Expansion of guideline to include adults

General
● Expansion of guideline to include adults
No Longer Contraindications
● Administration for ages 3 to 12 months
● Minor oropharyngeal procedures
● Head trauma
Route of Administration
● Emphasis on IV over IM route when feasible
Coadministered Medications
● Routine prophylactic anticholinergics no longer
recommended
● Routine prophylactic benzodiazepines may benefit adults but
not children
● Prophylactic ondansetron can slightly reduce vomiting

This recommendation is now omitted; a large
meta-analysis failed to corroborate this concern2,3 and the global
evidence now suggests minimal or no enhanced risk.
The previous guideline addressed only pediatric
administration; however, there is now sufficient ED literature to
also support the safety and efficacy of dissociative sedation in
adults lacking hypertension, heart disease, or risk factors
for coronary artery disease (see “Cardiac Disease” section
below)


Laryngeal stimulation. Ketamine is well known to preserve
and exaggerate protective airway reflexes,4,12,16 and there is
supportive evidence from non-ED settings that major
stimulation of the oropharynx (eg, endoscopy) during
dissociative sedation will increase the risk of laryngospasm.37
However, a large meta-analysis found no such increased risk for
typical ED oropharyngeal procedures (eg, intraoral laceration
repair, dental procedures, removal of oropharyngeal and
esophageal foreign bodies).2,3 Clinicians using ketamine for
such procedures should make every effort to avoid accumulation
of secretions or blood in the posterior pharynx while avoiding
vigorous stimulation of the posterior pharynx with either
suction or instruments.
Anatomy. Although the existing literature is inconclusive
about the suitability of ketamine in patients with a history of
airway instability, tracheal surgery, tracheal stenosis,
tracheomalacia, and laryngomalacia, it remains plausible that
these conditions likely entail a higher risk of laryngospasm and
airway obstruction.4,12,16
Upper respiratory infections. According to indirect
inconclusive evidence, active upper respiratory infection and
active asthma appear to present increased risk in children but
not adults. These features are well known to increase
laryngospasm risk in children during inhalational anesthesia.
Olsson and Hallen33 found that, in children with upper
respiratory infection, the risk was 5.5 times higher than in those
without, and when active asthma was present the risk was 3.7

times higher. Adults did not display such differences.33 It
remains uncertain whether this predisposition observed during
inhalational anesthesia applies to ketamine, although regardless
of drug, presumably the laryngospastic response has similar
underlying pathophysiology. Given that ketamine exaggerates
laryngeal reflexes,4,12,16 whereas inhalational anesthetics depress
them, the risk with ketamine might actually be higher in this
setting.
Shortly after the release of ketamine in 1970, anecdotal
associations between upper respiratory infection and
laryngospasm appeared, and as a result essentially every
ketamine review article or textbook chapter lists upper
respiratory infection as a contraindication.1,4,12,15,16 There is
insufficient evidence to clarify what specific magnitude of upper
respiratory infection signs and symptoms should preclude
ketamine administration.