Ketamine may be related to minor troponin elevations in children undergoing minor procedures in the ED

Long-term safety of ketamine and esketamine in treatment of depression

INTRODUCTION

Ketamine is an NMDA receptor antagonist that can produce rapid-acting antidepressant effects. Esketamine (Spravato), the S-enantiomer of racemic ketamine, was approved by the FDA for treatment-resistant depression in 2019. Here we review what is known about the long-term safety of both racemic ketamine and esketamine as therapies for psychiatric disorders.

AREAS COVERED

In this article, we conducted a safety review of ketamine and esketamine. In looking at ketamine and esketamine long-term safety effects, we considered data available from experimental studies and several phase-three clinical trials.

EXPERT OPINION

Based on available data, the most common side effects of ketamine/esketamine are generally transient, mild, and self-limited. These include dissociation, nausea, headache, elevated heart rate, and blood pressure. Treatment with esketamine may lead to an increased risk of lower urinary tract symptoms, such as dysuria or urgency. However, severe bladder pathology has not been reported among patients receiving doses of esketamine/ketamine in line with prescribing guidelines for depression. There is considerable data that ketamine at high doses can lead to long-term impairments in cognition. However, the esketamine clinical trials found that cognition generally remains stable or improves over time, suggesting that when used appropriately, there is no increased risk of cognitive impairment.

Ketamine may be related to reduced ejection fraction in children during the procedural sedation

Objective:

Ketamine is a dissociative anesthetic agent with sympathomimetic effects used commonly for procedural sedation in emergency department. The present study aimed to reveal the effect of ketamine on myocardium by measuring ejection fraction (EF).

Methods:

Patients less than 9 years old undergoing procedural sedation with ketamine secondary to minor trauma composed the study population by convenience sampling. Study patients received ketamine at a dose of 1.5 mg/kg. A cardiologist performed the measurements of cardiac contractility pre-ketamine and 10 min after the ketamine administration.

Results:

A total of 22 patients were enrolled into the study. Patient recruitment has been ceased after the 22nd patient because of the thought that more patients would not provide additional information. The study subjects had a mean age of 3.5 ± 2.2 years and 14 (64%) of them were male. EF reduced in 14 (63.6%) patients (mean: 5.6 ± 3.1; median: 5; interquartile range (IQR): 3.75–7; minimum–maximum (min–max): 1–14). Systolic blood pressures reduced in 10 of 14 patients with decreased EF and increased in 8 of 10 patients without decreased EF. The changes in systolic blood pressure in patients with decreased EF ( n = 14) were as follows: −7.6 ± 10.9; median: −7.5; IQR: −16.5 to 1.75; and min–max: −30 to 9. There were two patients with elevated high-sensitive troponin.

Conclusion:

Ketamine may reduce EF and systolic blood pressure in children less than 9 years old undergoing procedural sedation.