Ketamine

Anesthesia The use of ketamine in anesthesia reflects its characteristics. It is a drug of choice for short-term procedures when muscle relaxation is not required. The effect of ketamine on the respiratory and circulatory systems is different from that of other anesthetics. It suppresses breathing much less than most other available anesthetics. When used at anesthetic doses, ketamine usually stimulates rather than depresses the circulatory system. Protective airway reflexes are preserved, and it is sometimes possible to administer ketamine anesthesia without protective measures to the airways. It has been widely used for emergency surgery in field conditions in war zones, A 2011 clinical practice guideline supports the use of ketamine as a sedative in emergency medicine, including during physically painful procedures. Ketamine often raises blood pressure upon administration and is unlikely to lower blood pressure in most patients, making it useful in treating severe head injuries for which low blood pressure can be dangerous. Ketamine is an option in children as the sole anesthetic for minor procedures or as an induction agent followed by neuromuscular blocker and tracheal intubation. In particular, children with cyanotic heart disease and neuromuscular disorders are good candidates for ketamine anesthesia. Due to the bronchodilating properties of ketamine, it can be used for anesthesia in people with asthma, chronic obstructive airway disease, and with severe reactive airway disease, including active bronchospasm. Pain Ketamine infusions are used for acute pain treatment in emergency departments and in the perioperative period for individuals with refractory or intractable pain. The doses are lower than those used for anesthesia, usually referred to as sub-anesthetic doses. Adjunctive to morphine or on its own, ketamine reduces morphine use, pain level, nausea, and vomiting after surgery. Ketamine is likely to be most beneficial for surgical patients when severe post-operative pain is expected, and for opioid-tolerant patients. Ketamine is especially useful in the pre-hospital setting due to its effectiveness and low risk of respiratory depression. Ketamine has similar efficacy to opioids in a hospital emergency department setting for the management of acute pain and the control of procedural pain. It may also prevent opioid-induced hyperalgesia and postanesthetic shivering. For chronic pain, ketamine is used as an intravenous analgesic, mainly if the pain is neuropathic. It has the added benefit of counteracting spinal sensitization or wind-up phenomena experienced with chronic pain. In multiple clinical trials, ketamine infusions delivered short-term pain relief in neuropathic pain diagnoses, pain after a traumatic spine injury, fibromyalgia, and complex regional pain syndrome (CRPS). Esketamine was approved as a nasal spray for treatment-resistant depression in the United States and elsewhere in 2019. The Canadian Network for Mood and Anxiety Treatments (CANMAT) recommends esketamine as a third-line treatment for depression. The French drug regulatory agency’s 2026 approval of intravenous racemic ketamine for severe suicidal crisis marks the first official rapid-acting pharmacological option for imminent suicide risk. Most systematic reviews suggest that ketamine shows short-term efficacy in reducing suicidality with generally mild side effects, but the evidence is largely low quality and its long-term efficacy remains unclear. Existing evidence, though limited and low to very low certainty, suggests that a single intravenous dose of ketamine as an add-on to mood stabilizers may produce a rapid but transient antidepressant effect in bipolar depression. In February 2022, the US Food and Drug Administration (FDA) issued an alert to healthcare professionals concerning compounded nasal spray products containing ketamine intended to treat depression. Comparative efficacy of ketamine and esketamine The antidepressant effect of ketamine appears to be stronger and more sustained for racemic ketamine, while effects of esketamine are smaller and may diminish after treatment ends. Seizures Ketamine is used to treat status epilepticus that has not responded to standard treatments, but only case studies and no randomized controlled trials support its use. Asthma Ketamine has been suggested as a possible therapy for children with severe acute asthma who do not respond to standard treatment. This is due to its bronchodilator effects. A 2012 Cochrane review found there were minimal adverse effects reported, but the limited studies showed no significant benefit. == Contraindications ==

Some major contraindications for ketamine are: • Severe cardiovascular disease such as unstable angina or poorly controlled hypertension • Increased intracranial or intraocular pressure (however these remain controversial, with recent studies suggesting otherwise) • Poorly controlled psychosis • Severe liver disease such as cirrhosis • Pregnancy • Active substance use disorder (for serial ketamine injections) • Age less than 3 months == Adverse effects ==

At anesthetic doses, 10–20% of adults and 1–2% of children Psychotomimetic effects decrease when adding lamotrigine Liver toxicity and urologic disease Urologic diseases occur primarily in people who use large amounts of ketamine routinely, with 20–30% of frequent users having bladder complaints. It includes a range of disorders from cystitis to hydronephrosis to kidney failure. The typical symptoms of ketamine-induced cystitis are frequent urination, dysuria, and urinary urgency sometimes accompanied by pain during urination and blood in urine. The damage to the bladder wall has similarities to both interstitial and eosinophilic cystitis. The wall is thickened and the functional bladder capacity is as low as 10–150 mL. Management of ketamine-induced cystitis involves ketamine cessation as the first step. This is followed by NSAIDs and anticholinergics and, if the response is insufficient, by tramadol. The second-line treatments are epithelium-protective agents such as oral pentosan polysulfate or intravesical instillation of hyaluronic acid. Intravesical botulinum toxin is also useful. Hepatotoxicity (toxicity to the liver) of ketamine involves higher doses and repeated administration. In a group of chronic high-dose ketamine users, the frequency of liver injury was reported to be about 10%. There are case reports of increased liver enzymes involving ketamine treatment of chronic pain. cachexia, gastrointestinal diseases, hepatobiliary disorder, and acute kidney injury. Near-death experience Most people who were able to remember their dreams during ketamine anesthesia report near-death experiences (NDEs) when the broadest possible definition of an NDE is used. Ketamine can reproduce features that commonly have been associated with NDEs. A 2019 large-scale study found that written reports of ketamine experiences had a high degree of similarity to written reports of NDEs in comparison to other written reports of drug experiences. Addiction and tolerance Though there is no evidence that ketamine can cause physical dependence, some people who regularly use it can develop an addiction to it. Animal experiments also confirm the risk of misuse. Cognitive deficits as well as increased dissociation and delusions were observed in frequent recreational users of ketamine. == Interactions ==

Ketamine potentiates the sedative effects of propofol and midazolam. Naltrexone potentiates psychotomimetic effects of a low dose of ketamine, while lamotrigine and nimodipine decrease them. Clonidine reduces the increase of salivation, heart rate, and blood pressure during ketamine anesthesia and decreases the incidence of nightmares. Clinical observations suggest that benzodiazepines may diminish the antidepressant effects of ketamine. It appears most conventional antidepressants can be safely combined with ketamine. == Pharmacology ==

Pharmacodynamics Mechanism of action Ketamine is a mixture of equal amounts of two enantiomers: esketamine and arketamine. Esketamine is a far more potent NMDA receptor pore blocker than arketamine. Blocking of the NMDA receptor results in analgesia by preventing central sensitization in dorsal horn neurons; in other words, ketamine's actions interfere with pain transmission in the spinal cord. The mechanism of action of ketamine in alleviating depression is not well understood, but it is an area of active investigation. Due to the hypothesis that NMDA receptor antagonism underlies the antidepressant effects of ketamine, esketamine was developed as an antidepressant. Furthermore, animal research indicates that arketamine, the enantiomer with a weaker NMDA receptor antagonism, as well as (2R,6R)-hydroxynorketamine, the metabolite with negligible affinity for the NMDA receptor but potent alpha-7 nicotinic receptor antagonist activity, may have antidepressant action. Possible biochemical mechanisms of ketamine's antidepressant action include direct action on the NMDA receptor and downstream effects on regulators such as BDNF and mTOR. As an NMDA receptor antagonist, ketamine triggers a paradoxical acute burst of glutamate by selectively blocking inhibitory GABAergic neurons. This surge activates AMPA receptors, which modulate downstream signaling pathways in the limbic system to produce rapid antidepressant effects. Such downstream actions of the activation of AMPA receptors include upregulation of brain-derived neurotrophic factor (BDNF) and activation of its signaling receptor tropomyosin receptor kinase B (TrkB), activation of the mammalian target of rapamycin (mTOR) pathway, deactivation of glycogen synthase kinase 3 (GSK-3), and inhibition of the phosphorylation of the eukaryotic elongation factor 2 (eEF2) kinase. Molecular targets Ketamine principally acts as a pore blocker of the NMDA receptor, an ionotropic glutamate receptor. The S-(+) and R-(–) stereoisomers of ketamine bind to the dizocilpine site of the NMDA receptor with different affinities, the former showing approximately 3- to 4-fold greater affinity for the receptor than the latter. As a result, the S isomer is a more potent anesthetic and analgesic than its R counterpart. Ketamine may interact with and inhibit the NMDAR via another allosteric site on the receptor. With a couple of exceptions, ketamine actions at other receptors are far weaker than ketamine's antagonism of the NMDA receptor (see the activity table to the right). Although ketamine is a very weak ligand of the monoamine transporters (Ki > 60 μM), it has been suggested that it may interact with allosteric sites on the monoamine transporters to produce monoamine reuptake inhibition. Collectively, these findings shed doubt on the involvement of monoamine reuptake inhibition in the effects of ketamine in humans. However, later studies by different researchers found the affinity of ketamine of >10 μM for the regular human and rat D2 receptors, Moreover, whereas D2 receptor agonists such as bromocriptine can rapidly and powerfully suppress prolactin secretion, subanesthetic doses of ketamine have not been found to do this in humans and in fact, have been found to dose-dependently increase prolactin levels. Imaging studies have shown mixed results on inhibition of striatal [11C] raclopride binding by ketamine in humans, with some studies finding a significant decrease and others finding no such effect. However, changes in [11C] raclopride binding may be due to changes in dopamine concentrations induced by ketamine rather than binding of ketamine to the D2 receptor. At similar plasma concentrations (70 to 160 ng/mL; 0.29–0.67 μM) it also shows analgesic effects. When the anesthesia was maintained using nitrous oxide together with continuous injection of ketamine, the ketamine concentration stabilized at approximately 9.3 μM. In a single-case study, the concentration of ketamine in cerebrospinal fluid, a proxy for the brain concentration, during anesthesia varied between 2.8 and 6.5 μM and was approximately 40% lower than in plasma. Pharmacokinetics Ketamine can be absorbed by many different routes due to its water and lipid solubility. Intravenous ketamine bioavailability is 100% by definition, intramuscular injection bioavailability is slightly lower at 93%, Among the less invasive routes, the intranasal route has the highest bioavailability (45–50%) This also explains why oral ketamine levels are independent of CYP2B6 activity, unlike subcutaneous ketamine levels. After an intravenous injection of tritium-labelled ketamine, 91% of the radioactivity is recovered from urine and 3% from feces. The medication is excreted mostly in the form of metabolites, with only 2% remaining unchanged. Conjugated hydroxylated derivatives of ketamine (80%) followed by dehydronorketamine (16%) are the most prevalent metabolites detected in urine. == Chemistry ==

Structure In chemical structure, ketamine is an arylcyclohexylamine derivative. Ketamine is a chiral compound. The more active enantiomer, esketamine (S-ketamine), is also available for medical use under the brand name Ketanest S, while the less active enantiomer, arketamine (R-ketamine), has never been marketed as an enantiopure drug for clinical use. While S-ketamine is more effective as an analgesic and anesthetic through NMDA receptor antagonism, R-ketamine produces longer-lasting effects as an antidepressant. Detection Ketamine may be quantified in blood or plasma to confirm a diagnosis of poisoning in hospitalized people, provide evidence in an impaired driving arrest, or assist in a medicolegal death investigation. Blood or plasma ketamine concentrations are usually in a range of 0.5–5.0 mg/L in persons receiving the drug therapeutically (during general anesthesia), 1–2 mg/L in those arrested for impaired driving, and 3–20 mg/L in victims of acute fatal overdosage. Urine is often the preferred specimen for routine drug use monitoring purposes. The presence of norketamine, a pharmacologically active metabolite, is useful for confirmation of ketamine ingestion. == History ==

Ketamine was first synthesized in 1962 by Calvin L. Stevens, These investigations demonstrated ketamine's short duration of action and reduced behavioral toxicity made it a favorable choice over phencyclidine (PCP) as an anesthetic. The researchers wanted to call the state of ketamine anesthesia "dreaming", but Parke-Davis did not approve of the name. Hearing about this problem and the "disconnected" appearance of treated people, Mrs. Edward F. Domino, the wife of one of the pharmacologists working on ketamine, suggested "dissociative anesthesia". has been described as the single most important advance in the treatment of depression in more than 50 years. and has shifted the direction of antidepressant research and development. == Society and culture ==

Legal status While ketamine is marketed legally in many countries worldwide, it is also a controlled substance in many countries. • In Canada, ketamine has been classified as a Schedule I narcotic since 2005. • In December 2013, the government of India, in response to rising recreational use and the use of ketamine as a date rape drug, added it to Schedule X of the Drug and Cosmetics Act requiring a special license for sale and maintenance of records of all sales for two years. • In the United Kingdom, it was labeled a Class B drug on 12 February 2014. In 2025, the Home Office requested a review of the classification with a view to changing it to Class A, based on an increase in recreational use and the negative health consequences. • The increase in recreational use prompted ketamine to be placed in Schedule III of the United States Controlled Substances Act in August 1999. Recreational use At sub-anesthetic doses, ketamine produces a dissociative state, characterised by a sense of detachment from one's physical body and the external world that is known as depersonalization and derealization. At sufficiently high doses, users may experience what is called the "K-hole", a state of dissociation with visual and auditory hallucination. John C. Lilly, Marcia Moore, and D. M. Turner (among others) have written extensively about their own entheogenic and psychonautic experiences with ketamine. Turner died prematurely due to drowning during presumed unsupervised ketamine use. Recreational ketamine use has been implicated in deaths globally, with more than 90 deaths in England and Wales in 2005–2013. The majority of deaths were among young people. Several months after being found dead in his hot tub, actor Matthew Perry's October 2023 apparent drowning death was revealed to have been caused by a ketamine overdose, and, while other factors were present, the acute effects of ketamine were ruled to be the primary cause of death. Due to its ability to cause confusion and amnesia, ketamine has been used for date rape. == Research ==

A 2023 meta-analysis found that racemic ketamine, particularly at higher doses, is more effective than esketamine in reducing depression severity, with more sustained benefits over time. Ketamine appears to provide rapid (<12 h) and sustained (up to 1–2 weeks) reduction in anxiety across various clinical settings, with improvements correlating with depression improvements but not with peak dissociation. Ketamine has shown potential for rapid and tolerable symptom relief in obsessive-compulsive disorder, but evidence is limited and inconsistent. Several systematic reviews and meta-analyses suggest ketamine may produce short-term (≈ 24 hr) reductions in post-traumatic stress disorder symptoms, but overall evidence quality is low, long-term effects are unclear, and side effects occur. Ketamine shows promising short-term effects in reducing withdrawal, cravings, and improving abstinence across substance use disorders, especially when combined with therapy; however, evidence remains limited and heterogeneous, with unresolved concerns about optimal dosing, long-term safety, and misuse risk. Ketamine, especially when combined with psychotherapy, shows potential to reduce alcohol and cocaine use, but evidence is limited, mixed, and low-quality, with inconclusive results for opioids. The British critical psychiatrist Joanna Moncrieff has critiqued the use and study of ketamine and related drugs like psychedelics for treatment of psychiatric disorders, highlighting concerns including excessive hype around these drugs, questionable biologically-based theories of benefit, blurred lines between medical and recreational use, flawed clinical trial findings, financial conflicts of interest, strong expectancy effects and large placebo responses, small and short-term benefits over placebo, and their potential for difficult experiences and adverse effects, among others. == Veterinary uses ==

In veterinary anesthesia, ketamine is often used for its anesthetic and analgesic effects on cats, dogs, rabbits, rats, and other small animals. It is frequently used in induction and anesthetic maintenance in horses. It is an important part of the "rodent cocktail", a mixture of drugs used for anesthetising rodents. Veterinarians often use ketamine with sedative drugs to produce balanced anesthesia and analgesia, and as a constant-rate infusion to help prevent pain wind-up. Ketamine is also used to manage pain among large animals. It is the primary intravenous anesthetic agent used in equine surgery, often in conjunction with detomidine and thiopental, or sometimes guaifenesin. Ketamine appears not to produce sedation or anesthesia in snails. Instead, it appears to have an excitatory effect. == References ==