Authors: Amer, Marwa et al.
Anesthesia & Analgesia 141(2): 309-326, August 2025. doi:10.1213/ANE.0000000000007173
This Rapid Practice Guideline (RPG) was developed by an international panel of 23 experts, including a patient representative, to provide recommendations on ketamine use for analgo-sedation in critically ill adults on invasive mechanical ventilation. Evidence was synthesized from 17 randomized trials and 9 observational studies, with recommendations based on the GRADE framework.
The panel found very low to low certainty evidence regarding ketamine’s effects, with considerable uncertainty about benefits and harms. Ketamine monotherapy had unclear impact on mortality, sedation quality, or adverse effects. As an adjunct to standard sedatives, ketamine did not improve mortality outcomes, may slightly reduce ventilation duration, and showed uncertain impact on opioid sparing. Costs, resource needs, and patient values were variable across studies.
Two conditional recommendations were issued:
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Against ketamine monotherapy for analgo-sedation in critically ill adults when other agents are available.
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Ketamine may be considered as an adjunct to usual non-ketamine sedatives, but continuing standard regimens without ketamine is equally reasonable.
What you should know:
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Evidence on ketamine analgo-sedation remains limited and low certainty.
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Ketamine monotherapy is not recommended when other sedatives are available.
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As an adjunct, ketamine offers no mortality benefit, with only a minimal potential to shorten ventilation duration.
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Larger, high-quality trials are needed to clarify ketamine’s role in ICU sedation strategies.
Thank you to Anesthesia & Analgesia for publishing this important guideline on sedation management in critically ill patients.