ketamine (Ketalar, special K)
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Introduction
Tradename: Ketalar. DEA-controlled substance: class 3.
Indications
- general anesthesia, local anesthesia[8]
- surgical & diagnostic procedures that do not require skeletal muscle relaxation
- adjunctive agent for lower potency agents such as nitric oxide (NO)
- anesthetic in combination with neuromuscular blocking agent for use in rapid sequence endotracheal intubation[6]
- safe to use in children with increased intracranial pressure[7]
- may be useful as a rescue agent for severely agitated patients presenting a danger that are difficult to sedate[10]
- treatment of major depression
- may be useful for treatment-resistant depression[11]
- treatment of acute pain alone or in combination with opioid[12]
- intranasal or nebulized ketamine may be useful for treating acute pain in the elderly[14]
Contraindications
Caution:
- for use by or under the directed of physician experienced in administering general anesthetics
- resuscitation equipment should be available prior to administration
Dosage
- 1-4.5 mg/kg, usually 1-2 mg/kg IV given at 0.5 mg/kg/min
- 6.5-13 mg/kg IM
- for maintenance, use induction dose as needed
- pain adjunct:
- 5-10 mg IM titrated to effect
- subdissociative-dose IV ketamine (0.3 mg/kg)[9]
- intranasal or nebulized for treating acute pain in the elderly[14]
* Injection: 10 mg/mL (50 mL); 50 mg/mL (10 mL); 100 mg/mL (5 mL).
* Nebulizer 0.75-1.5 mg/kg[15]
Pharmacokinetics
- following a single dose
- unconsciousness lasts 10-15 minutes
- analgesia lasts 30-40 minutes
- amnesia may persist for 1-2 hours
- hepatically metabolized
- anesthetic action is terminated by redistribution from the CNS & hepatic conversion to a lower potency metabolite
- terminal 1/2life is 10-15 minutes
elimination via liver
1/2life = 2-4 hours
protein binding = 20-50 %
Adverse effects
- common (> 10%)
- emergent psychological reactions (less with IM administration)
- vivid dreams
- visual hallucinations
- hypertension
- increased cardiac output
- tachycardia
- tonic-clonic movements
- tremors
- vocalization
- dissociative symptoms[13]
- less common (1-10%)
- bradycardia, nausea/vomiting, hypotension, respiratory depression, anorexia, diplopia, pain at site of injection, rash, nystagmus
- uncommon (< 1%)
- laryngospasm, arrhythmias, myocardial depression, increase in cerebral blood, increased metabolic rate, increased intracranial pressure, increased intraocular pressure, increased skeletal muscle tone, fasciculations, hypersalivation, cough reflex may be depressed
Drug interactions
- non-depolarizing muscle relaxants in combination prolong respiratory depression
- hypnotic effect of thiopental may be antagonized
- halothane in combination may result arrhythmia
- theophylline in combination my result in seizures
Laboratory
Mechanism of action
- dissociative anesthetic with abuse potential
- street name special K
- rapidly acting general anesthetic with analgesic properties
- NMDA receptor antagonist[5]
- lowers intracranial pressure & increases cerebral perfusion in intubated children with increased intracranial pressure[7]
Notes
- chirally pure enantiomer esketamine is an investigational intranasal ketamine for treatment of refractory depression
More general terms
More specific terms
Additional terms
References
- ↑ Clinical Guide to Laboratory Tests, 3rd edition, NW Tietz ed, WB Saunders, Philadelphia, 1995
- ↑ Drug Information & Medication Formulary, Veterans Affairs, Central California Health Care System, 1st ed., Ravnan et al eds, 1998
- ↑ Kaiser Permanente Northern California Regional Drug Formulary, 1998
- ↑ Clinical Guide to Laboratory Tests, 3rd ed. Teitz ed., W.B. Saunders, 1995
- ↑ 5.0 5.1 Prescriber's Letter 10(11) 2003; detail doceument 191102
- ↑ 6.0 6.1 Jabre P et al Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: A multicentre randomised controlled trial. Lancet 2009 Jul 1; <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/19573904 <Internet> http://dx.doi.org/10.1016/S0140-6736(09)60949-1
Wenzel V and Lindner KH. Best pharmacological practice in prehospital intubation. Lancet 2009 Jul 1; <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/19573905 <Internet> http://dx.doi.org/10.1016/S0140-6736(09)61071-0 - ↑ 7.0 7.1 7.2 Bar-Joseph G et al. Effectiveness of ketamine in decreasing intracranial pressure in children with intracranial hypertension. J Neurosurg Pediatr 2009 Jul; 4:40. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19569909
- ↑ 8.0 8.1 Deprecated Reference
- ↑ 9.0 9.1 Motov S et al. Intravenous subdissociative-dose ketamine versus morphine for analgesia in the emergency department: A randomized controlled trial. Ann Emerg Med 2015 Mar 26 PMID: https://www.ncbi.nlm.nih.gov/pubmed/25817884
- ↑ 10.0 10.1 Isbister GK. Ketamine as rescue treatment for difficult-to-sedate severe acute behavioral disturbance in the emergency department. Ann Emerg Med 2016 Feb 18 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26899459 <Internet> http://www.annemergmed.com/article/S0196-0644%2815%2901562-0/abstract
- ↑ 11.0 11.1 Sanacora G, Frye MA, McDonald W et al A Consensus Statement on the Use of Ketamine in the Treatment of Mood Disorders. JAMA Psychiatry. 2017 Apr 1;74(4):399-405. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/28249076
Abbasi J Ketamine Minus the Trip: New Hope for Treatment-Resistant Depression. JAMA. Published online November 8, 2017 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29117311 https://jamanetwork.com/journals/jama/fullarticle/2662752 - ↑ 12.0 12.1 Brooks M First-Ever Ketamine Guidelines for Pain Management Released. Medscape - Jun 15, 2018. https://www.medscape.com/viewarticle/898134
- ↑ 13.0 13.1 Anand A et al. Ketamine versus ECT for nonpsychotic treatment-resistant major depression. N Engl J Med 2023 May 24; [e-pub]. PMID: https://www.ncbi.nlm.nih.gov/pubmed/37224232 https://www.nejm.org/doi/10.1056/NEJMoa2302399
Freedman R. Ketamine and ECT in depression - Risks and rewards. N Engl J Med 2023 May 24; [e-pub] PMID: https://www.ncbi.nlm.nih.gov/pubmed/37224235 https://www.nejm.org/doi/10.1056/NEJMe2305130 - ↑ 14.0 14.1 14.2 Almodibeg B, Forget P Challenges of acute pain management in older patients. Age Ageing. 2024 Apr 1;53(4):afae061. PMID: https://www.ncbi.nlm.nih.gov/pubmed/38557666 https://academic.oup.com/ageing/article/53/4/afae061/7638303
- ↑ 15.0 15.1 Dove D, Fassassi C, Davis A et al Comparison of Nebulized Ketamine at Three Different Dosing Regimens for Treating Painful Conditions in the Emergency Department: A Prospective, Randomized, Double-Blind Clinical Trial. Ann Emerg Med. 2021 Dec;78(6):779-787. PMID: https://www.ncbi.nlm.nih.gov/pubmed/34226073 Clinical Trial.