Professional Documents
Culture Documents
Pharmacology.: 2004 Saunders, An Imprint of Elsevier
Pharmacology.: 2004 Saunders, An Imprint of Elsevier
KETAMINE
Pharmacology.
Figure 34-1 A child undergoing repair of a laceration while dissociated with ketamine. The blank stare is
typical.
Ketamine differs from all other PSA agents in several important ways. First, it
uniquely preserves cardiopulmonary stability. Upper-airway muscular tone and
protective airway reflexes are maintained. Spontaneous respiration is preserved,
although when administered IV, ketamine must be given slowly (over 1 to 2
minutes) to prevent respiratory depression. Second, it differs from other agents in
that it lacks the characteristic dose-response continuum to progressive titration. At
doses below a certain threshold, ketamine produces analgesia and sedation.
However, once a critical dosage threshold (approximately 1 to 1.5 mg/kg IV or 3 to
4 mg/kg IM) is achieved, the characteristic dissociative state abruptly appears. This
dissociation has no observable levels of depth, and thus the only value of ketamine
"titration" is to maintain the presence of the state over time. Finally, the
dissociative state is not consistent with formal definitions of moderate sedation,
deep sedation, or general anesthesia (see Table 34-1 ), and therefore must be
considered from a different perspective than agents that exhibit the classical
sedation continuum.[13][96]
Ketamine is most effective and reliable when given IV or IM. Ketamine has a one
arm-brain circulation time when given IV with onset of dissociation noted within 1
minute and effective procedural conditions lasting for about 10 to 15 minutes.
When given IM, the same effect is achieved within 5 minutes, with effective
procedural conditions for about 15 to 30 minutes. The typical duration from dosing
until dischargeable recovery is 50 to 110 minutes when given IV, and 60 to 140
minutes when given IM.[92][97]
Like the benzodiazepines, ketamine undergoes substantial first pass hepatic
metabolism. As a result, oral and rectal administration results in less predictable
effectiveness and requires substantially higher doses. Clinical onset and recovery
are substantially longer than when given parenterally, and thus these routes are
rarely used in the ED.[61][62][98]
Ketamine can induce salivation, and is routinely coadministered with an
anticholinergic. Atropine is most commonly chosen in emergency medicine due to
its ready familiarity to clinicians and nurses, although glycopyrrolate is an equally
acceptable but not superior alternative (see Table 34-13 ).
Adult use.
Careful patient selection can help minimize potential adverse events (see Table 3413 ).[99][101]
Pediatric use.
In the largest published ED series (1022 patients) the following adverse airway
events were noted: airway malalignment (0.7%), transient laryngospasm (0.4%),
and transient apnea or respiratory depression (0.3%). All were quickly identified
and treated, and there were no sequelae.[4]
Vomiting was noted in 6.7% from the same series, and in most cases it occurred
well into recovery.[4] The incidence was age-related, occurring in 12.1% of children
aged 5 years or older, and 3.5% in those younger than 5 years.[94] There was no
evidence of aspiration[4]; indeed, in 30 years of regular use there have been no
documented reports of clinically significant ketamine-associated aspiration in
patients without established contraindications. Delayed vomiting may occur after
discharge, and patients should be advised of this possibility. Because of its unique
preservation of protective airway reflexes, ketamine may be preferred over other
agents for urgent or emergent procedures when fasting is not assured.[4][5][92]
Mild agitation during recovery (whimpering or crying) was noted in 17.6% of
children from the same series, with more pronounced agitation in 1.6%. The
incidence was age-related, with agitation occurring in 12.1% of children aged 5 or
older, and 22.5% in those younger than 5.[94] Only 2 of 1022 children had reactions
that treating clinicians judged severe enough to require treatment, and both
children responded promptly to small doses of midazolam.[4] Another study
quantified the degree of recovery agitation using a 0 to 100 mm visual analog
scale; the median rating of recovery agitation was a 5, likely below the threshold of
clinical importance.[103]
Copyright 2009 Elsevier Inc. All rights reserved. - www.mdconsult.com