Ketamine is just getting 50 years old and it seems to me that it is underused. Not only is it an excellent anaesthetic, it is also of great use for some very special neurological diseases. The problem, of course, is the lack of data for any of them, for no one will study a drug that you can buy for 15€ an ampule (500 mg!) and that is produced really cheaply by every second drug company. So don’t expect more data about the following applications:
- Status epilepticus – from animal experiments it is clear that NMDA receptors play a special role that changes over the development of status. Currently, I use ketamine as adjunct for burst suppression anesthesia (say with midazolam or propofol), but we might come to use it early, maybe even before starting to intubate people.
- Chronic pain – the analgesic properties are really not well understood, but Vitamin K seems to be an excellent add-on for complex regimens, in particular for neuropathic pain, say radicular avulsion, trigeminal neuralgia and so on.
- Migraine aura – while we have a great list of weapons against migraine headache, there is absolutely nothing known about the aura phase, which becomes relevant in the ED in the case of prolonged aura. I happily apply one-time anaesthetic ketamine infusions (0,5-07 mg S-Ketamine or about ~ 1-1,4 mg Ketamine) together with a topping of 2 mg midazolam and have very good experience. An alternative is proposal, but that needs more monitoring.
- Sedation for neurointerventional stroke therapy – the combination of ketamine with propofol (so-called ketofol) is perfect for keeping patient quiet and more or less still, without needing a tube or pressors and that is really important for the RR-sensitive proximal artery occlusion in stroke.
- RSI – this is, of course, the standard situation, where ketamine comes more handy than any other induction drug.
- There is a wonderful collection of interesting articles about ketamine in this issue of CNS neuroscience and therapeutics. The articles give personal opinions more than evidence, which is why I love them.
- This study about intranasal ketamine (very low dose, because used as a home self treatment strategy!) for prolonged migraine aura.
- A very conservative clinical practice guideline 2011 for using ketamine in ED procedures.