What is the role of ketamine (Ketalar) in procedural sedation and analgesia (PSA)?

Answer

Ketamine (Ketalar) elicits profound dissociative and amnestic actions. In doses typically used for PSA it does not affect pharyngeal-laryngeal reflexes and, thus, allows a patent airway as well as spontaneous respiration to maintain intact. This characteristic of the medication is particularly useful for emergency procedures when fasting is not assured. It should be mentioned, though, that reflexes may remain intact but cannot be assumed to be protective.^[15]Cardiovascular and respiratory stimulation and normal or slightly enhanced skeletal muscle tone are observed following administration, although transient respiratory depression may occur if administered too rapidly or in high doses. The unique dissociative action and partial agonist at opiate mu-receptors permits painful procedures to be performed in a consistent state of sedation and patient comfort. Ketamine is contraindicated in patients who have underlying conditions in which increased blood pressure or heart rate would pose risk of complications. An increase in oropharyngeal secretions is often triggered and this can be prevented by premedication with glycopyrrolate.

Onset of action for intravenous (IV) administration of ketamine is within 1 minute, and duration of action lasts about 10-15 minutes. The context sensitive half-life after administration is roughly 45 minutes and it does have an active metabolite with approximately 1/3 the activity of the parent compound. If administered intramuscularly (IM), the onset of action is observed in 3-5 minutes, and duration of procedural conditions lasts about 20-30 minutes.

Ketamine results in a dissociative state, and patients may not be able to speak or respond purposefully to verbal commands. Ketamine can cause vivid imagination, hallucinations, confusion, excitement, irrational behavior and severe anxiety. Emergence reactions are estimated to occur in approximately 12% of patients. Strayer and Nelson have estimated emergence phenomena to occur in between 10% and 20% of adults who have received ketamine.^[16]Symptoms can be expected to last from 1-3 hours.

The incidence of emergence delirium may be reduced by decreasing the recommended dose of ketamine and using it in conjunction with a benzodiazepine. A small hypnotic dose of a short-acting benzodiazepine is recommended to terminate severe emergence reactions. Emergence delirium is not typical in children younger than 15 years. In a randomized controlled study of adult ED patients, Sener et al found that the incidence of recovery agitation was significantly reduced when midazolam was coadministered with ketamine for procedural sedation.^[17]

A 1:1 mixture of ketamine with propofol can be used for procedural sedation and analgesia. This mixture has been associated with a reduced incidence of emergence delirium and may negate the need for concomitant benzodiazepine use. In a prospective case series study of 728 adults presenting to a trauma center for orthopedic procedures, the median dose of ketamine and propofol was 0.7 mg/kg. Bag-mask ventilation occurred in 21%, and recovery agitation occurred in 3.6% (50% of these patients required treatment for agitation).^[18]

A double-blind, randomized trial compared ketamine (0.5 mg/kg) plus propofol with placebo plus propofol in 193 adults and children. Respiratory depression was similar between the groups but less propofol was needed when ketamine was administered, and there was trend toward better sedation quality.^[12]

A prospective trial comparing ketamine plus propofol (ketofol) to midazolam plus fentanyl (MF) was conducted in the emergency setting by Nejati et al. Patients (n=62) requiring procedural sedation and analgesia for deep traumatic lacerations and reduction of bone fractures were included. No significant differences were observed for sedation time or physician satisfaction between the groups. Pain was significantly lower in the ketofol group compared with the MF group (p < 0.001).^[13]

The use of ketamine and propofol is a potential alternative in adults requiring procedural sedation.

Did this answer your question?

Yes No

Additional feedback? (Optional)

Thank you for your feedback!

American Society of Anesthesiologists. Continuum of depth of sedation definition of general anesthesia and levels of sedation/analgesia. October 27, 2004. Available at http://www.asahq.org/For-Healthcare-Professionals/~/media/For%20Members/documents/Standards%20Guidelines%20Stmts/Continuum%20of%20Depth%20of%20Sedation.ashx. Accessed: February 15, 2011.
American Dental Association. Guidelines for the Use of Sedation and General Anesthesia by Dentists. Available at https://www.ada.org/en/member-center/oral-health-topics/anesthesia-and-sedation. October 2016; Accessed: February 25, 2019.
Coté CJ, Wilson S, AMERICAN ACADEMY OF PEDIATRICS., AMERICAN ACADEMY OF PEDIATRIC DENTISTRY. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. Pediatrics. 2016 Jul. 138 (1):[Medline].
American Academy of Emergency Medicine. Procedural Sedation Consensus Statement. Available at https://www.aaem.org/resources/statements/position/procedural-sedation-consensus-statement. February 11, 2008; Accessed: February 25, 2019.
Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018: A Report by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology. Anesthesiology. March 2018. 128:437-479.
Green SM, Roback MG, Krauss BS. The Newest Threat to Emergency Department Procedural Sedation. Ann Emerg Med. 2018 Aug. 72 (2):115-119. [Medline]. [Full Text].
American Society of Anesthesiologists Standards, Guidelines, and Statements. Available at http://www.asahq.org/For-Healthcare-Professionals/~/media/For%20Members/documents/Standards%20Guidelines%20Stmts/Qualifications%20of%20Anesthesia%20Providers%20in%20the%20Office.ashx. Accessed: February 15, 2011.
Godwin SA, Caro DA, Wolf SJ, et al. Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med. 2005 Feb. 45(2):177-96. [Medline].
Miner JR, Moore JC, Plummer D, Gray RO, Patel S, Ho JD. Randomized Clinical Trial of the Effect of Supplemental Opioids in Procedural Sedation with Propofol on Serum Catecholamines. Acad Emerg Med. 2013 Apr. 20(4):330-337. [Medline].
Lan C, Shen X, Cui H, Liu H, Li P, Wan X, et al. Comparison of nitrous oxide to no sedation and deep sedation for diagnostic upper gastrointestinal endoscopy. J Gastrointest Surg. 2013 Jun. 17(6):1066-72. [Medline].
Drown MB. Integrative review utilizing dexmedetomidine as an anesthetic for monitored anesthesia care and regional anesthesia. Nurs Forum. 2011 Jul-Sep. 46(3):186-94. [Medline].
David H, Shipp J. A Randomized Controlled Trial of Ketamine/Propofol Versus Propofol Alone for Emergency Department Procedural Sedation. Ann Emerg Med. 2011 Jan 20. [Medline].
Nejati A, Moharari RS, Ashraf H, Labaf A, Golshani K. Ketamine/Propofol versus midazolam/fentanyl for procedural sedation and analgesia in the emergency department: a randomized, prospective, double-blind trial. Acad Emerg Med. 2011 Aug. 18(8):800-6. [Medline].
Lemoel F, Contenti J, Giolito D, Boiffier M, Rapp J, Istria J, et al. Adverse Events With Ketamine Versus Ketofol for Procedural Sedation on Adults: A Double-blind, Randomized Controlled Trial. Acad Emerg Med. 2017 Dec. 24 (12):1441-1449. [Medline].
Miller RD, Eriksson L, Fleisher L, Wiener-Kronish JP, William Y. Miller's Anesthesia. Seventh. Churchill Livingstone Elsevier; 2010.
Strayer RJ, Nelson LS. Adverse events associated with ketamine for procedural sedation in adults. Am J Emerg Med. 2008 Nov. 26(9):985-1028. [Medline].
Sener S, Eken C, Schultz CH, Serinken M, Ozsarac M. Ketamine with and without midazolam for emergency department sedation in adults: a randomized controlled trial. Ann Emerg Med. 2011 Feb. 57(2):109-114.e2. [Medline].
Andolfatto G, Willman E. A Prospective Case Series of Single-syringe Ketamine-Propofol (Ketofol) for Emergency Department Procedural Sedation and Analgesia in Adults. Acad Emerg Med. 2011 Mar. 18(3):237-45. [Medline].
Black E, Campbell SG, Magee K, Zed PJ. Propofol for Procedural Sedation in the Emergency Department: A Qualitative Systematic Review (June). Ann Pharmacother. 2013 May 21. [Medline].
Newstead B, Bradburn S, Appelboam A, Reuben A, Harris A, Hudson A, et al. Propofol for adult procedural sedation in a UK emergency department: safety profile in 1008 cases. Br J Anaesth. 2013 May 9. [Medline].
Hohl CM, Nosyk B, Sadatsafavi M, Anis AH. A cost-effectiveness analysis of propofol versus midazolam for procedural sedation in the emergency department. Acad Emerg Med. 2008 Jan. 15(1):32-9. [Medline].
Zed PJ, Abu-Laban RB, Chan WW, Harrison DW. Efficacy, safety and patient satisfaction of propofol for procedural sedation and analgesia in the emergency department: a prospective study. CJEM. 2007 Nov. 9(6):421-7. [Medline].
Weaver CS, Hauter WE, Brizendine EJ, Cordell WH. Emergency department procedural sedation with propofol: is it safe?. J Emerg Med. 2007 Nov. 33(4):355-61. [Medline].
Hohl CM, Sadatsafavi M, Nosyk B, Anis AH. Safety and clinical effectiveness of midazolam versus propofol for procedural sedation in the emergency department: a systematic review. Acad Emerg Med. 2008 Jan. 15(1):1-8. [Medline].
Wakai A, Blackburn C, McCabe A, Reece E, O'Connor G, Glasheen J, et al. The use of propofol for procedural sedation in emergency departments. Cochrane Database Syst Rev. 2015 Jul 29. 7:CD007399. [Medline].
Miner JR, Gray RO, Bahr J, Patel R, McGill JW. Randomized Clinical Trial of Propofol Versus Ketamine for Procedural Sedation in the Emergency Department. Acad Emer Med. 17(6):604-611.
Stark RD, Binks SM, Dutka VN, O'Connor KM, Arnstein MJ, Glen JB. A review of the safety and tolerance of propofol ('Diprivan'). Postgrad Med J. 1985. 61 Suppl 3:152-6. [Medline].
Mangar D, Holak EJ. Tourniquet at 50 mm Hg followed by intravenous lidocaine diminishes hand pain associated with propofol injection. Anesth Analg. 1992 Feb. 74(2):250-2. [Medline].
Valtonen M, Iisalo E, Kanto J, Tikkanen J. Comparison between propofol and thiopentone for induction of anaesthesia in children. Anaesthesia. 1988 Aug. 43(8):696-9. [Medline].
Valtonen M, Iisalo E, Kanto J, Rosenberg P. Propofol as an induction agent in children: pain on injection and pharmacokinetics. Acta Anaesthesiol Scand. 1989 Feb. 33(2):152-5. [Medline].
Jalota L, Kalira V, George E, Shi YY, Hornuss C, Radke O, et al. Prevention of pain on injection of propofol: systematic review and meta-analysis. BMJ. 2011 Mar 15. 342:d1110. [Medline].
Jewett J, Phillips WJ. Dexmedetomidine for procedural sedation in the emergency department. Eur J Emerg Med. 2010 Feb. 17(1):60. [Medline].
Maze M, Tranquilli W. Alpha-2 adrenoceptor agonists: defining the role in clinical anesthesia. Anesthesiology. 1991 Mar. 74(3):581-605. [Medline].
Kaukinen S, Kaukinen L, Eerola R. Preoperative and postoperative use of clonidine with neurolept anaesthesia. Acta Anaesthesiol Scand. 1979 Apr. 23(2):113-20. [Medline].
Ebert TJ, Hall JE, Barney JA, Uhrich TD, Colinco MD. The effects of increasing plasma concentrations of dexmedetomidine in humans. Anesthesiology. 2000 Aug. 93(2):382-94. [Medline].
Dyck JB, Maze M, Haack C, Azarnoff DL, Vuorilehto L, Shafer SL. Computer-controlled infusion of intravenous dexmedetomidine hydrochloride in adult human volunteers. Anesthesiology. 1993 May. 78(5):821-8. [Medline].
Venn RM, Karol MD, Grounds RM. Pharmacokinetics of dexmedetomidine infusions for sedation of postoperative patients requiring intensive caret. Br J Anaesth. 2002 May. 88(5):669-75. [Medline].
Virtanen R, Savola JM, Saano V, Nyman L. Characterization of the selectivity, specificity and potency of medetomidine as an alpha 2-adrenoceptor agonist. Eur J Pharmacol. 1988 May 20. 150(1-2):9-14. [Medline].
Devlin JW, Skrobik Y, Gélinas C, et al. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med. 2018 Sep. 46 (9):e825-e873. [Medline].
American Society of Anesthesiology. ASA Physical Status Classification System. October 15. 2014. [Full Text].
Deitch K, Miner J, Chudnofsky CR, Dominici P, Latta D. Does end tidal CO2 monitoring during emergency department procedural sedation and analgesia with propofol decrease the incidence of hypoxic events? A randomized, controlled trial. Ann Emerg Med. 2010 Mar. 55(3):258-64. [Medline].
Shankar V, Deshpande JK. Procedural sedation in the pediatric patient. Anesthesiology Clin N Am. 2005. 23:635-654. [Medline].
Doyle L, Colletti JE. Pediatric procedural sedation and analgesia. Pediatr Clin North Am. 2006. 53(2):790-807. [Medline].
Bhatt-Mehta V, Rosen DA. Sedation in children: Current concepts. Pharmacotherapy. 1998. 18(4):790-807. [Medline].
Mistry RB, Nahata MC. Ketamine for conscious sedation in pediatric emergency care. Pharmacotherapy. 2005. 25(8):1104-1111. [Medline].
Krauss B, Green SM. Procedural sedation and analgesia in children. Lancet. 2006 Mar 4. 367(9512):766-80. [Medline].
Patel KN, Simon HK, Stockwell CA, Stockwell JA, DeGuzman MA, Roerig PL, et al. Pediatric procedural sedation by a dedicated nonanesthesiology pediatric sedation service using propofol. Pediatr Emerg Care. 2009 Mar. 25(3):133-8. [Medline].
den Brinker M, Hokken-Koelega AC, Hazelzet JA, de Jong FH, Hop WC, Joosten KF. One single dose of etomidate negatively influences adrenocortical performance for at least 24h in children with meningococcal sepsis. Intensive Care Med. 2008 Jan. 34(1):163-8. [Medline].
Sulton C, McCracken C, Simon HK, Hebbar K, Reynolds J, Cravero J, et al. Pediatric Procedural Sedation Using Dexmedetomidine: A Report From the Pediatric Sedation Research Consortium. Hosp Pediatr. 2016 Sep. 6 (9):536-44. [Medline].
Bhatt M, Johnson DW, Chan J, Taljaard M, Barrowman N, Farion KJ, et al. Risk Factors for Adverse Events in Emergency Department Procedural Sedation for Children. JAMA Pediatr. 2017 Oct 1. 171 (10):957-964. [Medline].
Saunders M, Adelgais K, Nelson D. Use of intranasal fentanyl for the relief of pediatric orthopedic trauma pain. Acad Emerg Med. 2010 Nov. 17(11):1155-61. [Medline].
Tsze DS, Ieni M, Fenster DB, et al. Optimal Volume of Administration of Intranasal Midazolam in Children: A Randomized Clinical Trial. Ann Emerg Med. 2016 Nov 4. [Medline].
Leroy PL, Gorzeman MP, Sury MR. Procedural sedation and analgesia in children by non-anesthesiologists in an Emergency Department. Minerva Pediatr. 2009 Apr. 61(2):193-215. [Medline].
Bhatt M, Currie GR, Auld C, Johnson DW. Current Practice and Tolerance for Risk in Performing Procedural Sedation and Analgesia on Children Who Have Not Met Fasting Guidelines: A Canadian Survey Using a Stated Preference Discrete Choice Experiment. Acad Emerg Med. Nov 2010. 17(11):1207-1210.
Scherrer PD, Mallory MD, Cravero JP, Lowrie L, Hertzog JH, Berkenbosch JW, et al. The impact of obesity on pediatric procedural sedation-related outcomes: results from the Pediatric Sedation Research Consortium. Paediatr Anaesth. 2015 Jul. 25 (7):689-97. [Medline].
Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine. 5th ed. 2009.
Tintinalli J, Stapczynski J. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. 2010.
Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology. 2002 Apr. 96(4):1004-17. [Medline]. [Full Text].
Aboumarzouk OM, Agarwal T, Syed Nong Chek SA, Milewski PJ, Nelson RL. Nitrous oxide for colonoscopy. Cochrane Database Syst Rev. 2011 Aug 10. CD008506. [Medline]. [Full Text].
Maher EN, Hansen SF, Heine M, Meers H, Yaster M, Hunt EA. Knowledge of procedural sedation and analgesia of emergency medicine physicians. Pediatr Emerg Care. 2007 Dec. 23(12):869-76. [Medline].
Bhatt M, Kennedy RM, Osmond MH, Krauss B, McAllister JD, Ansermino JM, et al. Consensus-based recommendations for standardizing terminology and reporting adverse events for emergency department procedural sedation and analgesia in children. Ann Emerg Med. 2009 Apr. 53(4):426-435.e4. [Medline].
Naaz S, Ozair E. Dexmedetomidine in current anaesthesia practice- a review. J Clin Diagn Res. 2014 Oct. 8 (10):GE01-4. [Medline].

Media Gallery

of 0

Author

Alma N Juels, MD Assistant Clinical Professor, Department of Anesthesiology, University of Colorado School of Medicine; Attending Physician, Department of Anesthesiology, Denver Health and Hospital

Disclosure: Nothing to disclose.

Coauthor(s)

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Additional Contributors

Luis M Lovato, MD Associate Clinical Professor, University of California, Los Angeles, David Geffen School of Medicine; Director of Critical Care, Department of Emergency Medicine, Olive View-UCLA Medical Center

Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Marc S Orlewicz, MD Clinical Assistant Professor of Anesthesiology, Director of Clinical Simulator and Residency Site-Director for WSU/DMC Anesthesiology Residency Program, Wayne State University and Detroit Medical Center (WSU/DMC); Clinical Assistant Professor of Osteopathic Anesthesiology Residency Program, Michigan State University; Co-Director of Anesthesia Critical Care Services, Department of Anesthesiology, Surgical Intensivist, Harper Hospital and Sinai-Grace Hospital through WSU/DMC

Marc S Orlewicz, MD is a member of the following medical societies: American Society of Anesthesiologists, Society of Cardiovascular Anesthesiologists, Society of Critical Care Medicine, Society of Critical Care Anesthesiologists

Disclosure: Nothing to disclose.

Allen E Coleman, MD Fellow in Regional Anesthesia and Acute Pain Management, Department of Anesthesiology, University of Florida College of Medicine

Allen E Coleman, MD is a member of the following medical societies: American Society of Anesthesiologists, Michigan State Medical Society

Disclosure: Nothing to disclose.

Ryan M Dudley, DO Chief Resident, Department of Anesthesiology, Michigan State University College of Human Medicine, Wayne State University School of Medicine

Ryan M Dudley, DO is a member of the following medical societies: American Medical Association, American Osteopathic Association, American Society of Anesthesiologists

Disclosure: Nothing to disclose.

Regina A Bailey, MD, JD, LLM Resident Physician, Department of Emergency Medicine, Baylor College of Medicine

Regina A Bailey, MD, JD, LLM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Medical Association, Society for Academic Emergency Medicine, Emergency Medicine Residents' Association, American Bar Association

Disclosure: Nothing to disclose.

What is the role of ketamine (Ketalar) in procedural sedation and analgesia (PSA)?

Answer

Related Questions:

References

Tables

Contributor Information and Disclosures