LHP E84 Nebulized Ketamine?

[@JeffreyBytes]

Great episode, Dr. Jarvis. I do have a concern regarding the potential use of ketamine on BLS units. I'm not very knowledgeable about ketamine, so please forgive my ignorance. One of the adverse effects of ketamine that I am aware of is respiratory depression, but it wasn't touched on in this episode. Do we know the risk of respiratory depression associated with sub-dissociative doses of nebulized ketamine? While the current pre-hospital ALS practice of administering fentanyl for severe pain likely carries a higher risk of respiratory depression, it is also much more easily countered with naloxone. Although we hope never to need naloxone to address a complication we caused, it is a viable option. As far as I'm aware, no such option exists for ketamine (sans great BLS BVM skill). This is just a concern I have, and I would love to hear others' thoughts on this matter.

[@FlightbridgeedHEMS]

Thanks for the comment and question. Respiratory depression is always a concern with almost every drug. One of the advantages of ketamine, even at full dissociative doses much higher than the ones used in this trial, is relatively little respiratory depression. Again, no drug is perfectly safe and we should absolutely use appropriate monitoring (SpO2 and EtCO2 in particular) with any drug with any potential for respiratory depression. To add some data to this, in one of Dr Motov's prior trials (1) comparing low-dose IV ketamine to morphine, there was no respiratory depression with either group. In short, I'm pretty comfortable with the risk of respiratory depression with ketamine, particularly sub-dissociative dosing in well-monitored patients. I'm actually more comfortable with it than with opioids. Thanks again for the great question! Jeff (1) Motov S, Mann S, Drapkin J, Butt M, Likourezos A, Yetter E, Brady J, Rothberger N, Gohel A, Flom P, et al.: Intravenous subdissociative-dose ketamine versus morphine for acute geriatric pain in the Emergency Department: A randomized controlled trial. Am J Emerg Med. 2019;February;37(2):220-7.