Ketamine Safety and Use in the Emergency Department for Pain and Agitation/Delirium: A Health System Experience

Abstract

Introduction: Two protocols were developed to guide the use of subdissociative dose ketamine (SDDK) for analgesia and dissociative sedation ketamine for severe agitation/excited delirium in the emergency department (ED). We sought to evaluate the safety of these protocols implemented in 18 EDs within a large health system. Methods: We conducted a retrospective chart review to evaluate all adult patients who received intravenous (IV) SDDK for analgesia and intramuscular (IM) dissociative sedation ketamine for severe agitation/excited delirium in 12 hospital-based and six freestanding EDs over a one-year period from the protocol implementation. We developed a standardized data collection form and used it to record patient information regarding ketamine use, concomitant medication use, and any comorbidities that could have impacted the incidence of adverse events. Results: Approximately 570,000 ED visits occurred during the study period. SDDK was used in 210 ED encounters, while dissociative sedation ketamine for severe agitation/excited delirium was used in 37 ED encounters. SDDK was used in 83% (15/18) of sites while dissociative sedation ketamine was used in 50% (9/18) of sites. Endotracheal intubation, non-rebreather mask, and nasal cannula ≥ four liters per minute were identified in one, five, and three patients, respectively. Neuropsychiatric adverse events were identified in 4% (9/210) of patients who received SDDK. Conclusion: Patients experienced limited neuropsychiatric adverse events from SDDK. Additionally, dissociative sedation ketamine for severe agitation/excited delirium led to less endotracheal intubation than reported in the prehospital literature. The favorable safety profile of ketamine use in the ED may prompt further increases in usage.

Battlefield pain summit 2022: Expert consensus statements

“…Ketamine has a favorable safety profile 7,8 and is currently used on the battlefield as a first-line intervention for moderate to severe pain when the casualty is in hemorrhagic shock, in respiratory distress, or at significant risk of developing either condition 9 . Intramuscular or intranasal routes of administration demonstrate comparable efficacy with that of intravenous administration 10,11 .…”

The adverse effects of Ketamine on Procedural Sedation and Analgesia (PSA) in the Emergency Department

“…Ketamine exhibits dissociative sedation and analgesic properties as it is an N-methyl-D-aspartate receptor antagonist. [ 9 ] Past studies have shown the effectiveness and safety of sub dissociated doses of Ketamine in emergency room, so it is one of the most commonly used drugs for PSA. [ 8 9 ] Using Ketamine as an analgesic in the pre-hospital setting – especially in case of trauma patients have been reported beneficial.…”

“…[ 9 ] Past studies have shown the effectiveness and safety of sub dissociated doses of Ketamine in emergency room, so it is one of the most commonly used drugs for PSA. [ 8 9 ] Using Ketamine as an analgesic in the pre-hospital setting – especially in case of trauma patients have been reported beneficial. Procedures such as wound debridement/washing, closed reduction etc., in trauma patients require adequate sedation to prevent severe pain, agitation and anxiety.…”

Wilderness Medical Society Clinical Practice Guidelines for the Treatment of Acute Pain in Austere Environments: 2024 Update

“…Ketamine is unique among pain control medications in that it has variable effects at different doses, and care must be taken to remain within the range of "pain dose" or "low dose" ketamine (0.1-0.5 mg/kg IV or 1-2 mg/kg IM). 128,129 At higher doses (1-2 mg/kg IV or 3-5 mg/kg IM), ketamine causes dissociation, a type of moderate sedation often employed in hospital use. 130 Between these dosing ranges, ketamine can cause hallucinations, euphoria/dysphoria, delirium, and other undesirable effects.…”