
*Laryngospasm (0.3%)  
*Laryngospasm (0.3%)  
**Only associated with unusually high IV doses  
**Only associated with unusually high IV doses  
Line 67: Line 60:
*Muscular hypertonicity and random, purposeless movements (common)  
*Muscular hypertonicity and random, purposeless movements (common)  
*Clonus, hiccuping, or short-lived nonallergic rash of face and neck
*Clonus, hiccuping, or short-lived nonallergic rash of face and neck
* May increase intraocular pressure


=== Intracranial pressure elevation ===
===Intracranial pressure elevation===
*'''Cerebral perfusion pressure (CPP) was compromised only in the patients with pre-existing intracranial hypertension and obstruction to the flow of cerebral spinal fluid.''' This has, however, led to the persistent belief that ketamine is contraindicated in patients with traumatic head injuries. Studies done subsequently have shown, however, that the effects of ketamine on cerebral haemodynamics and ICP are in fact variable and depend on both the presence of additional anaesthetic agents and PaCO2 values.<ref>Filanovsky, Y., Philip Miller et al. Myth: Ketamine should not be used as an induction agent for intubation in patients with head injury. CJEM 2010;12(2):154-7. [http://cjem-online.ca/sites/cjem-online.ca/files/pg154_0.pdf PDF]</ref> Meta-analysis also suggests that Ketamine does not increase ICP and provides favorable hemodynamics.<ref>Wang X et al. Ketamine does not increase intracranial pressure compared with opioids: meta-analysis of randomized controlled trials. J Anesth 2014. PubMed ID: 24859931</ref>
*'''Cerebral perfusion pressure (CPP) was compromised only in the patients with pre-existing intracranial hypertension and obstruction to the flow of cerebral spinal fluid.''' This has, however, led to the persistent belief that ketamine is contraindicated in patients with traumatic head injuries. Studies done subsequently have shown, however, that the effects of ketamine on cerebral haemodynamics and ICP are in fact variable and depend on both the presence of additional anaesthetic agents and PaCO2 values.<ref>Filanovsky, Y., Philip Miller et al. Myth: Ketamine should not be used as an induction agent for intubation in patients with head injury. CJEM 2010;12(2):154-7. [http://cjem-online.ca/sites/cjem-online.ca/files/pg154_0.pdf PDF]</ref> Meta-analysis also suggests that Ketamine does not increase ICP and provides favorable hemodynamics.<ref>Wang X et al. Ketamine does not increase intracranial pressure compared with opioids: meta-analysis of randomized controlled trials. J Anesth 2014. PubMed ID: 24859931</ref>


Line 75: Line 67:
*Metaanalysis has shown that when ketamine is used in the presence of controlled ventilation, in conjunction with anaesthetics which reduce cerebral metabolism such as GABA receptor agonists, '''ICP is not increased'''.<ref>Himmelseher S. et al. Revising a dogma: ketamine for patients with neurological injury? Anesth Analg. 2005 Aug;101(2):524-34 [http://www.researchgate.net/publication/7708550_Revising_a_dogma_ketamine_for_patients_with_neurological_injury/file/72e7e529656bccca4f.pdf PDF]</ref>
*Metaanalysis has shown that when ketamine is used in the presence of controlled ventilation, in conjunction with anaesthetics which reduce cerebral metabolism such as GABA receptor agonists, '''ICP is not increased'''.<ref>Himmelseher S. et al. Revising a dogma: ketamine for patients with neurological injury? Anesth Analg. 2005 Aug;101(2):524-34 [http://www.researchgate.net/publication/7708550_Revising_a_dogma_ketamine_for_patients_with_neurological_injury/file/72e7e529656bccca4f.pdf PDF]</ref>


====Pediatrics====
===Serious===
*In ventilated children with prior intracranial hypertension, ketamine decreased intracranial pressure (ICP) and prevented elevations during interventions without lowering blood pressure and CPP. <ref> Bar-Joseph G, Guilburd Y, Tamir A, Guilburd JN. Effectiveness of ketamine in decreasing intracranial pressure in children with intracranial hypertension. J Neurosurg Pediatr. 2009;4(1):40–46. </ref>


====Prehospital====
===Common===
*In prehospital head trauma patients in Vietnam, no adverse effects on consciousness were observed when Ketamine was uses for analgesia<ref>Tran, Kim. Quynh Nguyen, et al. A Comparison of Ketamin and Morphine Analgesia in Prehospital Trauma Care: A cluster randomized clinic trial in rural Quang Tri Province, Vietnam. Prehosp Emerg Care. 2014 Apr-Jun;18(2):257-64. doi: 10.3109/10903127.2013.851307</ref>


==Disposition==
==Pharmacology==
=== Discharge Criteria  ===
*Half-life:
*Return to pretreatment level of verbalization/awareness
*Metabolism:
*Return to pretreatment level of purposeful neuromuscular activity
*Excretion:
*Do NOT have to wait until the pt can ambulate or tolerate PO
*Mechanism of Action:


=== Discharge Instructions  ===
==Comments==
*NPO for 2hr
*Given as a slow push bolus.
*No independent ambulation for 2hr
**Rapid bolus increases risk for apnea.
*IV preferred over IM (faster recovery, less emesis)
*Nystagmus is seen as an effect of the medication


== See Also  ==
== See Also  ==

Revision as of 01:09, 6 July 2015

General

  • Type:
  • Dosage Forms:
  • Common Trade Names:

Adult Dosing

Procedural Sedation or Induction

  • 1 mg/kg IV, followed by 0.5-1 mg/kg IV PRN

or

  • 4-5 mg/kg IM → repeat 2-4 mg/kg IM after 10 min if first dose unsuccessful

Analgesia

  • 0.1-0.5 mg/kg IV PRN[1]

Pediatric Dosing

Procedural Sedation or Induction

  • 1.5-2 mg/kg IV

or

  • 4-5 mg/kg IM[2]

or

  • 3-6 mg/kg IN[3]

Special Populations

Contraindications

  • Allergy to class/drug

Absolute

  • <3 month old
  • Known or suspected schizophrenia, even if currently stable or controlled with medications

Relative

  • Major procedures involving posterior pharynx (e.g. endoscopy)
    • Typical minor ED oropharyngeal procedures are okay
  • Airway instability (e.g. tracheal stenosis, tracheal surgery)
  • Active pulmonary infection, including URI or asthma (unless for induction)
  • CAD, HTN, CHF
  • CNS masses, hydrocephalus (head trauma okay)
  • Glaucoma/acute globe injury
  • Thyroid disorder or on thyroid medication

Adverse Reactions

  • Laryngospasm (0.3%)
    • Only associated with unusually high IV doses
    • Tx = BVM ventilation; intubation is rarely needed
  • Apnea or respiratory depression (0.8%)
    • Associated with rapid IV push
    • Transient
  • Hypersalivation (rare)
  • Emesis, usually well into recovery (8.4%)
  • Recovery agitation, aka emergence reaction (mild in 6.3%, clinically important in 1.4%)
  • Muscular hypertonicity and random, purposeless movements (common)
  • Clonus, hiccuping, or short-lived nonallergic rash of face and neck

Intracranial pressure elevation

  • Cerebral perfusion pressure (CPP) was compromised only in the patients with pre-existing intracranial hypertension and obstruction to the flow of cerebral spinal fluid. This has, however, led to the persistent belief that ketamine is contraindicated in patients with traumatic head injuries. Studies done subsequently have shown, however, that the effects of ketamine on cerebral haemodynamics and ICP are in fact variable and depend on both the presence of additional anaesthetic agents and PaCO2 values.[4] Meta-analysis also suggests that Ketamine does not increase ICP and provides favorable hemodynamics.[5]

Neurologic Injury

  • Metaanalysis has shown that when ketamine is used in the presence of controlled ventilation, in conjunction with anaesthetics which reduce cerebral metabolism such as GABA receptor agonists, ICP is not increased.[6]

Serious

Common

Pharmacology

  • Half-life:
  • Metabolism:
  • Excretion:
  • Mechanism of Action:

Comments

  • Given as a slow push bolus.
    • Rapid bolus increases risk for apnea.
  • IV preferred over IM (faster recovery, less emesis)
  • Nystagmus is seen as an effect of the medication

See Also

References

  1. ↑ Morton NS. Ketamine for procedural sedation and analgesia in pediatric emergency medicine: a UK perspective. Paediatr Anaesth. 2008;18:25-29
  2. ↑ Green S. et al. What is the optimal dose of intramuscular ketamine for pediatric sedation?. Acad Emerg Med. 1999 Jan;6(1):21-6
  3. ↑ Hall, D, et al. Intranasal ketamine for procedural sedation. Emerg Med J. 2014; 31:789-90.
  4. ↑ Filanovsky, Y., Philip Miller et al. Myth: Ketamine should not be used as an induction agent for intubation in patients with head injury. CJEM 2010;12(2):154-7. PDF
  5. ↑ Wang X et al. Ketamine does not increase intracranial pressure compared with opioids: meta-analysis of randomized controlled trials. J Anesth 2014. PubMed ID: 24859931
  6. ↑ Himmelseher S. et al. Revising a dogma: ketamine for patients with neurological injury? Anesth Analg. 2005 Aug;101(2):524-34 PDF
Retrieved from "https://www.wikem.org/w/index.php?title=Ketamine&oldid=41758"