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Section IconKetamine, Acute Pain
Subdissociative ketamine (SDK) is a valuable and established alternative for the treatment of acute pain.
It is safe, effective, and inexpensive.
Acute pain in hypotensive patients who do not tolerate other analgesics.
Acute pain or as an adjunct to other analgesics in a patient who is at risk for opioid dependence;1 includes managing acute pain in a patient who taking opioids daily for chronic pain.
Absolute: Allergy or hypersensitivity to ketamine2
Relative: History of psychosis or psychiatric disease, excluding depression2
Procedure & Administration
Administer bolus at 0.1 to 0.3 mg/kg over 10 to 15 minutes.
Administration via pump is preferred.
Administer infusion at 0.15 to 0.2 mg/kg/hr; it can be mixed by using 100 mg ketamine in 100 mL NS.
Titrate every 30 minutes until pain is relieved.
Use when IV route is not desired.3
0.5 to 1 mg/kg
Do not exceed more than 1 mL per naris.
Use high-concentration ketamine formulation (50 mg/mL in children and 100 mg/mL in adults)..
Special Considerations
Nursing staff might be unfamiliar with analgesic dosing.
Make it clear that emergent phenomena are not seen until at high doses are reached and do not require cardiopulmonary monitoring.
Institutional policies can dictate the advisability of pulse oximetry, cardiac monitoring, and nursing administration.
In this setting, SDK is intended and dosed for analgesia, not moderate or deep sedation. Specific sedation monitoring and safety requirements should not apply.
Discharge Procedure
No special instructions are necessary.
Where to Learn More
  1. Strayer RJ, Motov SM, Nelson LS. Something for pain: responsible opioid use in emergency medicine. Am J Emerg Med. 2017;35(2):337-341.
  2. Green SM, Roback MG, Kennedy RM, et al. Clinical practice guideline for emergency department ketamine dissociative sedation: 2011 update. Ann Emerg Med. 2011;57(5):449-461.
  3. Shimonovich S, Gigi R, Shapira A, et al. Intranasal ketamine for acute traumatic pain in the emergency department: a prospective, randomized clinical trial of efficacy and safety. BMC Emerg Med. 2016;16(1):43.
  4. Niesters M, Martini C, Dahan A. Ketamine for chronic pain: risks and benefits. Br J Pharmacol. 2013;77:357-367.
  5. Patil S, Anitescu M. Efficacy of outpatient ketamine infusions in refractory chronic pain syndromes: a 5-year retrospective analysis. Pain Med. 2012;13:263-269.
  6. Ahern TL, Herring AA, Miller S, et al. Low-dose ketamine infusion for emergency department patients with severe pain. Pain Med. 2015;16:1402-1409.

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