ketamine (Rx)

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Brand and Other Names:Ketalar

Dosing & Uses

AdultPediatric

Dosage Forms & Strengths

injectable solution: Schedule III

  • 10mg/mL
  • 50mg/mL
  • 100mg/mL
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Anesthesia Induction

Load

  • IV: 1-4.5 mg/kg slow IV once 
  • Alternatively (off-label): 0.5-2 mg/kg slow IV if adjuvant drugs (eg, midazolam) are used, OR
  • IM: 6.5-13 mg/kg IM once
  • Alternatively (off-label): 4-10 mg/kg IM once if adjuvant drugs (eg, midazolam) are used

Maintenance

  • 50% of IV ketamine induction dose administered PRN, OR
  • 0.1-0.5 mg/min IV continuous infusion

Dosage Forms & Strengths

injectable solution: Schedule III

  • 10mg/mL
  • 50mg/mL
  • 100mg/mL
more...

Sedation/Analgesia (Off-label)

ACEP recommends as safe in children

3 months or older

IM

  • 4-5 mg/kg IM once, ACEP Clinical Guidelines (Green 2004); may give a repeat dose (range 2-5 mg/kg) if sedation inadequate after 5-10 min or if additional doses are required 

IV

  • Various recommendations
  • 1.5-2 mg/kg over 30-60 sec; may administer incremental doses of 0.5-2 mg/kg IV q5-15min PRN if initial sedation inadequate (Mace et al., Ann Emerg Med, 44: 342-377 [2004]), OR 
  • 0.25-0.5 mg/kg (Harriet Lane)

Oral

  • 6-10 mg/kg PO once; mix with 0.2-0.3 mL/kg of a beverage; give 30 min before procedure

16 years or older

Load

  • IV: 1-4.5 mg/kg slow IV once
  • Alternatively (off-label): 0.5-2 mg/kg slow IV if adjuvant drugs (eg, midazolam) are used, OR
  • IM: 6.5-13 mg/kg IM once
  • Alternatively (off-label): 4-10 mg/kg IM once if adjuvant drugs (eg, midazolam) are used

Maintenance

  • 50% of IV ketamine induction dose administered PRN, OR
  • 0.1-0.5 mg/min IV continuous infusion
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Interactions

Interaction Checker

and ketamine

No Results

     activity indicator 
    No Interactions Found
    Interactions Found

    Contraindicated

      Serious - Use Alternative

        Significant - Monitor Closely

          Minor

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            Adverse Effects

            >10%

            Emergence rxns

            HTN

            Increased cardiac output

            Increased ICP

            Tachycardia

            Tonic-clonic movements

            Visual hallucinations

            Vivid dreams

            1-10%

            Bradycardia

            Diplopia

            Hypotension

            Increased IOP

            Injection-site pain

            Nystagmus

            <1%

            Anaphylaxis

            Cardiac arrhythmia

            Depressed cough reflex

            Fasciculations

            Hypersalivation

            Increased IOP

            Increased metabolic rate

            Hypertonia

            Laryngospasm

            Respiratory depression or apnea with large doses or rapid infusions

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            Warnings

            Contraindications

            Hypersensitivity

            Conditions in which an increase in blood pressrue would be hazardous

            Cautions

            Increases ICP (head raising may alleviate); causes hypersalivation (may be controlled with atropine/glycopyrrolate)

            Not for use alone in surgery or diagnostic procedures of the pharynx, or bronchial tree, mechanical stimulation of the pharynx, larynx, or bronchial tree; avoid mechanical stimulation of the pharynx if ketamine used alone

            May cause CNS depression; use caution when operating heavy machinery; do not engage in hazardous activities or operate hazardous machinery for at least 24 hr after anesthesia

            May cause dependence and tolerance with prolonged use; discontinuation of long term use has been associated with a withdrawal syndrome with psychotic features

            Treat CNS abnormalities, CNS masses, or hydrocephalus as a relative contraindication, due to increased intracranial pressure produced by ketamine

            Therapy may increase intraocular pressure, use with caution in patients with increased intraocular pressure; avoid use in patients with eye injury or other ophthalmic disorder

            Glaucoma or acute globe injury may be considered a relative contraindication

            Therapy may enhance sympathomimetic effect; use caution in patients with porphyria or a thyroid disorder; may consider porphyria and thyroid disorder or thyroid therapy a relative contraindication

            Use caution in patients with coronary artery disease, catecholamine depletion, hypertension and tachycardia; monitor cardiac function continuously in patients with increased blood pressure, heart rate, and cardiac output, thereby increasing myocardial oxygen demand

            Use caution in patients with cerebrospinal fluid pressure elevation; increase in cerebrospinal fluid pressure may be associated with use

            Use with cautioin in chronic alcoholic patients or acutely intoxicated

            Use requires patient monitoring, to be administered only by experienced personnel who are not actively engaged in the procedure or surgery; in nonintubated and/or nonmechanically ventilated patients, appropriate equipment and qualified personnel should be immediately available to use appropriate equipment for rapid institution of respiratory and/or cardiovascular support

            Too rapid administration will cause respiratory depression

            Do NOT put diazepam or barbiturates in same syringe/bag

            Safety for obstetric procedures not established

            Children may require head positioning, supplemental oxygen, occasional bad-valve-mask ventilatory support and measures top address laryngospasm

            Use caution in patients with significant LV dysfunction, as the sympathetic stimulation may not be adequate to overcome the negative inotropic effects, resulting in deterioration

            Emergence reactions

            • Postanesthetic emergence reactions, manifested as dreamlike state, vivid imagery, hallucinations, and/or delirium reported in ~12%
            • Least common in children younger than 15 yr, elderly older than 65 yr, or when administered IM
            • May occur up to 24 hr postoperatively
            • Occurrence may be decreased by using lower recommended dose in conjunction with a benzodiazepine for anesthesia induction
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            Pregnancy & Lactation

            Pregnancy category: C

            Lactation: Not known if excreted in breast milk; effect on nursing infant unknown

            Pregnancy Categories

            A:Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

            B:May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

            C:Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

            D:Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

            X:Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

            NA:Information not available.

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            Pharmacology

            Mechanism of Action

            Produces dissociative anesthesia

            Blocks NMDA receptor

            Overdose may lead to panic attacks and aggressive behavior; rarely seizures, increased ICP, and cardiac arrest

            Very similar in chemical makeup to PCP (phencyclidine), but it is shorter acting and less toxic

            Absorption

            Onset: 30 sec (IV); 3-4 min (IM)

            Duration: 5-10 min (IV); 12-25 min (IM): dissociative state may last >20 min

            Peak plasma concentration: 0.75 pg/mL

            Metabolism

            Liver

            Elimination

            Excretion: Urine (91%), feces (3%)

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            Administration

            IV Incompatibilities

            Additive: Barbiturates, diazepam

            Syringe: Barbiturates, diazepam, doxapram

            IV Compatibilities

            Additive: Morphine sulfate

            Syringe: Bupivacaine with fentanyl, clonidine with tetracaine, lidocaine with morphine sulfate, meperidine, morphine tartrate

            Y-site: Ceftazidime, propofol

            IV Preparation

            IV infusion: Prepare 1 or 2 mg/mL solution by adding 50 mg to 500 mL or to 250 mL, respectively, of D5W or NS

            IV/IM Administration

            Administer IM, OR

            By slow IV injection over at least 60 sec

            Do not give 100 mg/mL preparation undiluted

            Storage

            Store at controlled room temperature

            Colorless to slightly yellow solution; may darken upon prolonged exposure to light but this does not affect potency

            Do not use if precipitate is present

            Protect from light

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            Images

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            Formulary

            FormularyPatient Discounts

            Adding plans allows you to compare formulary status to other drugs in the same class.

            To view formulary information first create a list of plans. Your list will be saved and can be edited at any time.

            Adding plans allows you to:

            • View the formulary and any restrictions for each plan.
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            • Compare formulary status to other drugs in the same class.
            • Access your plan list on any device – mobile or desktop.

            The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

            Tier Description
            1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
            2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
            3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
            4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            NC NOT COVERED – Drugs that are not covered by the plan.
            Code Definition
            PA Prior Authorization
            Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
            QL Quantity Limits
            Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of the drug that will be covered.
            ST Step Therapy
            Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.
            OR Other Restrictions
            Drugs that have restrictions other than prior authorization, quantity limits, and step therapy associated with each prescription.
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