Subdissociative Dose Ketamine in the Emergency Department

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It was my distinct pleasure to sit down with Sergey Motov (@painfreeED) to discuss subdissociative dose ketamine (SDK) and its use in the Emergency Department.

Ketamine is an NMDA receptor antagonist agent well-loved by the Emergency Medicine physician for its multitude of uses, depending on dosing. This dose-dependent effect has been referred to by some in the EM world as the "Ketamine-brain continuum"[1].

 
 
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Please note that this dosing is a continuum, and that there is overlap in some of the effects. We will be focusing on ketamine for pain, or SDK.

 
 

Indications for SDK:

  • Chronic cancer and non-cancer pain conditions

  • Neuropathic pain

  • Opioid-tolerant pain

  • Opioid hyperalgesic states

  • Acutely painful conditions in the Emergency Department

Contraindications for SDK:

  • Allergy to ketamine

  • Significant underlying psychiatric conditions

  • Pregnancy (lacking data to support use)

  • Children < 2 mo of age

Side Effects of SDK:

  • Nausea (~10%)

  • Dizziness (~30-60%)

  • Feeling of Unreality (~60-80%)

How to Administer:

  • 0.1-0.3 mg/kg (as Sergey notes, consider a starting dose range of 0.1-0.15 mg/kg)

  • Administered in 50-100 mL saline bag over 15 minutes OR 20 mg fixed dose diluted in 100 mL saline over 15 minutes

 

REFERENCES

1.  https://emupdates.com/the-ketamine-brain-continuum/

2.  Motov S, Rosenbaum S, Vilke GM, Nakajima Y.  Is There a Role for Intravenous Subdissociative-Dose Ketamine Administered as an Adjunct to Opioids or as a Single Agent for Acute Pain Management in the Emergency Department?     J Emerg Med. 2016 Dec;51(6):752-757. [https://www.ncbi.nlm.nih.gov/pubmed/27693070]

3.  Motov S, Rockoff B, Cohen V, Pushkar I, Likourezos A, McKay C, Soleyman-Zomalan E, Homel P, Terentiev V, Fromm C. Intravenous Subdissociative-Dose Ketamine Versus Morphine for Analgesia in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2015 Sep;66(3):222-229.e1. [https://www.ncbi.nlm.nih.gov/pubmed/25817884]

4.  Motov S, Mann S, Drapkin J, Butt M, Likourezos A, Yetter E, Brady J, Rothberger N, Gohel A, Flom P, Mai M, Fromm C, Marshall J. Intravenous subdissociative-dose ketamine versus morphine for acute geriatric pain in the Emergency Department: A randomized controlled trial. Am J Emerg Med. 2018 May 16. pii: S0735-6757(18)30407-8. [https://www.ncbi.nlm.nih.gov/pubmed/29807629]