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(S)-(+)-Ketamine hydrochloride
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Ketamine Description
It has been shown to be effective in treating depression in patients with bipolar disorder who have not responded to antidepressants. In persons with major depressive disorder, it produces a rapid antidepressant effect, acting within two hours as opposed to the several weeks taken by typical antidepressants to work. It is also a popular anesthetic in veterinary medicine.
MEDICINAL USE
One 10 ml vial of 1000 mg ketamine
Indications for use as an anaesthetic:
- Pediatric anesthesia (as the sole anesthetic for minor procedures or as an induction agent followed by muscle relaxant and endotracheal intubation);
- Asthmatics or patients with chronic obstructive airway disease;
- As part of a cream, gel, or liquid for topical application for nerve pain — the most common mixture is 10% ketoprofen, 5% lidocaine, and 10% ketamine. Other ingredients found useful by pain specialists and their patients, as well as the compounding pharmacists who make the topical mixtures, include amitriptyline, cyclobenzaprine, clonidine, tramadol, and mepivacaine and other longer-acting local anaesthetics.
- In emergency medicine if an entrapped patient is suffering severe trauma;
- Emergency surgery in field conditions in war zones;
- To supplement spinal/epidural anesthesia/analgesia using low doses;
In medical settings, ketamine is usually injected intravenously or intramuscularly. Since it suppresses breathing much less than most other available anaesthetics, ketamine is still used in human medicine as an anesthetic; however, due to the hallucinations it may cause, it is not typically used as a primary anesthetic, although it is the anaesthetic of choice when reliable ventilation equipment is not available. Ketamine tends to increase heart rate and blood pressure. Because it tends to increase or maintain cardiac output, it is sometimes used in anesthesia for emergency surgery when the patient’s fluid volume status is unknown (e.g., from traffic accidents). Ketamine can be used in podiatry and other minor surgery, and occasionally for the treatment of migraine. Research is ongoing in France, the Netherlands, Russia, Australia and the US into the drug’s usefulness in pain therapy, depression, and for the treatment of alcoholism and heroin addiction
In veterinary anesthesia, ketamine is often used for its anesthetic and analgesic effects on cats, dogs, rabbits, rats, and other small animals. Veterinarians often use ketamine with sedative drugs to produce balanced anesthesia and analgesia, and as a constant-rate infusion to help prevent pain wind-up. Ketamine is used to manage pain among large animals, though it has less effect on bovines. It is the primary intravenous anesthetic agent used in equine surgery, often in conjunction with detomidine and thiopental, or sometimes guaifenesin.
Ketamine may be used in small doses (0.1–0.5 mg/kg·h) as a local anesthetic, particularly for the treatment of pain associated with movement and neuropathic pain. It may also be used as an intravenous coanalgesic with opiates to manage otherwise intractable pain, particularly if this pain is neuropathic (pain due to vascular insufficiency or shingles are good examples). It has the added benefit of counteracting spinal sensitization or wind-up phenomena experienced with chronic pain. At these doses, the psychotropic side effects are less apparent and well managed with benzodiazepines.Ketamine is a coanalgesic, so is most effective when used alongside a low-dose opioid; while it does have analgesic effects by itself, the higher doses required can cause disorienting side effects. The combination of ketamine with an opioid is, however, particularly useful for pain caused by cancer.
The effect of ketamine on the respiratory and circulatory systems is different from that of other anesthetics. When used at anesthetic doses, it will usually stimulate rather than depress the circulatory system. It is sometimes possible to perform ketamine anesthesia without protective measures to the airways. Ketamine is also a potent analgesic and can be used in subanesthetic doses to relieve acute pain; however, its psychotropic properties must be taken into account. Patients have reported vivid hallucinations, “going into other worlds” or “seeing God” while anesthetized, and these unwanted psychological side effects have reduced the use of ketamine in human medicine. They can, however, usually be avoided by concomitant application of a sedative such as a benzodiazepine.
Low-dose ketamine is recognized for its potential effectiveness in the treatment of complex regional pain syndrome (CRPS). Although low-dose ketamine therapy is established as a generally safe procedure, reported side effects in some patients have included hallucinations, dizziness, lightheadedness and nausea. Therefore, nurses administering ketamine to patients with CRPS should do so only in a setting where a trained physician is available if needed to assess potential adverse effects on patients.
In some neurological intensive care units, ketamine has been used in cases of prolonged seizures. Some evidence indicates the NMDA-blocking effect of the drug protects neurons from glutamatergic damage during prolonged seizures.
- Pain Management
- The dissociative anesthetic effects of ketamine have also been applied for postoperative pain management. Low doses of ketamine have been found to significantly reduce morphine consumption, as well as reports of nausea following abdominal surgery.
- Oral ketamine
- • Ketamine can be started using the oral route or patients may be changed from a subcutaneous infusion when pain is controlled.
- • Starting dose: 5-10 mg four times daily
- • Increase dose in 5-10 mg increments
- • Usual dose range: 10-60 mg four times daily
- Subcutaneous ketamine infusion
- • Starting dose: 50-150 mg/24 hours
- • Review daily, increase dose in 50-100 mg increments
- • Usual dose range: 50-600 mg/24 hours
- Converting from a 24-hour SC ketamine infusion to oral ketamine
- • Oral ketamine is more potent than SC ketamine (due to liver metabolism). Many patients require a dose reduction of 25-50% when changing to oral ketamine.
- • Titrate dose in 5-10 mg increments
- • Some specialists stop the SC infusion when the first dose of oral ketamine is given. Others gradually reduce the infusion dose as the oral dose is increased.
Legal status
The increase in illicit use prompted ketamine’s placement in Schedule III of the United States Controlled Substance Act in August 1999.In the United Kingdom, it became labeled a Class C drug on 1 January 2006. In Canada, ketamine is classified as a Schedule I narcotic, as of August 2005. In Hong Kong, as of 2000, ketamine is regulated under Schedule 1 of Hong Kong Chapter 134 Dangerous Drugs Ordinance. It can only be used legally by health professionals, for university research purposes, or with a physician’s prescription. By 2002, ketamine was classified as schedule III in Taiwan; given the recent rise in prevalence in East Asia; however, rescheduling into schedule I or II is being considered.
International brand names
Brand names for ketamine vary internationally:
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