What is the recommended dose of ketamine (intravenous anesthetic) for pain management in a conscious 30-year-old male with no significant medical history undergoing a shoulder reduction?

Ketamine Dosing for Conscious Shoulder Reduction in Adults

For procedural sedation during shoulder reduction in a 30-year-old male, administer 2 mg/kg intravenous ketamine as a slow bolus over 60 seconds, which provides adequate sedation in 95% of patients without requiring supplemental doses. 1, 2

Recommended Dosing Protocol

• Administer 2 mg/kg IV ketamine as the standard dose for orthopedic procedures including shoulder reduction 1, 2
• Infuse slowly over 60 seconds to minimize respiratory depression and enhanced vasopressor response 2
• Onset of action occurs within 30-96 seconds, allowing immediate procedural intervention 1, 3
• This dose achieves successful procedure completion in 98.9% of cases 1

Alternative Dosing Considerations

• Avoid lower doses (1.5 mg/kg) as they result in 54% of patients requiring additional ketamine, compared to only 5.5% with 2 mg/kg dosing 1, 3
• If IV access is unavailable, use 4 mg/kg intramuscular with onset in 3-4 minutes 1, 3
• The FDA-approved dosing range for induction is 1-4.5 mg/kg IV, but 2 mg/kg represents the optimal balance of efficacy and safety for procedural sedation 2

Adjunctive Medication Strategy

Consider administering midazolam 0.05-0.1 mg/kg IV prior to ketamine to reduce emergence reactions, particularly since recovery agitation occurs in 13% of adult patients receiving ketamine alone 1, 4

• The combination of 0.07 mg/kg midazolam followed by 2 mg/kg ketamine provides effective sedation with minimal emergence phenomena 4
• This combination is safe and well-tolerated in adult ED patients undergoing painful procedures 4

Essential Monitoring Requirements

Continuous monitoring is mandatory throughout the procedure and recovery period:

• Maintain continuous pulse oximetry with target SpO2 >93% on room air 1, 2
• Monitor heart rate and blood pressure at 5-minute intervals 2
• Have emergency airway equipment immediately available 2
• Ketamine causes dose-dependent increases in heart rate and blood pressure through sympathetic stimulation 5

Expected Recovery Timeline

• Average recovery time is 84 minutes (range 22-215 minutes) from administration to discharge readiness 1, 3
• Mean time to achieve discharge criteria is approximately 64 minutes when combined with midazolam 4
• Do not discharge until the patient returns to baseline mental status with stable vital signs and adequate airway reflexes 5

Anticipated Adverse Effects

Common side effects to expect:

• Emesis occurs in 7-8% of patients 1, 3
• Nausea occurs in 4-5% of patients 3
• Laryngospasm occurs in 0.9-1.4% of patients 1
• Mild emergence reactions occur in approximately 17.6% of patients, with moderate-to-severe agitation in only 1.6% 5
• Respiratory compromise occurs in 6% of cases but is typically transient and responsive to supplemental oxygen 4

Critical Pitfalls to Avoid

Underdosing is the most common error: 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, 3

Rapid administration increases risk: Administering ketamine too quickly (faster than 60 seconds) increases the likelihood of respiratory depression and exaggerated cardiovascular responses 2

Contraindications must be screened: Avoid ketamine in patients with uncontrolled hypertension, ischemic heart disease, cerebrovascular disease, active psychosis, or elevated intracranial pressure 5, 2

Antisialagogue Consideration

Administer an antisialagogue prior to ketamine induction due to the potential for increased salivation during ketamine administration 2