Low-Dose Ketamine for ICU Delirium Management
There is currently insufficient evidence to recommend the use of low-dose ketamine for the treatment of ICU delirium, as no evidence was found to inform a recommendation regarding the use of ketamine for delirium treatment in critically ill adults.
Current Evidence on Ketamine for ICU Delirium
The 2018 Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU explicitly states that "no evidence was found to inform a recommendation regarding the use of an NMDA antagonist (e.g., ketamine) for delirium treatment" 1. This represents the most authoritative and recent guidance on this topic.
While ketamine has been studied for other indications in the ICU setting, such as:
- Pain management (particularly post-surgical pain)
- Sedation
- Procedural analgesia
Its role in delirium management remains unclear and potentially concerning.
Potential Risks of Ketamine in Delirium
Recent research suggests ketamine may actually increase delirium risk:
- A 2021 study found ketamine analgosedation was independently associated with increased delirium (adjusted odds ratio 5.60; 95% CI, 1.09-29.15) 2
- A large RCT found that a single sub-anesthetic dose of ketamine administered perioperatively did not decrease delirium in older adults after major surgery 1
Current Recommended Approaches for ICU Delirium
Instead of ketamine, the guidelines recommend:
Non-pharmacological interventions as first-line approach:
- Reorientation strategies
- Environmental stability (minimizing transfers, reducing noise)
- Managing sensory deficits (ensuring access to glasses/hearing aids)
- Early mobilization
- Sleep-wake cycle regulation 3
Pharmacological interventions (when necessary):
- The guidelines suggest not routinely using haloperidol, atypical antipsychotics, or statins to treat delirium (conditional recommendation, low quality of evidence) 1
- For severe agitation that poses safety risks, atypical antipsychotics may be considered 3
- Benzodiazepines should be avoided except for alcohol/benzodiazepine withdrawal delirium 3
Implementation of the ABCDEF bundle:
- Assess and manage pain
- Both spontaneous awakening and breathing trials
- Choice of appropriate analgesia and sedation
- Delirium assessment, prevention, and management
- Early mobility
- Family engagement 3
Conclusion
Based on current evidence and guidelines, low-dose ketamine cannot be recommended for ICU delirium treatment due to lack of supporting evidence and potential risks. Clinicians should focus on non-pharmacological interventions, addressing underlying causes, and following established delirium management protocols while avoiding medications that may worsen delirium.
If pharmacological intervention is deemed necessary for severe symptoms, atypical antipsychotics would be preferred over ketamine based on current evidence and guidelines.