Systematic review of parenteral ketamine for managing acute agitation in emergency settings.
Christopher Peter, Satish Suhas, Guru S Gowda, Deepak Ghadigaonkar, Krishna Prasad Muliyala, Venkata Senthil Kumar Reddi
Asian Journal of Psychiatry 2025 DOI: 10.1016/j.ajp.2024.104344 (opens in new tab)
Study at a glance
AI-extracted from the abstract| Characteristics | Systematic review Peer reviewed |
|---|---|
| Sample size | 1,516 |
| Population | Patients receiving parenteral ketamine for acute agitation in emergency settings |
| Intervention | ketamine |
| Dose | mean dose of 3.83 ± 1.07 mg/kg intramuscularly, 2.09 ± 1.56 mg/kg intravenously |
| Topics | Ketamine Esketamine |
| Keywords | Aggression Emergency medicine Psychiatric emergencies Sedation Ketamine therapy Agitation management |
| Citations | 6 |
| Key findings | Parenteral ketamine provides rapid sedation for acute agitation, with an average onset of 6.1 minutes, but 24.5% of patients required additional doses or rescue medications. |
Abstract
Agitation, a significant psychiatric issue often linked to conditions like schizophrenia, bipolar disorder, and major depression, invariably pose challenges in emergency settings. Acute agitation occurs in 2.6 % of emergency cases and up to 12.2 % among patients with schizophrenia or bipolar disorder. With limited available options for effective management of acute agitation, ketamine is emerging as a fast-onset alternative to antipsychotics like haloperidol. This systematic review, following PRISMA guidelines, searched databases in April 2024 for studies on parenteral ketamine for acute agitation in emergency settings. Data extraction included patient demographics, ketamine administration details, sedation time, need for additional doses, adverse events, and intubation rates. The search yielded 7410 results, narrowing to 29 suitable studies with 1516 patients (mean age 35.5 ± 12.4 years, 67.9 % male). Ketamine was administered intramuscularly (IM) in 69 % of studies, intravenously (IV) in 6.9 %, and either IV or IM in 24.1 %. Most patients (86.5 %) received IM ketamine at a mean dose of 3.83 ± 1.07 mg/kg, while 13.5 % received IV ketamine at 2.09 ± 1.56 mg/kg. Sedation occurred on average in 6.1 min. However, 24.5 % needed rescue medications or additional doses. Adverse effects included tachycardia (5.1 %), hypertension (5.5 %), hypersalivation (5.6 %), nausea (2.1 %), emergence reactions (1.4 %), and, rarely, cardiac arrest (0.2). While 19.1 % required intubation, the reasons for the same could not be attributed to ketamine exclusively. Furthermore, there was no evidence for worsening or development of psychotic symptoms with ketamine. This review highlights the effectiveness and safety of parenteral ketamine for managing acute agitation in emergency settings. However, further research is needed to optimize ketamine use in this challenging scenario.
Comparable studies
Other systematic reviews and meta-analyses on ketamine, most cited first.
| Study | Year | Design | Participants |
|---|---|---|---|
| The effect of a single dose of intravenous ketamine on suicidal ideation: a systematic review and individual participant data meta-analysis Depressed patients with suicidal ideation at baseline | 2017 | Systematic review and individual participant data meta-analysis | n = 167 |
| Ketamine use: a review Ketamine users | 2011 | Systematic review | |
| Ketamine and Other NMDA Antagonists: Early Clinical Trials and Possible Mechanisms in Depression Participants with major depression in placebo-controlled, double-blind, randomized... | 2015 | Systematic review and meta-analysis | |
| Ketamine and postoperative pain – a quantitative systematic review of randomised trials Surgical patients from 25 countries | 2004 | Systematic review | n = 2,839 |
| Side-effects associated with ketamine use in depression: a systematic review. Patients with depression | 2018 | Systematic review |
Citations in the library
Cited by 2
- Esketamine in treatment-resistant depression with and without comorbid borderline personality disorder: A real-world longitudinal study of suicidal ideation and self-harm. Asian Journal of Psychiatry June 1, 2026
- Multimodal predictors of response to intravenous ketamine in treatment-resistant depression: toward personalized treatment in major depressive and bipolar disorders. CNS Spectrums September 28, 2026
Cites 6
- Intravenous Esketamine in Adult Treatment-Resistant Depression: A Double-Blind, Double-Randomization, Placebo-Controlled Study Biological Psychiatry November 4, 2015
- Long-term safety of ketamine and esketamine in treatment of depression Expert Opinion on Drug Safety April 13, 2022
- EFFICACY AND SAFETY OF RACEMIC KETAMINE AND ESKETAMINE FOR DEPRESSION: A SYSTEMATIC REVIEW AND META-ANALYSIS Expert Opinion on Drug Safety March 9, 2022
- Comparative Effectiveness of Intravenous Ketamine and Intranasal Esketamine in Clinical Practice Among Patients With Treatment-Refractory Depression: An Observational Study. The Journal of Clinical Psychiatry February 1, 2023
- Ketamine Treatment for Depression in Patients With a History of Psychosis or Current Psychotic Symptoms: A Systematic Review. The Journal of Clinical Psychiatry July 13, 2021
and 1 more in the library