Low Dose Ketamine
Low Dose Ketamine
Low Dose Ketamine
Craig Smollin MD
Associate Medical Director,
California Poison Control Center, SF Division
Assistant Professor of Emergency Medicine, UCSF
Objectives
2/16/2014
Phencyclidine
Ketamine
PCP
Ketamine History
Ketamine
1962: Ketamine synthesized by Stevens
1965: Ketamine trials in humans. Most
promising of 200 different PCP derivatives
1970: Ketamine released for clinical use in
U.S.
2/16/2014
Mechanism of action
NMDA Receptors
Complex pharmacology
Neurotransmitter glutamate
Glutamate released with noxious peripheral stimuli
Activation of NMDA receptors associated:
Dissociative Dosing
Hyperalgesia
Neuropathic pain
Reduced opioid sensitivity.
Route
Dose
Onset
Time to peak
effect
Duration of
action
Intravenous
1.0 mg/kg
< 1 min
3-5 min
5-10 min
Intramuscular
2-4 mg/kg
2-5 min
20 min
30 min
Nasal
5 mg/kg
10 min
20 min
1 hour
Poorly defined as
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Clinical Scenario #1
2/16/2014
2/16/2014
Intranasal ketamine?
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Clinical Scenario #1
Clinical Scenario #1
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Fentanyl PCA
Oxycodone
Ketorolac
Methadone
Venlafexine
Gabapentin
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Clinical Scenario #2
A 35 year old male with h/o IV heroin
abuse presents with a left deltoid abscess.
Exam sig for a 10 x 7 cm left lateral deltoid
abscess. He complains of 10/10 pain and
will barely allow you to touch his arm. He
screams out in pain when the nurse
attempts to place an IV. Home meds
include methadone 120 mg daily. He is
given a total of 4 mg of dilaudid without
improvement in pain. How would you
continue to manage of this patient?
Clinical Scenario #3
Clinical Scenario #2
Several small studies suggest a
particular benefit of LDK in this patient
population
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Clinical Scenario #3
Clinical Scenario #3
Clinical Scenario #4
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2/16/2014
68 patients enrolled
Rx groups: ketamine (0.2 mg/kg + infusion) vs placebo
Outcome: validated asthma score
Results: No difference between the two groups
Clinical Scenario #4
Clinical Scenario #4
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2/16/2014
Thank You
Questions?
References
Johansson P, et. al The effect of combined treatment with morphine sulphate and low-dose
ketamine in a prehospital setting, Scandinavian Journal of Trauma, Resuscitation and
Emergency Medicine
Gurnani A. et al. Analgesia for acute musculoskeletal trauma: low-dose subcutaneous
infusion of ketamine. Anaesth Intensive Care 1996 Feb; 24(1): 32-6
Galinski M, et al. Management of severe acute pain in emergency settings: ketamine reduces
morphine consumption. Am J Emerg Med. 2007;25:385-390.
Andolfatto, G et. al, Intranasal Ketamine for Analgesia in the Emergency Department: A
Prospective Observation Series. Academic Emergency Medicine. Oct 2013;20(10) 1050-4
Lester L, Braude DA, Niles C, Crandall CS, et al. Low-dose ketamine for analgesia in the ED:
a retrospective case series. Am J Emerg Med. 2010;28:820-876
Gharaei B, et. al. Opioid-Sparing Effect of Preemptive Bolus Low-Dose Ketamine for
Moderate Sedation in Opioid Abusers Undergoing Extracorporeal Shock Wave Lithotripsy: A
Randomized Clinical Trial. Anesthesia and Analgesia Jan 2013; 116(1) 75-80
Uprety D, et. al Ketamine infusion for sickle cell pain crisis refractory to opioids: a case report
and review of literature
Roberts J., et al. Intramuscular ketamine for the Rapid Tranquilization of the Uncontrollable,
Violent, and Dangerous Adult Patient. J Trauma. 2001;51:1008-1010
Cong M, et. al. Ketamine sedation for patients with acute agitation and psychiatric illness
requiring aeromedical retrieval Emerg Med J 2012 29:335-337
Allen J, et. al. The Efficacy of Ketamine in Pediatric Emergency Department Patients Who
Present With Acute Severe Asthma. J of Emer Med 2011, 41(5)492-494
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