Orotracheal intubation |
Alternative for patients whose mental status led them to impede optimal preoxygenation and to manage anatomically difficult airways |
1. Relative hemodynamic stability 2. Provides analgesia, amnesia, and sedation in a single agent 3. Allows continued spontaneous breathing |
Risk of dissociative effects (hallucinations, disorientation, vivid dreams, sensory and/or perceptual illusions) |
1.0mg/kg to 1.5mg/kg bolus IV |
Merelman et al.(1919 Merelman AH, Perlmutter MC, Strayer RJ. Alternatives to rapid sequence intubation: contemporary airway management with ketamine. West J Emerg Med. 2019;20(3):466-71.) Weingart et al.(2424 Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med. 2012;59(3):165-75.e1.) Jabre et al.(2525 Jabre P, Combes X, Lapostolle F, Dhaouadi M, Ricard-Hibon A, Vivien B, Bertrand L, Beltramini A, Gamand P, Albizzati S, Perdrizet D, Lebail G, CholletXemard C, Maxime V, Brun-Buisson C, Lefrant JY, Bollaert PE, Megarbane B, Ricard JD, Anguel N, Vicaut E, Adnet F; KETASED Collaborative Study Group. Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial. Lancet. 2009;374(9686):293-300.) |
Analgesia |
Alternative for patients who no longer respond to high doses of opioids, patients with difficulty finding a suitable vein and perioperative analgesia |
1. Reduces cumulative morphine consumption 2. Fewer adverse effects than opioids 3. Can be administered intramuscularly |
Risk of dissociative effects (hallucinations, disorientation, vivid dreams, sensory and/or perceptual illusions) |
0.25 to 0.5mg/kg bolus IV and 0.05 to 0.4mg/kg/h in continuous infusion |
Cohen et al.(44 Cohen SP, Bhatia A, Buvanendran A, Schwenk ES, Wasan AD, Hurley RW, et al. Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Chronic Pain From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. Reg Anesth Pain Med. 2018;43(5):521-46.) Bell et al.(2626 Bell RF, Eccleston C, Kalso EA. Ketamine as an adjuvant to opioids for cancer pain. Cochrane Database Syst Rev. 2012;11:CD003351) Himmelseher et al.(2727 Himmelseher S, Durieux ME. Ketamine for perioperative pain management. Anesthesiology. 2005;102(1):211-20.) Lee et al.(2828 Lee EN, Lee JH. The effects of low-dose ketamine on acute pain in an emergency setting: a systematic review and meta-analysis. PLoS One. 2016;11(10):e0165461.) |
Agitation and delirium
|
Alternative to sedation in the prehospital setting, and a rescue medication in ED |
1. Controls agitation faster than standard medications for delirium 2. Can be administered subcutaneously, and intramuscularly |
May cause: 1. Hypersalivation, 2. Emergence reaction, 3. Laryngospasm, 4. Vomiting |
3 to 5mg/kg bolus IM Mankowitz et al.(5) Hurth et al.(29) or 2mg/kg IV bolus |
Mankowitz et al.(55 Mankowitz SL, Regenberg P, Kaldan J, Cole JB. Ketamine for rapid sedation of agitated patients in the prehospital and emergency department settings: a systematic review and proportional meta-analysis. J Emerg Med. 2018;55(5):670-81.) Hurth et al.(2929 Hurth KP, Jaworski A, Thomas KB, Kirsch WB, Rudoni MA, Wohlfarth KM. The reemergence of ketamine for treatment in critically ill adults. Crit Care Med. 2020;48(6):899-911.) |
Procedural sedation |
Alternative for elderly patients or in trauma, hypovolemia, and sepsis |
1. Can be used in cases of hypovolemia, hypotension, and bronchospasm 2. Can be used in combination with propofol |
May cause: 1. Agitation, 2. Vomiting, 3. Recovery reactions, such as confusion, anxiety and hallucinations |
0.5 - 1mg/kg IV |
Bellolio et al.(3030 Bellolio MF, Gilani WI, Barrionuevo P, Murad MH, Erwin PJ, Anderson JR, et al. Incidence of adverse events in adults undergoing procedural sedation in the emergency department: a systematic review and meta-analysis. Acad Emerg Med. 2016;23(2):119-34.) Lemoel et al.(3131 Lemoel F, Contenti J, Giolito D, Boiffier M, Rapp J, Istria J, et al. Adverse events with ketamine versus ketofol for procedural sedation on adults: a double-blind, randomized controlled trial. Acad Emerg Med. 2017;24(12):1441-9.) |
Refractory status epilepticus |
Alternative for patients with refractory epilepsy |
1.Suitable for patients with hemodynamic instability 2. It does not increase ICP |
1.Large prospective randomized trials are needed to test safety, efficacy, and dosing 2. The use of concurrent anesthetics with ketamine, often necessary to treat RSE, might lead to adverse effects, such as severe acidosis |
2.0mg/kg I.V bolus and 1.5 - 5.0mg/kg/h in continuous infusion |
Alkhachroum et al.(77 Alkhachroum A, Der-Nigoghossian CA, Mathews E, Massad N, Letchinger R, Doyle K, et al. Ketamine to treat super-refractory estado epiléptico. Neurology. 2020;95(16):e2286-e94.) Gaspard et al.(2121 Gaspard N, Foreman B, Judd LM, Brenton JN, Nathan BR, McCoy BM, et al. Intravenous ketamine for the treatment of refractory estado epiléptico: a retrospective multicenter study. Epilepsia. 2013;54(8):1498-503.) |
Bronchospasm and asthma |
Alternative in severe asthmaticus status refractory to conventional therapy |
1. May reduce airway resistance, mean peak airway pressure, arterial partial pressure of carbon dioxide. 2. May increase partial pressure of oxygen and lung compliance. |
1.There is no consensus about the optimum doses and duration of the infusion of ketamine infusion. 2. May increase airway secretions |
0.1 - 2.0 mg/kg I.V bolus and 0.15 - 2.5mg/kg/h in continuous infusion |
Esmailian et al.(3232 Esmailian M, Koushkian Esfahani M, Heydari F. The effect of low-dose ketamine in treating acute asthma attack; a randomized clinical trial. Emerg (Tehran). 2018;6(1):e21.) Goyal et al.(1414 Goyal S, Agrawal A. Ketamine in status asthmaticus: a review. Indian J Crit Care Med. 2013;17(3):154-61.) |
Traumatic brain injury and intracranial hypertension |
Does not increase intracranial pressure |
1. May offer protection from cellular mechanisms of neuronal death 2. Relative hemodynamic stability |
1. There is no evidence that ketamine is more efficacious than other sedatives. 2. Longer recovery after infusion was discontinued |
0.8mg/kg/h in continuous infusion IV |
Bourgoin et al.(3333 Bourgoin A, Albanèse J, Wereszczynski N, Charbit M, Vialet R, Martin C. Safety of sedation with ketamine in severe head injury patients: comparison with sufentanil. Crit Care Med. 2003;31(3):711-7.) Roberts et al.(3434 Roberts DJ, Hall RI, Kramer AH, Robertson HL, Gallagher CN, Zygun DA. Sedation for critically ill adults with severe traumatic brain injury: a systematic review of randomized controlled trials. Crit Care Med. 2011;39(12):2743-51.) |
Ethanol abstinence |
Alternative for patients with severe withdrawal symptoms |
Ketamine infusion is associated with: 1. Reduced use of GABA agonists, 2. Shorter ICU stay, 3. Fewer intubations |
Risk of dissociative effects (hallucinations, disorientation, vivid dreams, sensory and/or perceptual illusions) |
0.15 - 0.3mg/kg/h in continuous infusion until delirium resolved |
Pizon et al.(2222 Pizon AF, Lynch MJ, Benedict NJ, Yanta JH, Frisch A, Menke NB, et al. Adjunct ketamine use in the management of severe ethanol withdrawal. Crit Care Med. 2018;46(8):e768-e71.) Wong et al.(3535 Wong A, Benedict NJ, Armahizer MJ, Kane-Gill SL. Evaluation of adjunctive ketamine to benzodiazepines for management of alcohol withdrawal syndrome. Ann Pharmacother. 2015;49(1):14-9.) |