10 Ways to Safely Push Ketamine in the ED
Published: Mar 19, 2014 | Updated: Mar 20, 2014
By Elbert Chu, Associate Producer, MedPage Today
Reviewed by Zalman S. Agus, MD; Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner
A doctor recently took me on a ketamine trip, and I enjoyed it immensely.
Reuben Strayer, MD, led a "We should do ____ more often" session at the recent American Academy of Emergency Medicine (AAEM) meeting. The blank was, as you've probably guessed, "push ketamine," the N-methyl-D-aspartate receptor antagonist originally used in horses, but notorious as a street drug often called "Special K."
Clinically, ketamine has an established presence among anesthesiologists, psychiatrists, pediatric EDs, and has even spread to rural Uganda. Now, it seems physicians in the general ED have started to push ketamine more often. Richard Levitan, MD, recently called it a "comeback kid."
The number of articles about ketamine in PubMed has jumped to 730 in 2013, from 384 in 2000. But even as researchers study ketamine as a new antidepressant, some have warned of urinary tract dysfunction in long-term use and pointed out a growing problem of abuse in Southeast and East Asia.
So why is ketamine earning a spot in the general ED now? Here are 10 ways to ketamine can be used safely, lightly remixed from Strayer's presentation and with information from Howard Mell, MD, MPH, and Graham Walker, MD.
1. Push Ketamine for Analgesia
Analgesia is a sweet spot for ketamine, and underutilized, according to Strayer, an assistant clinical professor of emergency medicine at Mount Sinai. He said ketamine is a safe and powerful analgesic at 0.15 mg/kg and can be an option when opiates fail to reduce pain. And it's Strayer's second-line choice after opiates for recovering addicts, patients on methadone, or those with marginal blood pressure or breathing.
2. Consider Ketamine for Procedural Sedation
Strayer's ketamine pros are complete analgesia, sedation, and amnesia. Ketamine maintains airway reflexes and augments cardiorespiratory tone. "It's really a wonder drug for procedural sedation," Strayer said: It provides rapid onset, predictable duration, can be used intramuscularly, and has an unmatched margin of safety.
3. Reach For Ketamine in Rapid Sequence Induction (RSI)
Because ketamine has bronchodilation properties, Strayer recommended ketamine for patients being intubated for asthma or COPD. He also prefers ketamine as the RSI induction agent in all hypotensive patients, including trauma versus etomidate. It's Strayers "agent of choice" because it can be used in all patients where increase in heart rate and blood pressure is acceptable. "Dose big," said Strayer. He advised docs to take advantage of the long flat part at the end of the dose response curve.
Levithan referenced a 2011 clinical guideline for dissociative sedation as the definitive paper for RSI at a recent talk. The exception here is obtunded patients and those who are very hypotensive.
4. Dilate in Asthma
In cases where adult and pediatric patients who have near death asthma attacks, and intubation is imminent, Strayer recommended ketamine for its bronchodilation profile at induction dose, given over 30-60 seconds.
5. Sedate Post-Intubation
An under-sedated intubated patient is a dangerous situation. In this case, push ketamine, not vecuronium, says Strayer. Choose ketamine when RSI isn't the right SI, and when you don't want paralysis.
6. Keep It Handy as a Tranquilizer
Speed, safety, reliability, and intramuscular dosing are Strayer's top reasons to reach for ketamine to tranquilize patients, as discussed in the ACEP Excited Delirium Task Force.
"Ketamine is unrivaled for this indication," Strayer said. "No matter how big strong, or intoxicated, ketamine turns him into a complete bunny rabbit while ABCs are maintained 100% of the time."
He added that doctors need to weigh ketamine's risk of increased heart rate and blood pressure (see #8) against dangers to staff and nearby patients if using it to sedate someone having an uncontrolled thrashing rage. This is equivalent to procedural sedation – so treat patients as such. They should have one-to-one nursing or a physician at bedside. Strayer recommended ketamine 500 mg IM x 1.
7. Manage Ketamine's Psychiatric Distress
The psychiatric distress caused by ketamine is not dangerous, says Strayer. Prevent it by pre-induction comfort and pre-induction coaching. Tell them the drug will give them very vivid dreams, but they can control it. He recommended suggestions such as, "Imagine that you are on a beach." Anticipate any distress and be careful with small doses. Eventually, patients just need to metabolize the drug. Strayer added that docs can use propofol to manage hypertension, which is better than ketofol.
8. Remember the Cardiac Factor
The main downer on the ketamine party is that it can cause hypertension and tachycardia. A recent paper described two patients on ketamine who had cardiac arrest following RSI, although over at Resus.me, Cliff G. Reid, MD, notes three possible confounders the authors didn't take into account. Still, doctors should be aware of this risk, particularly in critically ill patients.
9. Lock it Down: Prevent Abuse
Afraid of ketamine dependency? Ketamine is not euphoric like opiates, Strayer said. It makes patients feel kind of weird, so people less likely to turn into addicts. Mell mentioned that he has staff double the number of inventory checks for ketamine, to prevent diversion, and also includes supervisors in the protocols.
10. Limit Risks of Laryngospasm, Hypertonicity, Hypersalivation
Laryngospasm is less common in adults than children but can happen. Anyone receiving dissociative-dose ketamine should be monitored as a procedural sedation patient. Strayer said physicians should respond with positive pressure ventilation, paralyze the patient, and intubate. Other possible side effects include hypertonicity, and hypersalivation. Also, there's no reversal agent.
Here's Strayer's guide to what happens at different doses of ketamine:
| Dose | Phase/Purpose | Response |
| 10-20 mg (0.1-0.3 mg/kg) | Analgesia | ABCs no problem. Second line to opiates, setup a ketamine drip for fine tuning. |
| 30 mg (0.2-0.5 mg/kg) | Recreational | Patient converses, walks, and follows directions, but is stoned. Psychiatric distress unlikely. |
| 50 mg (0.4-0.8 mg/kg) | Partial Dissociation/AVOID | Patients have some consciousness, some awareness, barely feel connected to the world and their own bodies. Might be able to speak or move. Most will find it terrifying, sometimes they freak out. This is where your patient should not be. |
| 100 mg (>0.7 mg/kg) | Dissociated/Intubate and Tranquilizer | Unaware, awake but unconscious -- this is the "K-hole." Patient feels nothing, forms no memories. |
| 1000 mg | Still dissociated/Still Safe | Higher doses do not intensify affect, just prolong the duration, suggesting a "remarkable margin of safety." |
Bonus: In recent years, researchers have debunked a swirl of myths surrounding ketamine. Strayer dug up studies that address alleged contraindications [1234567].
Here are Strayer's slides from the AAEM ketamine trip session and his write up at Emergency Medicine Updates.
Strayer, Mell, and Walker disclosed no relevant relationships with industry.
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