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|Ketamine Hydrochloride

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Ketamine Hydrochloride

Pronouncation: (KEET-uh-MEEN HIGH-droe-KLOR-ide)
Class: General anesthetic

Trade Names:
Ketalar
- Injection 10 mg/mL
- Injection 50 mg/mL
- Injection 100 mg/mL

Mechanism of Action

Pharmacology

Produces rapid-acting anesthetic state with profound analgesia, normal pharyngeal-laryngeal reflexes, normal or slightly enhanced skeletal muscle tone, cardiovascular and respiratory stimulation, and, occasionally, transient and minimal respiratory depression.

Pharmacokinetics

Absorption

Ketamine is rapidly absorbed. Mean C _max is 0.75 mcg/mL. T _max is 1 hr.

Distribution

Distribution t _½ is approximately 10 to 15 min. Ketamine is rapidly distributed into body tissues, with high concentrations in body fat, liver, lungs, and brain. Protein binding with this drug is not significant.

Metabolism

Undergoes N-demethylation and hydroxylation of cyclohexone ring. The N-demethylated metabolite is less than 1/ 6 as potent and the demethyl cyclohexone derivative is less than 1/ 10 as potent as the drug.

Elimination

Elimination t _½ is 2.5 hr. Approximately 91% is excreted in urine and 3% in feces.

Indications and Usage

Diagnostic and surgical procedures that do not require skeletal muscle relaxation; induction of anesthesia; supplementation of low-potency agents, such as nitrous oxide.

Contraindications

Patients in whom significant BP elevation would be a serious hazard; hypersensitivity to the drug.

Dosage and Administration

Adults and Children: induction of anesthesia

IV Initial: 1 to 4.5 mg/kg via slow infusion (over 60 sec); usual dose for 5 to 10 min anesthesia: 2 mg/kg. Maintenance: One-half to full induction dose, repeated as needed. Alternatively IV 0.1 to 0.5 mg/min infusion, augmented with diazepam IV 2 to 5 mg.

IM Initial: 6.5 to 13 mg/kg. Maintenance: One-half to full induction dose, repeated as needed.

Storage/Stability

Store vials at controlled room temperature (59° to 86°F). Protect from light.

Drug Interactions

Halothane

Decreased cardiac output, BP, and pulse.

Tubocurarine and other nondepolarizing muscle relaxants

Increased neuromuscular effects, resulting in prolonged respiratory depression.

Incompatibility

Ketamine is physically incompatible with diazepam and barbiturates.

Laboratory Test Interactions

None well documented.

Adverse Reactions

Cardiovascular

Hypertension; tachycardia; hypotension; bradycardia; arrhythmia.

CNS

Increased ICP. Emergence reaction: Vivid imagery; hallucinations; delirium; confusion; excitement; irrational behavior.

Dermatologic

Transient erythema; morbilliform rash.

EENT

Diplopia; nystagmus; increased intraocular pressure.

GI

Anorexia; nausea; vomiting; hypersalivation.

Respiratory

Respiratory stimulation; severe respiratory depression; apnea after rapid injection; laryngospasm; other airway obstruction.

Precautions

Warnings

Emergence reactions

Emergence reactions occur in approximately 12% of patients. The incidence is least in young (younger than 15 yr of age) and elderly (older than 65 yr of age) patients. Also less frequent with IM use.

Psychological manifestations

Severity varies between pleasant dream-like states, vivid imagery, hallucinations and emergence delirium sometimes accompanied by confusion, excitement and irrational behavior. The duration is ordinarily a few hours; however, recurrences have been seen up to 24 hr postoperatively. No residual psychological effects are known. The incidence may be reduced by using lower dosages with IV diazepam. These reactions may be reduced if verbal, tactile and visual patient stimulation is minimized during recovery. This does not preclude monitoring vital signs.

Management

To terminate a severe emergence reaction, a small hypnotic dose of a short-acting or ultrashort-acting barbiturate may be required. When used on an outpatient basis, do not release patient until recovery from anesthesia is complete. Patients should be accompanied by an adult.

Pregnancy

Category B .

Lactation

Undetermined.

Children

Safety and efficacy in children less than 16 yr have not been established.

Alcohol

Use with caution in chronic alcoholics and acutely alcohol intoxicated patients.

Cerebrospinal fluid pressure

Cerebrospinal fluid pressure increase has been reported following administration.

Hypertension or cardiac decompensation

In patients with these conditions, monitor function continuously during procedure.

Preoperative preparation

Give atropine, scopolamine, or another drying agent at an appropriate interval prior to induction.

Respiratory effects

May occur with overdosage or too rapid a rate of administration.

Respiratory surgery/diagnostic procedures

Do not use in surgery or diagnostic procedures of the pharynx, larynx, or bronchial tree. Do not administer ketamine alone because pharyngeal and laryngeal reflexes are usually active. Muscle relaxants, with proper attention to respiration, may be required.

Visceral pain

In surgical procedures involving visceral pain pathways, supplement with an agent that obtunds visceral pain.

Overdosage

Symptoms

Respiratory depression.

Patient Information

Advise patient that neurologic effects may persist for 24 hr after anesthesia. Advise patient to use caution during this period while driving or performing other tasks requiring mental alertness.

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