The American Society of Regional Anesthesia and Pain Medicine, The American Academy of Pain Medicine, and The American Society of Anesthesiologists state that evidence supports the use of ketamine for acute pain as stand-alone treatment, as an adjunct to opioids, and as an intranasal formulation.

The following is recommended:
Subanesthetic ketamine infusions should be considered for patients undergoing painful surgery (grade B recommendation, moderate level of certainty).
Ketamine may be considered for opioid-dependent or opioid-tolerant patients undergoing surgery (grade B recommendation, low level of certainty).
Ketamine may be considered for opioid-dependent or opioid-tolerant patients with acute or chronic sickle cell pain (grade C recommendation, low level of certainty).
For patients with sleep apnea, ketamine may be considered as an adjunct to limit opioids (grade C recommendation, low level of certainty).
It is recommended that ketamine bolus doses do not exceed 0.35 mg/kg, and infusions for acute pain generally do not exceed 1 mg/kg per hour in settings without intensive monitoring. Ketamine's adverse effects will prevent some patients from tolerating higher doses in acute pain settings, and unlike for chronic pain therapy, lower doses (ie, 0.1–0.5 mg/kg per hour) may be needed to achieve an adequate balance of analgesia and adverse effects (grade C recommendation, moderate level of certainty).
Evidence supports use of subanesthetic IV ketamine bolus doses (up to 0.35 mg/kg) and infusions (up to 1 mg/kg per hour) as adjuncts to opioids for perioperative analgesia (grade B recommendation, moderate level of certainty).
The use of intranasal ketamine is beneficial for acute pain management, providing not only effective analgesia but also amnesia and procedural sedation. (grade C recommendation, low-to-moderate level of certainty).
Moderate evidence supports the benefit of the addition of ketamine to an opioid-based IV-PCA for acute and perioperative pain management (grade B recommendation, moderate level of certainty).

There is no mention of suicidal ideation in the guidelines. [1]

Ketamine can induce rapid antidepressant effects, in contrast to the delayed effects seen with current treatments. It can also induce a rapid amelioration of suicidal ideation in major depressed patients and rapidly reduce anhedonia. Proposed mechanisms of ketamine’s action may act in a complementary fashion to exert the acute changes in synaptic plasticity, leading to sustained strengthening of excitatory synapses, which are necessary for antidepressant behavioral actions. [2]

A subanaesthetic dose (0.5 mg/kg) by intravenous infusion, typically over 40 min is effective in controlling suicidal ideation. Lowering the dose to 0.2–0.25 mg/kg and infusion over 2–3 min is effective in controlling suicidal tendencies in smaller populations. [3]

A systematic review and individual participant data meta-analysis examining the effects of a single dose of ketamine on suicidal ideation
found that ketamine rapidly reduced suicidal thoughts within one day and for up to one week in patients. Individual participant data were obtained from 10 comparison intervention studies that used saline or midazolam as controls, and included a total 167 patients. The primary outcome measures were suicide items from clinician-administered and self-reported scales obtained for up to one week post-ketamine administration. Ketamine rapidly reduced (one day) suicidal ideation on both the clinician-administered (p<0.001) and self-reported outcome measures (p<0.001). Effect sizes were moderate-to-large (Cohen’s d=0.51–0.85) at all time points post-dose. [4]

A meta-analyses assessing acute effects of intravenous (IV) ketamine in patients with suicidal ideation included five single-arm clinical trials, comprising 99 unique subjects with current suicidal ideation. Of the 99 patients, 63 were treated with IV ketamine 0.2 mg/kg bolus and 36 were treated with 0.5 mg/kg infusion. Given the maximum endpoint of four hours, a decrease was found in suicidal ideation (SMD = −0.92; 95%CI: −1.40 to −0.44; p <0.001), with low heterogeneity across studies (I2 = 21.6%). Although not significantly (p = 0.27), the effect of ketamine bolus (SMD = −2.11; p = 0.06) was higher as compared with relevant effect of ketamine infusion (SMD = −0.86; p = 0.001). [5]

KETALAR (ketamine hydrochloride) is indicated as the sole anesthetic agent for diagnostic and surgical procedures that do not
require skeletal muscle relaxation, for the induction of anesthesia prior to the administration of other general anesthetic agents, and to supplement low-potency agents, such as nitrous oxide.

The initial dose of KETALAR administered intravenously may range from 1 mg/kg to 4.5 mg/kg. The average amount required to produce 5 to 10 minutes of surgical anesthesia within 30 seconds following injection is 2 mg/kg. Administer KETALAR slowly (i.e., over a period of 60 seconds). Do not intravenously inject the 100 mg/mL concentration of KETALAR without proper dilution. Dilute KETALAR with an equal volume of either Sterile Water for injection, USP, 0.9% Sodium Chloride Injection, USP (Normal Saline), or 5% Dextrose in Water. Use immediately after dilution.

The initial dose of KETALAR administered intramuscularly may range from 6.5 to 13 mg/kg. A dose of 9 to 13 mg/kg usually produces surgical anesthesia within 3 to 4 minutes following injection, with the anesthetic effect usually lasting 12 to 25 minutes.

KETALAR injection is a clear, colorless, sterile solution available in multiple-dose vials containing either 10 mg ketamine base (equivalent to 11.53 mg ketamine hydrochloride), 50 mg ketamine base (equivalent to 57.67 mg ketamine hydrochloride) or 100 mg ketamine base (equivalent to 115.33 mg ketamine hydrochloride). It can come in the following: 200 mg/20 mL (10 mg/mL), 500 mg/10 mL (50 mg/mL), 500 mg/5 mL (100 mg/mL).

Warnings and precautions for KETALAR include: hemodynamic instability, emergence delirium reactions, respiratory depression, drug-induced liver injury, increase in cerebrospinal fluid pressure. Avoid KETALAR administration as a sole anesthetic agent during procedures of the pharynx, larynx, or bronchial tree, including mechanical stimulation of the pharynx.

Concomitant administration of KETALAR and theophylline or aminophylline may lower the seizure threshold. Sympathomimetics and vasopressin may enhance the sympathomimetic effects of ketamine. Concomitant use of ketamine with opioid analgesics, benzodiazepines, or other central nervous system (CNS) depressants, including alcohol, may result in profound sedation, respiratory depression, coma, and death.

KETALAR contains ketamine, a Schedule III controlled substance under the Controlled Substance Act. Thus, abuse and dependence may be possible.

KETALAR injection should be stored at 20°C to 25°C (68°F to 77°F); excursions permitted between 15°C to 30°C (59°F to 86°F). Protect from light.

A search of the published medical literature revealed 1 study investigating the researchable question:

Can ketamine provide rapid-onset, anti-suicidal benefit for patients with acute, severe suicidal ideation?

B - One high-quality study or multiple studies with limitations  Read more→