Ketamine Update

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Mazdak M., Dr -

Could you please clarify recommended dose for IM ketamin in paediatric procedural sedation ,and acutecpain management in ED , thx .

David B. -

I completely agree with almost everything said in this segment, as ketamine really is a fantastic induction agent and a useful sedative agent after intubation. Due to drug shortages we have used ketamine frequently for continuous sedation (out of BZD's can't use precedex due to cost) in intubated patients with a myriad of diagnosis including sepsis.

I would, however, modify one statement regarding the Jabre paper. Tekwani et al in Annals demonstrated a non-statistically significant increase in mortality in septic patients receiving etomidate, (about 8% absolute increase), which was very similar in the Jabre study when looking at the subset of patients with sepsis (absolute increase in mortality of 7%). For a majority of patients etomidate is probably as good as ketamine, and even in sepsis the jury is still out. However, I would not state that the paper did not show any difference in outcomes between patients who received etomidate and ketamine in septic patients. The data from RCT's regarding etomidate vs "other induction agent" is as follows in septic patients:

versed (21/59) 36% mortality vs. etomidate (26/61) 43% mortality (TEKWANI)

Ketamine (12/35) 34% vs. etomidate (17/41) 41% (JABRE)

While its not statistically significant and it is certainly a 2ndary outcome analysis prone to significant bias, I can't think of a reason not to use ketamine while I can think of a reason to not use etomidate in the subset of patients with severe sepsis requiring intubation.

Mel H. -

David B, I agree, there is this disturbing tend is all the studies that the etomidate group does a little worse, but never quite reaching "significance" until we get a study with more power it seems reasonable to avoid it, at least in the sickest patients I think. I am sure Dave Newman is about to fire a missile at me for posting this ;)

Howard L. -

I just tried Ketamine/Propofol 0.5mg/kg IV for each and was disappointed. It didn't even phase the patient, I ended up titrating additional propofol to be able to complete the procedure (an additional 120 mg of Propofol was required). Is my experience uncommon? Should the initial dose be increased? Guidance appreciated.

Minh L., Dr -

ketamine at 0.5mg/kg IV is a subdissociative dose..for analgesia
o.5-0.75mg/kg IV ketamine is the dose used in the antideepressant trials! not meant for procedural sedation or induction anaesthesia/TIVA maintenance

If you want to use it for procedural sedation and RSI induction, you need 1mg/kg for sedation initially, 2mg/kg for RSI induction

Cameron -

Not statistically significant = no difference. I still think it is the best choice in the hemodynamically compromised.

Paul B., M.D. -

Just used 0.5mg/kg Ketamine for pain control in a shoulder dislocation in a patient who was screaming in pain despite opioids. Pain control was phenomenal and rapid. It allowed me to reduce the patient without "procedural sedation" although now pharmacy refuses to dispense it for that indication because there are no conclusive studies that support its use for that indication. It can only be considered procedural sedation and we have to have a nurse sit out during the entire time that the patient is "under." It is funny how the rumor mill works in hospitals because I immediately went on vacation after doing it and when I came back the director thought that I had used a drip for pain control in an RSD patient. The patient did vomit post procedure. He was completely satisfied with it regarding his pain control but vaguely remembers the reduction. I think I will use it again only if I need to control a patient's pain prior to Xray and opioids are not working. Then when the patient comes back I move to propofol and deal with the patient as need be. I think possibly another indication might be in severe burns where opioids are not working and the patient does not need intubation.

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