This document provides information on the emergency medicines ketamine and fentanyl. Ketamine can be used for induction and maintenance of anesthesia, procedural sedation and analgesia, and sedation during ventilation. Common side effects include increased blood pressure, muscle tone changes, nausea and vomiting. Emergence reactions may occur for up to 24 hours after use. Fentanyl is an opioid analgesic that can be used for severe acute or chronic pain and breakthrough cancer pain. It comes in various forms including sublingual tablets, lozenges, injections and patches. Proper administration techniques are described to maximize benefits and minimize risks.

1. Emergency medicines
(Ketamine and Fentanyl
Zeeshan Naseer

2. Ketamine (Ketalar 200mg/2ml)
 Indications
 Induction and maintenance of anaesthesia
 Procedural sedation and analgesia
 Sedation during ventilation
 DOSE - When used as sole agent:
 IV, up to 1–1.5 mg/kg slowly titrated to effect over 2–5 minutes; then give half dose
every 10 minutes if required.
 IM, 3–4 mg/kg; give half dose after 10 minutes if required.

3. Administration advice
Dilute dose with an equal volume of water for
sodium chloride 0.9% or glucose 5% before IV injection.
Give IV slowly (over at least 1 minute); rapid
administration may result in respiratory depression and
enhanced hypertensive response.
Common Adverse effects (>1%)
Raised BP and pulse rate, increased muscle
tone (sometimes like seizures), hyper-
salivation, nausea and vomiting,
emergence reactions
After a single dose, analgesic effects last about
40 minutes and amnesia lasts 1–2 hours

4. Emergence reactions
May occur during recovery and for up to
24 hours. They include vivid (possibly
unpleasant) dreams, restlessness,
hallucinations and irrational behaviour.
Urinary tract symptoms
There are reports of urinary symptoms including dysuria,
frequency, suprapubic pain and haematuria associated with
chronic ketamine misuse, as well as rare reports in patients
prescribed regular ketamine for chronic pain. Symptoms may
be reversible if ketamine is stopped but continued use could
lead to severe, irreversible damage.

5. Illicit/recreational use of ketamine
occurs (known as ‘special K’ or
‘vitamin K’)
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6. Fentanyl
 Opioid analgesic
 Severe Pain – Acute and chronic pain
 Breakthrough pain in patients stabilised on opioid analgesia for cancer pain
(lozenge, buccal and sublingual tablets)
 Epidural analgesia
 1) Abstral 100mcg – 800 mcg Sublingual tablets.
 2) Actiq 200mcg – 1600 mcg Lozenges
 3) Fentanyl Injection 100mcg/2ml
 4) Patches (Durogescis 12mcg/hours – 100mcg/hour)

7. Dose: 1.5mcg/kg (Maximum 100 mcg intranasal)
Analgesic effect: 100–150 micrograms fentanyl SC is
approximately equivalent to 10 mg morphine IM/SC.
Dose for tablets and patches:
Start low and go slow
?Dose conversions
12 micrograms/hour patch is approximately equivalent
to 45 mg oral morphine daily.

8. Intranasal
Draw up required volume into a syringe (allow an extra 0.1 mL
with first dose for priming), then attach an atomiser. Sit child at
a 45 degree angle or with head to one side. Squirt dose in
approximately 0.2 mL aliquots (to maximise absorption and
minimise sneezing) alternating between nostrils. Allow a short
interval (<1 minute) between aliquots if using only one nostril.

9. Patch
Write the date and time of application on the patch with permanent marker,
then apply it to dry, hairless, non-irritated skin on the upper part of your
or upper arm. Do not apply straight after a hot bath or shower, wait until skin
is cool and dry. Do not use if patch is damaged or cut. Check the patch is still
attached on the days between patch changes.
Remove after 3 days (72 hours) and put a new patch on a different place.
sure you know how to dispose of patches safely.
When wearing the patch, do not allow it to come into contact with direct
sources of heat such as electric blankets, heat pads, heat lamps, saunas or
baths.
After removing a patch, avoid exposing that area of skin to the sun for 2 days
as it may be more sensitive.

10. Warning
Abstral®, Actiq® and Fentora® are not
interchangeable. When switching, begin new brand
with its starting dose and titrate to minimise serious
toxicity.
Sedation score
•0 – wide awake
•1 – easy to rouse
•2 – easy to rouse, but cannot stay awake
•3 – difficult to rouse.
Aim to keep the sedation score <2; a score of 2
represents early respiratory depression.
Reference: Australian Medicines Handbook (AMH
2021)