Ketamine Dosing for Conscious Sedation During Shoulder Reduction
For shoulder reduction in adults, administer 2 mg/kg intravenous ketamine, which provides rapid onset of adequate sedation within 30-96 seconds and allows successful completion of the procedure in 98.9% of cases. 1, 2
Recommended Dosing Protocol
Intravenous Administration (Preferred Route)
- Standard dose: 2 mg/kg IV ketamine for orthopedic procedures including shoulder reduction 3, 1
- This dose provides adequate sedation for fracture and joint reduction without requiring additional doses in 95% of patients 1, 4
- Onset of action occurs within 30-96 seconds, allowing immediate procedural intervention 1, 4
Alternative Dosing Considerations
- Lower doses (1.5 mg/kg IV) may be considered but result in 54% of patients requiring additional ketamine, compared to only 5.5% with higher dosing 1, 4
- Intramuscular route (4 mg/kg IM) can be used if IV access is unavailable, though onset is slower at approximately 3-4 minutes 3, 5
Adjunctive Medication
Consider adding midazolam 0.05-0.1 mg/kg IV prior to ketamine to reduce emergence reactions, particularly in adults where recovery agitation occurs in 13% of cases 3, 6, 2
The combination of midazolam 0.07 mg/kg followed by ketamine 2 mg/kg has been specifically studied in adult emergency department patients and provides effective sedation with high patient satisfaction (99%) 6
Monitoring Requirements
Essential Parameters
- Continuous pulse oximetry (maintain SpO2 >93% on room air) 1, 4
- Heart rate and blood pressure at regular intervals 4, 2
- Respiratory status throughout procedure and recovery 1, 4
Expected Recovery Timeline
- Average recovery time: 84 minutes (range 22-215 minutes) from administration to discharge readiness 1, 7
- Most patients achieve discharge criteria within 64 minutes when ketamine is combined with midazolam 6
- Recovery time may be shorter with lower total ketamine doses 7
Anticipated Adverse Effects
Common Side Effects (Manageable)
- Recovery agitation: 13% of adult patients, may require treatment with benzodiazepine 2
- Emesis: 7-8% of patients 1, 4
- Nausea: 4-5% of patients 1, 4
- Transient clonic movements: 7% (typically require no treatment) 2
Serious Adverse Events (Rare)
- Respiratory compromise: 6% (transient, does not alter disposition) 6
- Laryngospasm: 0.9-1.4% 1
- No episodes of laryngospasm were reported in the largest adult ketamine study 2
Clinical Pearls and Pitfalls
The combination approach (midazolam + ketamine) is superior to ketamine alone in adults because it significantly reduces the 13% incidence of recovery agitation while maintaining procedural efficacy 6, 2
Avoid underdosing: Studies demonstrate that 1 mg/kg results in inadequate sedation requiring supplemental doses in over half of patients, prolonging procedure time and increasing total drug exposure 1, 4
Success rate is excellent: Adequate sedation for shoulder reduction is achieved in 98.9% of cases with appropriate dosing, and all patients maintain oxygen saturation >93% when properly monitored 1, 2