Ketamine: Difference between revisions
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*IV preferred over IM (faster recovery, less emesis) | *IV preferred over IM (faster recovery, less emesis) | ||
*Nystagmus is seen as an effect of the medication | *Nystagmus is seen as an effect of the medication | ||
*IM "Ketamine dart" for special needs children when IV not easily obtainable<ref>Pruit JW et al. Intramuscular ketamine, midazolam, and glycopyrrolate for pediatric sedation in the emergency department. J Oral Maxillofac Surg. 1995 Jan;53(1):13-7; discussion 18.</ref> | |||
**Minimal respiratory drive and airway tone impact | |||
**Components mixed in single syringe: | |||
***3 mg/kg ketamine | |||
***0.05 mg/kg midazolam (reduces dysphoric reactions) | |||
***0.005 mg/kg glycopyrrolate (reduces oral secretions; may increase HR on top of ketamine however) | |||
== See Also == | == See Also == | ||
Revision as of 18:47, 13 February 2016
General
- Type: Dissociative anesthetic
- Dosage Forms: 10, 50, 100 mg/ml
- Routes of administration: IV, IM
- Common Trade Names: Ketalar
Adult Dosing
Procedural Sedation or Induction
Options:'
- 1 mg/kg IV, followed by 0.5-1 mg/kg IV PRN
- 4-5 mg/kg IM → repeat 2-4 mg/kg IM after 10 min if first dose unsuccessful
Subdissociative Analgesia
Pediatric Dosing
Procedural Sedation or Induction
Options
Special Populations
- Pregnancy Rating: B
- Lactation risk:
- Renal Dosing
- Adult
- Pediatric
- Hepatic Dosing
- Adult
- Pediatric
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%)
- Can pretreat with midazolam 0.05 mg/kg (2-4 mg for most adults)[5]
- 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.[6] Meta-analysis also suggests that Ketamine does not increase ICP and provides favorable hemodynamics.[7]
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.[8]
Pharmacology
- Half-life: 2.5 hours
- Metabolism: Hepatic
- Excretion: Urine
- Mechanism of Action: Excact mechanism unknown
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
- IM "Ketamine dart" for special needs children when IV not easily obtainable[9]
- Minimal respiratory drive and airway tone impact
- Components mixed in single syringe:
- 3 mg/kg ketamine
- 0.05 mg/kg midazolam (reduces dysphoric reactions)
- 0.005 mg/kg glycopyrrolate (reduces oral secretions; may increase HR on top of ketamine however)
See Also
- Sedation (Main)
- Procedural Sedation
- Intranasal Sedation
- Delayed sequence intubation
- Sympathomimetic Toxicity
- Ketofol
References
- ↑ Morton NS. Ketamine for procedural sedation and analgesia in pediatric emergency medicine: a UK perspective. Paediatr Anaesth. 2008;18:25-29
- ↑ Ahern TL, et al. The first 500: initial experience with widespread use of low-dose ketamine for acute pain management in the ED. Am J Emerg Med. 2015 Feb;33(2):197-201. PMID: 25488336.
- ↑ Green S. et al. What is the optimal dose of intramuscular ketamine for pediatric sedation?. Acad Emerg Med. 1999 Jan;6(1):21-6
- ↑ Hall, D, et al. Intranasal ketamine for procedural sedation. Emerg Med J. 2014; 31:789-90.
- ↑ Sener S, Eken C, Schultz CH, Serinken M, Ozsarac M. Ketamine with and without midazolam for emergency department sedation in adults: a randomized controlled trial. Ann Emerg Med. 2011 Feb;57(2):109-114.e2
- ↑ 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
- ↑ 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
- ↑ Himmelseher S. et al. Revising a dogma: ketamine for patients with neurological injury? Anesth Analg. 2005 Aug;101(2):524-34 PDF
- ↑ Pruit JW et al. Intramuscular ketamine, midazolam, and glycopyrrolate for pediatric sedation in the emergency department. J Oral Maxillofac Surg. 1995 Jan;53(1):13-7; discussion 18.