Guidelines for Safe Administration of Ketamine

Monitoring and Safety

When ketamine is administered for moderate procedural sedation, care consistent with that required for general anesthesia should be provided, as recommended by the American Society of Anesthesiologists 1
Practitioners administering ketamine must be able to identify and rescue patients from unintended deep sedation or general anesthesia, as recommended by the American Society of Anesthesiologists 1
For patients receiving ketamine, maintain vascular access throughout the procedure until the patient is no longer at risk for cardiorespiratory depression, as recommended by the American Society of Anesthesiologists 1
When administering oral ketamine, allow sufficient time for absorption and peak effect before considering supplementation, as recommended by the American Society of Anesthesiologists 2
If patients develop hypoxemia or significant hypoventilation during sedation, they should be encouraged to breathe deeply, administered supplemental oxygen, and provided positive pressure ventilation if needed, as recommended by the American Society of Anesthesiologists 2

Strong evidence supports the use of intravenous ketamine in the perioperative period to reduce opioid use in the first 24 hours after hip and knee arthroplasty, according to the American Academy of Orthopaedic Surgeons 3

The American Society of Anesthesiologists recommends small doses of ketamine in two specific scenarios: surgery with high risk of acute pain or chronic postoperative pain, and patients with vulnerability to pain, particularly those taking long-term opioids or with opioid addiction 4
The maximum dose of ketamine for perioperative pain is 0.5 mg/kg/h after anesthesia induction, with a continuous infusion at 0.125-0.25 mg/kg/h, and the infusion should be stopped 30 minutes before the end of surgery 5, 4

For severe acute pain management, subanesthetic doses of ketamine include boluses <0.35 mg/kg, infusions at 0.5-1 mg/kg/h, and when used in IV-PCA (patient-controlled analgesia): 1-5 mg per dose 6

Ketamine should not be used in patients with uncontrolled cardiovascular disease, pregnancy, active psychosis, severe liver dysfunction, or high intracranial/ocular pressure 6
Continuation of ketamine treatment in the postoperative period increases risk of hallucinations without significantly enhancing analgesic effect 5, 4

Regular assessment of sedation levels and respiratory status is essential when using ketamine 6

For pediatric procedural sedation, a combination of ketamine and midazolam has shown fewer complications compared to midazolam/meperidine regimens, with 88% of patients successfully sedated at initial doses of 1 mg/kg or less, as recommended by the American Academy of Pediatrics 7