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Dissociative anaesthetic / analgesic Pregnancy: Use only for life-threatening procedures. Uterotonic effects at high doses.

Ketamine (Procedural Sedation / Burns)

Brand names: Ketalar

Adult dose

Dose: Procedural sedation: 1–2 mg/kg IV or 4–6 mg/kg IM; Analgesia (sub-dissociative): 0.1–0.5 mg/kg IV
Route: IV or IM
Frequency: Single doses for procedures; repeat as needed for ongoing procedures
Max: Titrated — IV induction 2 mg/kg; IM 6 mg/kg
Burns dressing changes: 1–2 mg/kg IV (onset 60 seconds) or 4 mg/kg IM (onset 5 min). Add midazolam 0.03–0.05 mg/kg IV to reduce emergence reactions. Sub-dissociative analgesia: 0.1–0.3 mg/kg IV slow over 15 min. Pre-oxygenate, airway equipment available.

Paediatric dose

Dose: 1.5 mg/kg
Route: IV or IM
Frequency: Single procedural doses
Max: 2 mg/kg IV; 6 mg/kg IM
Concentration: 50 mg/ml
Procedural sedation: 1.5–2 mg/kg IV (onset 1 min) or 4–6 mg/kg IM (onset 3–5 min). Add atropine to reduce secretions (0.01 mg/kg). Fasting not required for emergency burns dressing changes (protective reflexes preserved). Emergence reactions less common in children <10 years.

Dose adjustments

Renal

No significant dose adjustment.

Hepatic

Use with caution in severe hepatic impairment; prolonged duration.

Paediatric weight-based calculator

Procedural sedation: 1.5–2 mg/kg IV (onset 1 min) or 4–6 mg/kg IM (onset 3–5 min). Add atropine to reduce secretions (0.01 mg/kg). Fasting not required for emergency burns dressing changes (protective reflexes preserved). Emergence reactions less common in children <10 years.

Clinical pearls

  • Ideal procedural agent: maintains protective airway reflexes, analgesic and sedative
  • Emergence reactions: give midazolam 0.05 mg/kg IV before ketamine to reduce incidence
  • Bronchodilator properties: useful in burns patients with inhalation injury or asthma
  • Document dissociation carefully — uncooperative behaviour not the same as insufficient analgesia
  • Sub-dissociative IV ketamine (0.1–0.3 mg/kg) — effective for procedural pain without full dissociation

Contraindications

  • History of psychosis or schizophrenia
  • Uncontrolled hypertension
  • Ischaemic heart disease (relative — increases cardiac demand)
  • Active head injury with raised ICP (relative — historically controversial but now re-evaluated)

Side effects

  • Emergence reactions (hallucinations, dysphoria — reduce with midazolam)
  • Tachycardia and hypertension (sympathomimetic)
  • Hypersalivation (give atropine in children)
  • Laryngospasm (rare but possible — airway equipment essential)
  • Nystagmus
  • Raised ICP (debated — recent evidence suggests may be safe in TBI)

Interactions

  • CNS depressants — additive CNS depression
  • Thyroid hormones — may cause hypertension and tachycardia
  • Halothane — increased risk of cardiac arrhythmias
  • Benzodiazepines — reduce emergence reactions

Monitoring

  • Airway and SpO2
  • BP and HR
  • Level of sedation
  • Emergence behaviour

Reference: BNFc; BNF; BBA Procedural Sedation Guidelines; ACEP Ketamine Guidelines. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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