Changing practice Critical Care Emergency

Ketamine – the truth

C – Clinical practice

Ketamine has been in clinical use since the early 1960s. While long used for paediatric procedural sedation, ketamine is now being increasingly used in adult patients for procedural sedation, analgesia, sedation of agitated patients, in the management of asthma and seizures, as an adjunct in delayed sequence intubation, and as an induction agent in any emergency intubation.

H – How/where/why?

In any emergency situation where sedation and/or analgesia are required and it is preferable not to depress respiratory or cardiovascular function. Doses in increments of .1mg/kg for simple analgesia to 0.5 to 2mg/kg for sedation or anaesthetic induction. Can also be used IMI in doses of 2-4mg/kg.

A – Affecting who?

Emergency departments, intensivists, proceduralists. Should only be used by junior doctors under senior supervision.

N – New or old?

Ketamine is an old drug that is finding new uses due to its dosing flexibility, haemodynamic and respiratory stability, and relative lack of serious side effects.

G – Good or bad?

Ketamine has long been associated with emergence phenomena in adults (less common than thought and easily managed), an association with seizures (evidence does not support this) and a reputation to raise intracranial pressure (it may do but by very small increments and only transiently). Ketamine is advantageous in emergency department intubations as it will not cause respiratory and cardiovascular depression, and it is a bronchodilator. Ketamine has also been utilised safely by the Royal Flying Doctor Service in North Queensland, and other aeromedical retrieval services, to safely transport behaviourally disturbed patients without the need for intubation (Link here).

E – Evidence

Despite its long history of use, there are surprisingly few large clinical trails of ketamine outside of its use in anaesthesia.

1. Ketamine use in the treatment of refractory status epilepticus. Epilepsy Research. 2013 Jul;105(1-2):183-8.

2. Anaesthesia in haemodynamically compromised emergency patients: does ketamine represent the best choice of induction agent? Anaesthesia [Internet] 2009;64(5):532-539.

3. IV Ketamine to Avoid Ventilation in Patients with Asthma. J Emerg Med. 2011;41(5):492-494.

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