Neonatal Drug Therapy Manual

Ketamine

Disclaimer: Official controlled document is the CHEO and Ottawa Hospital online copy. It is the responsibility of user to ensure that any paper copy version is the same as the online version before use.

Alternate Name(s): 
Ketalar
Classification: 
General Anesthetic
Original Date: 
February 2010
Revised Date: 
November 2021
Indications: 
  • Adjunct therapy for sedation and analgesia in the neonatal intensive care unit
  • Moderate sedation for diagnostic and therapeutic procedures
Administration: 
  • IV direct (infusion rate: 0.5 mg/kg/min   max: 2 mg/min)
  • IV continuous infusion
  • Subcutaneous
  • Intranasal
  • IM
Dosage: 
  • IV direct, SC, IM: 0.5 - 2 mg/kg/dose

Ketamine Equivalents

1 mg 1000 mcg
1 mg/mL

 

1000 mcg/mL

 

  • IV/SC continuous infusion:
    • Preterm neonates:  100 - 500 mcg/kg/hour
    • Term neonates: 100 - 900 mcg/kg/hour
    • Titrate dose according to effect/side effects. A maximum dose has not been established, but one report in mechanically ventilated children used a maximum dose of up to 3600 mcg/kg/hour. Several tapering protocol can be implemented, one approach would be to decrease by 10% every 6 to 8 hours.
  • Intranasal: 0.5 - 2 mg/kg/dose.  Additional dose may be repeated after 7 minutes if adequate sedation not obtained.
Side Effects: 
  • CNS: tonic-clonic movements, elevated intracranial pressure, hallucinations
    • Controversy exists with regard to the anesthetic neurotoxicity caused by Ketamine. Repeated high Ketamine doses (20 mg/kg) and other N-methyl-D-Asparate (NMDA) antagonists have been associated with increased neuroapoptosis in the developing brain on animal models. Both brain immaturity and prolong exposures were necessary to produce neuroapoptotic  cell death. Clinical applicability of these findings is limited since the development age of the rodent models in these studies corresponded to 16-22-weeks-old-fetus.
  • CVS: tachycardia and hypertension (dose-dependent)
  • GI: hypersalivation
  • Opthalmic: nystagmus
Parameters to Monitor: 
  • Cardiovascular effects; HR, BP, RR, oxygen saturation
Reconstitution and Stability: 

CHEO:

IV direct:

- Use Ketamine 1 mg/mL (1000 mcg/mL) - 3 mL prefilled syringe prepared by pharmacy

- If patient receiving Ketamine by continuous infusion, use appropriate setting on pump to administer bolus dose

IV continuous infusion:

- Use 1 mg/mL (1000 mcg/mL) prefilled syringe prepared by pharmacy.

** Ketamine 5 mg/mL (5000 mcg/mL) prefilled syringe can also be dispensed by pharmacy if required

SC continuous infusion:

- Use Ketamine 5 mg/mL (5000 mcg/mL) prefilled syringe prepared by pharmacy

Intranasal:

- Use Ketamine 10 mg/mL vial.  Ideal volume is 0.3 to 0.5 mL per nostril,  (maximum 1 mL per nostril)

 

Instructions for mixing from vials:

  • Ketamine 10 mg/mL
    • Add 2 mL (20 mg) to 18 mL of 0.9% NaCl
    • Final concentration: 1 mg/mL (equivalent to 1000 mcg/mL)
  • Ketamine 10 mg/mL
    • Add 10 mL (100 mg) to 10 mL of 0.9% NaCl
    • Final concentration: 5 mg/mL (equivalent to 5000 mcg/ml)

 

TOH

IV direct/IV continuous infusion: 

Ketamine 10 mg/mL 

• Add 2 mL (20 mg) to 18 mL of D5W 

• Final concentration: 1 mg/mL (equivalent to 1000 mcg/mL) 
 

Compatibility: 

- Solutions Compatible: D5W, 0.9% NaCl

- Y-site Compatible: fentanyl, hydromorphone, midazolam, morphine, SMOF. Ketamine at concentrations < 10 mg/mL is compatible with heparin 0.5-1 unit/mL. 

Notes: 
  • Onset of action for :
    • intranasal route : up to 10 minutes
    • subcutaneous route: within 15-30 minutes
References: 

- Golding CL, Miller JL, Gessouroun MR, Johnson PN. Ketamine Continuous Infusions in Critically Ill Infants and Children.  Annals of Pharmacotherapy 2016, Vol. 50 (3) 234-41

- Milesi C, Baleine J, Mura T, Benito-Castro F, Ferragu F, Thiriez G, et al.  Nasal midazolam vs ketamine for neonatal intubation in the delivery room: a randomised trial.  Archives of disease in childhood Fetal and neontal edition 2018 May; 103 (3):F221-F226

- Yan J, Jiang H. Dual effects of Ketamine: neurotoxicity versus neuroprotection in anesthesia for the developing brain. Journal of neurosurgical anesthesiology 2014 Apr;26 (2):155-60

- American Society on Health-System Pharmacists (ASHP). Handbook on Injectable Drugs. 19th Edition. Bethesda: ASHP 2017

 

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