What are the guidelines for using ketamine (Ketamine) intramuscularly (IM) for sedation?

From the Guidelines

Ketamine can be administered intramuscularly at a dose of 4 mg/kg for procedural sedation in both adults and children, as supported by the study by McCarty et al 1. Onset of action typically occurs within 3-4 minutes, with a duration of sedation lasting approximately 15-30 minutes. Prior to administration, patients should be monitored with continuous pulse oximetry, blood pressure measurements, and cardiac monitoring. Patients should fast for at least 6 hours before elective procedures. Ketamine may cause increased secretions, so consider pretreatment with an antisialagogue like glycopyrrolate (0.01 mg/kg) or atropine (0.01 mg/kg). During the procedure, maintain a patent airway and have resuscitation equipment readily available. Ketamine works as a dissociative anesthetic that preserves respiratory drive and airway reflexes while providing analgesia and amnesia. It can cause emergence reactions (hallucinations, nightmares) in up to 30% of adults, which can be reduced by administering midazolam (0.03 mg/kg IV or 0.1 mg/kg IM) concurrently, as reported by Wathen et al 1. Ketamine should be used cautiously in patients with cardiovascular disease, increased intracranial pressure, psychosis, thyroid disorders, or porphyria, as noted in the study by Aggarwal et al, referenced in 1. Recovery should occur in a monitored setting until the patient returns to baseline mental status. Some key points to consider when using ketamine for sedation include:

• Monitoring for adverse events such as emesis, recovery agitation, and airway complications, as reported in the study by Green et al 1
• Using a treatment protocol with a initial dose of 4 mg/kg and allowing for repeat doses as needed, as described in the study by Green et al 1
• Considering the use of midazolam to reduce emergence reactions, as reported in the study by Wathen et al 1
• Being aware of the potential for increased heart rate, blood pressure, and cardiac output, as noted in the study referenced in 1.

From the FDA Drug Label

The initial dose of ketamine hydrochloride injection administered intramuscularly may range from 6.5 to 13 mg/kg. A dose of 9 to 13 mg/kg usually produces surgical anesthesia within 3 to 4 minutes following injection, with the anesthetic effect usually lasting 12 to 25 minutes.

The guidelines for using ketamine intramuscularly (IM) for sedation are as follows:

• The initial dose of ketamine hydrochloride injection administered IM may range from 6.5 to 13 mg/kg.
• A dose of 9 to 13 mg/kg usually produces surgical anesthesia within 3 to 4 minutes following injection, with the anesthetic effect usually lasting 12 to 25 minutes.
• Administer a benzodiazepine, if clinically indicated, for the prevention of neuropsychological manifestations during emergence from anesthesia 2.

From the Research

Guidelines for Using Ketamine IM for Sedation

• The use of ketamine intramuscularly (IM) for sedation has been studied in various settings, including emergency departments and pediatric care 3, 4.
• A reduced-dose guideline of 2 mg/kg IM ketamine has been shown to be effective for severe agitation in adults, with a success rate of 87% and no subsequent intubations due to excess ketamine 3.
• Ketamine has also been used for procedural sedation in adults, with a study finding that it is a useful medication, but careful attention should be made in patient selection to minimize the risk of myocardial ischemia 5.
• In pediatric patients, ketamine has been shown to be safe and effective for sedation, with a study of 1,022 cases finding a low rate of complications, including transient airway complications and emesis 4.

Dosage and Administration

• The dosage of ketamine for IM sedation has varied in studies, with ranges from 1-1.5 mg/kg for pediatric patients 6 to 2 mg/kg for adult patients 3 to 4 mg/kg for pediatric patients 4.
• The mode of administration has also been studied, with a review finding that intravenous administration may be preferred over IM administration due to trends indicating better efficacy and safety 7.

Safety Profile

• Ketamine has been shown to have a wide margin of safety, with a low rate of complications, including airway complications, emesis, and recovery agitation 4.
• However, careful attention should be made in patient selection, particularly in adults with underlying cardiac disease, to minimize the risk of myocardial ischemia 5.
• Ketamine has also been shown to be effective in decreasing intracranial pressure in pediatric patients with intracranial hypertension, without lowering blood pressure and cerebral perfusion pressure 6.