Evaluating Ketamine Dosing Practices During Emergency Department Intubation Using Shock Index Stratification

Background  The accurate dosing of ketamine during rapid sequence intubation in emergency settings is critical, especially in patients with varying hemodynamic states. This study describes ketamine dosing practices during rapid sequence intubation in a tertiary emergency department, focusing on concordance with predefined dosing ranges based on shock index. The primary goal is to analyze registry data to assess concordance with recommended weight-based dosing ranges, considering shock index and shock dosing. Methods  We analyzed intubation data from the Emergency Medicine - Airway Registry (EM-AWARE) from 2015 to 2021. We included adult patients aged 18 years and above who underwent intubation with ketamine as the sole sedative agent, and stratified patients into two groups: those with a normal shock index below 0.9 and those with an abnormal shock index at or above 0.9. Data were analyzed to determine the proportion of patients who received ketamine doses within, below, or above predefined dosing ranges, and results were compared across the two groups. Results  Forty-six patients met the inclusion criteria. There were 29 patients in the normal shock index group, and among these patients, 72% (n = 21) received a dose within the predefined range, and 28% (n = 8) received doses below the range. There were 17 patients in the abnormal shock index group, with 76% (n = 13) receiving a reduced dose within the predefined range and 24% (n = 4) receiving doses outside the range, primarily above the recommended shock dosing range. Overall rates of dosing outside predefined ranges were similar between groups, ranging from 24% to 28%.  Conclusion  In this single-centre registry analysis, approximately one-quarter of emergency department patients received ketamine doses outside predefined ranges during intubation, regardless of shock index. These findings highlight persistent variability in ketamine dosing practices during emergency airway management.