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Journal ArticleDOI

Clinical Practice Guideline for Emergency Department Ketamine Dissociative Sedation: 2011 Update

TL;DR: An evidence-based clinical practice guideline for the administration of the dissociative agent ketamine for emergency department procedural sedation and analgesia is updated.
About: This article is published in Annals of Emergency Medicine.The article was published on 2011-05-01. It has received 446 citations till now. The article focuses on the topics: Procedural sedation and analgesia & Guideline.
Citations
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Journal ArticleDOI
TL;DR: Pharmacological target deconvolution of ketamine and its metabolites will provide insight critical to the development of new pharmacotherapies that possess the desirable clinical effects of ketamines, but limit undesirable side effects.
Abstract: Ketamine, a racemic mixture consisting of (S)- and (R)-ketamine, has been in clinical use since 1970. Although best characterized for its dissociative anesthetic properties, ketamine also exerts analgesic, anti-inflammatory, and antidepressant actions. We provide a comprehensive review of these therapeutic uses, emphasizing drug dose, route of administration, and the time course of these effects. Dissociative, psychotomimetic, cognitive, and peripheral side effects associated with short-term or prolonged exposure, as well as recreational ketamine use, are also discussed. We further describe ketamine’s pharmacokinetics, including its rapid and extensive metabolism to norketamine, dehydronorketamine, hydroxyketamine, and hydroxynorketamine (HNK) metabolites. Whereas the anesthetic and analgesic properties of ketamine are generally attributed to direct ketamine-induced inhibition of N-methyl-D-aspartate receptors, other putative lower-affinity pharmacological targets of ketamine include, but are not limited to, γ-amynobutyric acid (GABA), dopamine, serotonin, sigma, opioid, and cholinergic receptors, as well as voltage-gated sodium and hyperpolarization-activated cyclic nucleotide-gated channels. We examine the evidence supporting the relevance of these targets of ketamine and its metabolites to the clinical effects of the drug. Ketamine metabolites may have broader clinical relevance than was previously considered, given that HNK metabolites have antidepressant efficacy in preclinical studies. Overall, pharmacological target deconvolution of ketamine and its metabolites will provide insight critical to the development of new pharmacotherapies that possess the desirable clinical effects of ketamine, but limit undesirable side effects.

621 citations


Additional excerpts

  • ...Innes, 1997; Weber et al., 2004; Green et al., 2011; Gao et al., 2016)....

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Journal ArticleDOI
TL;DR: This clinical policy from the American College of Emergency Physicians is the revision of a 2005 clinical policy evaluating critical questions related to procedural sedation in the emergency department.

455 citations


Cites background from "Clinical Practice Guideline for Eme..."

  • ...Many recent studies have described the use of ketamine administered with propofol to evoke deep sedation levels during painful ED procedures.(11-20)...

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  • ...respirations, and cardiopulmonary stability.(1,11) In the ED, ketamine is commonly administered to evoke dissociative levels of sedation....

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  • ...During recent years, there has been a continuously growing body of evidence addressing ketamine, midazolam, fentanyl, propofol, and etomidate that significantly adds to the depth of understanding of these agents’ use in the ED.(1,11-20,30,39,43,58,61-88) The use of short-acting sedative agents such as propofol and etomidate for ED procedural sedation and analgesia has gained widespread acceptance....

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  • ...Multiple studies have continued to support this practice.(11,70-76,89) Studies addressing the use of ketamine as a sole agent in the adult procedural sedation and analgesia ED population have also been published....

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Journal ArticleDOI
TL;DR: The present article attempts to review the current useful applications of ketamine in anesthesia, pain and critical care based on scientific evidence gathered from textbooks, journals, and electronic databases.
Abstract: Ketamine was introduced commercially in 1970 with the manufacturer's description as a "rapidly acting, nonbarbiturate general anesthetic" and a suggestion that it would be useful for short procedures. With the help of its old unique pharmacological properties and newly found beneficial clinical properties, ketamine has survived the strong winds of time, and it currently has a wide variety of clinical applications. It's newly found neuroprotective, antiinflammatory and antitumor effects, and the finding of the usefulness of low dose ketamine regimens have helped to widen the clinical application profile of ketamine. The present article attempts to review the current useful applications of ketamine in anesthesia, pain and critical care. It is based on scientific evidence gathered from textbooks, journals, and electronic databases.

254 citations


Cites background from "Clinical Practice Guideline for Eme..."

  • ...[43] This dissociative sedation can be readily achieved by administration of a single IV or IM loading dose of ketamine followed by titration.[43] Intranasal ketamine is being used in a wide range of clinical doses for procedural sedation in children (0....

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  • ...It is useful for procedures in the mentally disabled who are often uncooperative.[43] This dissociative sedation can be readily achieved by administration of a single IV or IM loading dose of ketamine followed by titration....

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  • ...the drug continues to be widely administered in the operation theatres as an inexpensive and simple alternative to inhalational anesthesia.[43] In African countries and rural India where there is a paucity of anesthetic manpower, equipment and money, ketamine plays a major role in anesthetic service delivery in secondary health care facilities and in high-risk cases in tertiary institutions....

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Journal ArticleDOI
TL;DR: There may be an emerging role for ketamine in treatment of refractory depression and Post-Traumatic Stress Disorder, and the history of ketamine, its pharmacology, putative mechanisms of action and current clinical applications are reviewed.
Abstract: Ketamine was introduced into clinical practice in the 1960s and continues to be both clinically useful and scientifically fascinating. With considerably diverse molecular targets and neurophysiological properties, ketamine’s effects on the central nervous system remain incompletely understood. Investigators have leveraged the unique characteristics of ketamine to explore the invariant, fundamental mechanisms of anesthetic action. Emerging evidence indicates that ketamine-mediated anesthesia may occur via disruption of corticocortical information transfer in a frontal-to-parietal (“top down”) distribution. This proposed mechanism of general anesthesia has since been demonstrated with anesthetics in other pharmacological classes as well. Ketamine remains invaluable to the fields of anesthesiology and critical care medicine, in large part due to its ability to maintain cardiorespiratory stability while providing effective sedation and analgesia. Furthermore, there may be an emerging role for ketamine in treatment of refractory depression and post-traumatic stress disorder. In this article, we review the history of ketamine, its pharmacology, putative mechanisms of action, and current clinical applications.

237 citations


Cites background from "Clinical Practice Guideline for Eme..."

  • ...However, anecdotal observations suggest a higher risk of airway complications with ketamine in infants less than 3 months of age (Green and Johnson, 1990; Green et al., 2011), likely due to infant-specific differences in airway reactivity and anatomy rather than ketamine itself....

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Journal ArticleDOI
TL;DR: An overview of the drug's pharmacokinetics and pharmacodynamics is provided while also discussing the potential benefits and risks of ketamine administration in various clinical settings.
Abstract: After nearly half a century on the market, ketamine still occupies a unique corner in the medical armamentarium of anesthesiologists or clinicians treating pain. Over the last two decades, much research has been conducted highlighting the drug's mechanisms of action, specifically those of its enantiomers. Nowadays, ketamine is also being utilized for pediatric pain control in emergency department, with its anti-hyperalgesic and anti-inflammatory effects being revealed in acute and chronic pain management. Recently, new insights have been gained on ketamine's potential anti-depressive and antisuicidal effects. This article provides an overview of the drug's pharmacokinetics and pharmacodynamics while also discussing the potential benefits and risks of ketamine administration in various clinical settings.

163 citations

References
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Journal ArticleDOI
TL;DR: Ketamine—Its Pharmacology and Therapeutic Uses Paul white;Walter Way;anthony Trevor; Anesthesiology
Abstract: Ketamine—Its Pharmacology and Therapeutic Uses Paul white;Walter Way;anthony Trevor; Anesthesiology

1,415 citations

Journal ArticleDOI
TL;DR: The safe sedation of children for procedures requires a systematic approach that includes no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications.
Abstract: The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical supervision; careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications; appropriate fasting for elective procedures and a balance between depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure; a focused airway examination for large tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction; a clear understanding of the pharmacokinetic and pharmacodynamic effects of the medications used for sedation, as well as an appreciation for drug interactions; appropriate training and skills in airway management to allow rescue of the patient; age- and size-appropriate equipment for airway management and venous access; appropriate medications and reversal agents; sufficient numbers of people to carry out the procedure and monitor the patient; appropriate physiologic monitoring during and after the procedure; a properly equipped and staffed recovery area; recovery to presedation level of consciousness before discharge from medical supervision; and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.

1,070 citations

Journal ArticleDOI
TL;DR: Ketamine-induced psychotic symptoms were strikingly reminiscent of the subject's symptoms during active episodes of their illness, and antagonism of NMDA-sensitive glutamatergic transmission in brain exacerbates symptoms of schizophrenia.

890 citations

Journal ArticleDOI
TL;DR: La kétamine est actuellement considérée comme une option raisonnable pour ľinduction anesthésique chez les nouveau-nés prématurés en hypotension.
Abstract: Pendant presque 25 ans ďexperience clinique, les benefices et les limitations de ľanesthesie a la ketamine ont ete generalement bien definis. Les revues extensives de White et al.2 ainsi que celles de Reeves et al.43 ont enormement aide a comprendre ľanesthesie dissociative. Neanmoins, des etudes recentes continuent a nous eclairer sur les differents aspects de la pharmacologie de la ketamine et suggerent de nouvelles utilisations cliniques de cette drogue. Ľidentification du recepteur du N-M ethyl-Aspartate amene une preuve que ľanesthesie et ľanalgesie a la ketamine ont chacune un mecanisme ďaction different. La liaison stereospecifique de la (+) ketamine aux recepteurs opiaces in vitro, ľemergence plus rapide de ľanesthesie, et une incidence plus basse de sequelles lors de ľemergence, rend la (+) ketamine une drogue promettante pour des recherches futures. Les applications cliniques de la ketamine qui ressortent recemment, et qui probablement augmenteront dans le futur sont reliees e ľutilisation orale, rectale et intra-nasale de la ketamine pour des fins ďanalgesie, de sedation ou induction anesthesique. La ketamine est actuellement consideree comme une option raisonnable pour ľinduction anesthesique chez les nouveau-nes prematures en hypotension. Ľexperience initiale avec la ketamine en injection epidurale et intrathecale ne fut pas prometteuse et les donnees sont encore preliminaires dans ce domaine. Ľutilisation de la ketamine dans les catastrophes et les manoeuvres militaires va probablement etre plus frequente. La disponibilite clinique du midazolam va complementer ľanesthesie a la ketamine de plusieurs facons. Cette benzodiazepine est rapidement metabolisee. Elle reduit la stimulation cardiovasculaire de la ketamine ainsi que les phenomenes ďemergence sans avoir des metabolites actifs. Elle est disponible sous une forme aqueuse et n’est pas irritante lors de ľinjection intra-veineuse comme le diazepam. La combinaison de la ketamine et du midazolam sera bien acceptee par les patients contrairement a ce qui arrive quand on utilise la ketamine seule. Finalement, il est necessaire de mentionner la possibilite ďabus de la ketamine.126 Alors que la ketamine n’est pas une substance controlee (aux Etats-Unis) la prudence suggere aux medecins de prendre des precautions appropriees contre son utilisation non-autorisee.

672 citations


"Clinical Practice Guideline for Eme..." refers background in this paper

  • ...Coadministered Benzodiazepines As with anticholinergics, the prophylactic coadministration of benzodiazepines has been traditionally recommended with the intent of preventing or reducing recovery reactions.(4,12,15,16) A single controlled trial in ED adults found that midazolam pretreatment (0....

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  • ...Isomers The 2 optimal isomers of ketamine, R( ) and S( ), have different properties, but the literature is inconclusive about whether this might be clinically important.(4,12,15,16,110) The S( ) ketamine may exhibit enhanced dissociative/analgesic potency, greater amnesia, faster elimination, and fewer recovery reactions and may have neuroprotective effects....

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  • ...Coadministered Anticholinergics Traditionally the prophylactic coadministration of an anticholinergic (ie, atropine or glycopyrrolate) has been routinely recommended, with the intent of mitigating oral secretions and thus presumably airway adverse events.(1,12,15,16) However, large case series of patients have been safely treated without this adjunct....

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  • ...Shortly after the release of ketamine in 1970, anecdotal associations between upper respiratory infection and laryngospasm appeared, and as a result essentially every ketamine review article or textbook chapter lists upper respiratory infection as a contraindication.(1,4,12,15,16) There is insufficient evidence to clarify what specific magnitude of upper respiratory infection signs and symptoms should preclude ketamine administration....

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  • ...According to inconclusive evidence, it has been widely recommended that ketamine be avoided in children or adults with known or possible coronary artery disease, congestive heart failure, or hypertension.(12,15,16,43) Ketamine inhibits the reuptake of catecholamines, and the resulting sympathomimetic effect produces mild to moderate increases in blood pressure, pulse rate, cardiac output, and myocardial oxygen consumption....

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