Do I need to be Nil Per Os (NPO) for ketamine administration?

From the Guidelines

Ketamine administration does not necessarily require a strict NPO status, but standard NPO guidelines should be followed for procedural sedation or anesthesia to reduce the risk of aspiration. For procedural sedation or anesthesia, it is generally recommended to follow standard NPO guidelines: no solid food for 6-8 hours and clear liquids allowed up to 2 hours before the procedure 1. However, for low-dose ketamine used for pain management or mental health treatments given orally, intranasally, or as a slow infusion, strict NPO status may not be necessary 1. The specific NPO requirements should be determined by your healthcare provider based on your individual circumstances, the dose being administered, and the setting of administration 1. Some key points to consider when determining NPO requirements for ketamine administration include:

• The route and purpose of administration
• The dose being administered
• The setting of administration
• The patient's individual medical history and circumstances Always follow the instructions provided by your medical team, as they will consider these factors when determining appropriate NPO guidelines 1.

From the FDA Drug Label

While vomiting has been reported following ketamine administration, some airway protection may be afforded because of active laryngeal-pharyngeal reflexes. However, since aspiration may occur with ketamine and since protective reflexes may also be diminished by supplementary anesthetics and muscle relaxants, the possibility of aspiration must be considered Ketamine is recommended for use in the patient whose stomach is not empty when, in the judgment of the practitioner, the benefits of the drug outweigh the possible risks.

Ketamine administration does not necessarily require the patient to be NPO (nothing by mouth), but the possibility of aspiration must be considered, especially when used with other anesthetics or muscle relaxants. The decision to use ketamine in a patient with a non-empty stomach should be made by the practitioner, weighing the potential benefits against the possible risks 2.

From the Research

NPO Status for Ketamine Administration

• The requirement for NPO (nil per os) status before ketamine administration is not strictly necessary, as suggested by a study on procedural sedation in the emergency department 3.
• The study found that NPO status ≥8 hours may have similar or worse outcomes than NPO <8 hours, contrary to many suggested guidelines.
• Another study on reducing the use of NPO past midnight for inpatient diagnostic and therapeutic procedures also supports a reduced fasting duration before procedures necessitating anesthesia or sedation 4.

Ketamine Administration and NPO Status

• Ketamine is a dissociative anesthetic used for procedural sedation and pain management, and its administration does not necessarily require NPO status 5, 6, 7.
• The use of ketamine for pain management has been shown to be effective and safe, with benefits including increased pain control and reduction in opioid consumption and tolerance 6, 7.
• However, the decision to require NPO status before ketamine administration should be made on a case-by-case basis, taking into account the individual patient's needs and medical history.

Clinical Application of Ketamine

• Ketamine is used extensively in the emergency department for procedural sedation and the facilitation of brief painful procedures, and its use for acute pain management is supported by guidelines from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists 6.
• Clinicians should be familiar with the pharmacodynamics of ketamine to appropriately anticipate its therapeutic and adverse effects, and to ensure safe and effective use in clinical practice 7.