The research article is about Ketamine safety and use in the emergency department for pain and agitation/delirium. This study was done using retrospective, electronic chart reviews to evaluate the the safety and effects of ketamine use in 18 emergency departments. In 2017 two ketamine protocols were developed to provide guidance for the use of subdissociative-dose ketamine (SDDK) for acute pain and IM ketamine for dissociative sedation for severe agitation/delirium at all EDs across the US. The protocol included indications for ketamine as well as recommended dosages and monitoring parameters. These protocols were developed by emergency physicians, pharmacists, mid-levels, and nurses based on research and current literature. This study was done to evaluate the safety of these protocols implemented in 18 EDs within a large health system. The objectives was to describe the incidence of serious respiratory and cardiovascular adverse events requiring intervention within tow hours after ketamine administrations and also describing the incidence of neuropsychiatric adverse events after the SDDK administration during ED encounter. To determine the percentage of ketamine orders in the ED for analgesia or severe agitation/delirium that were adherent to the approved protocols, and evaluating real world ketamine use in a large integrated health system with a diverse group of providers.
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I have not heard of this used in our ER’s so it was an interesting read for me. I have a friend who has received Ketamine for depression and it worked really well. She was terrified because of all the side effects with it. But as far as I know, she did not experience any side effects. I work in a rural community also and there are a lot of people with pain in my area. This might be a good option to explore for them because like I said, I haven’t heard of it being used. I need to reach out to some of my ER friends.
My EMS department uses ketamine for sedation and pain control as well. We use it as an adjunct with fentanyl or morphine for pain control and I’ve had found that it works very well. I’ve had one incident of mild transient hypoxia after using it for sedation prior to cardioversion, but it was nothing that a little O2 via nasal cannula couldn’t fix. This has been found in 1.8% of patients given ketamine in the ED (Mankowitz, Regenberg, Kaldan, & Cole, 2018). As for neuropsychiatric events, after giving ketamine with fentanyl for a crush injury to the hand the patient reported that he felt like he was at a Pink Floyd concert.
Mankowitz, S., Regenberg, P., Kaldan, J., & Cole, J. (2018, September 07). Ketamine for Rapid Sedation of Agitated Patients in the Prehospital and Emergency Department Settings: A Systematic Review and Proportional Meta-Analysis. Retrieved July 05, 2020, from https://www.sciencedirect.com/science/article/abs/pii/S0736467918307273
Very interesting! I am familiar with Ketamine use in adjunct with opiates for the reduction of fractures in the emergency department, for use in procedural sedation and also I have done low dose Ketamine infusions on patient’s with chronic pain to ‘reset’ their receptors and make them more sensitive to a lower dose narcotic or even get them off chronic narcotic use. I have personally never seen an adverse event from Ketamine that required an intubation, but I have seen people get delirious and wild from it. An article published by the Journal of Emergency Medicine complied an extensive list of studies and showed that ketamine given at doses of 1-2 mg/kg for procedural sedation reflected very rare cardiopulmonary side effects, but a high incidence of hallucinations, anxiety and fear.
Strayer, R. J., & Nelson, L. S. (2008). Adverse events associated with ketamine for procedural sedation in adults. The American Journal of Emergency Medicine, 26(9), 985-1028. doi:http://dx.doi.org.butlerlib.butlercc.edu/10.1016/j.ajem.2007.12.005
Very interesting! I am familiar with Ketamine use in adjunct with opiates for the reduction of fractures in the emergency department, for use in procedural sedation and also I have done low dose Ketamine infusions on patient’s with chronic pain to ‘reset’ their receptors and make them more sensitive to a lower dose narcotic or even get them off chronic narcotic use. I have personally never seen an adverse event from Ketamine that required an intubation, but I have seen people get delirious and wild from it. An article published by the Journal of Emergency Medicine complied an extensive list of studies and showed that ketamine given at doses of 1-2 mg/kg for procedural sedation reflected very rare cardiopulmonary side effects, but a high incidence of hallucinations, anxiety and fear. Although having cardiopulmonary side effects was a rare event, hospital protocols should have an emergency protocol in place for supportive care for a patient experiencing those side effects.
Strayer, R. J., & Nelson, L. S. (2008). Adverse events associated with ketamine for procedural sedation in adults. The American Journal of Emergency Medicine, 26(9), 985-1028. doi:http://dx.doi.org.butlerlib.butlercc.edu/10.1016/j.ajem.2007.12.005
The conclusion of the study did say that at a smaller dose Ketamine was more effective and have less side effects than the Ketamine protocol that some of these hospitals have implemented in the study. It has been used in my ED for pain relief, depression and for mild sedation for breaks or dislocations.
This is an interesting study! The VA has been prescribing ketamine in it nasal spray form as a treatment option for treatment resistant depression “limiting it to individual cases of patients who are preapproved and have failed 2 antidepressant trials. Esketamine will not be on the VA formulary for widespread use” (Geppert, 2019). It is interesting to think of a medication that has such side effects becoming more and more acceptable to be used but for many of our patients they will do anything to ease their depressive symptoms. It would be interesting to me if they think eventually this would replace opiates for pain relief likely causing a ketamine crisis.
Resources:
Geppert, C. (2019, October). The VA Ketamine Controversies. Retrieved July 09, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6837336/
I thought this was interesting in light of the use of Ketamine and subsequent death of Elijah McClain in Aurora, Colorado last August. He was given 500mg of Ketamine by paramedics and weighed only 140lbs. This dose was about double the recommended dose per the study you sited as well as other dosing charts I have looked at. I have used Ketamine in the PACU for pain control and had not seen any negative effects, except for the occasional trippy dream or hallucination told to me by my patient. I have no problem with its use in the hospital and believe it can help many patients. I wonder however at its use in the field where there are extenuating circumstances, weight and medical history of the patient are unknown as well as patient receiving this medication without consent or proper medical evaluation of need.
In Wichita, paramedics use Ketamine for patients for agitation/delirium at a weight based dose. We also use it in the ER more for procedural sedation. While there are not many adverse reactions to the medication, I found an interesting article about secondary medication being required once the Ketamine wears off. “A high proportion (62.5%) of patients required additional pharmacologic treatment for agitation, implying that administering Ketamine is useful only for initial control of severe agitation” (Hopper, 2015). Most ER’s see this first hand and have protocols to follow for patients afterwards. It is very interesting to see statistics for Ketamine usage.