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".
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
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]