Ketamine use in adult intensive care unit: a narrative review of emerging applications, efficacy challenges, and safety concerns

Abstract

Ketamine, a dissociative anesthetic with distinct sedative and analgesic properties, is receiving renewed attention in critical care owing to its unique pharmacological profile. Although historically limited by concerns over psychoactive side effects, its ability to maintain hemodynamic stability has prompted growing interest in its use in intensive care settings. This narrative review synthesizes emerging evidence on 10 potential applications of ketamine in the intensive care unit (ICU), including opioid-sparing analgesia, sedation during mechanical ventilation, rapid sequence intubation, and management of sepsis, postcardiac surgery states, acute brain injury, super-refractory status epilepticus, acute severe asthma, delirium, and psychiatric disorders. Although ketamine shows promising advantages—such as reduced opioid use and improved cardiovascular stability—the quality of supporting evidence remains low, with limitations including small sample sizes, study heterogeneity, and methodological concerns. Evidence regarding its impact on long-term outcomes, such as mortality, cognitive function, and length of ICU stay remains inconclusive. Some data suggest that ketamine may reduce the incidence of ICU delirium and aid in managing refractory psychiatric conditions; however, concerns about adverse effects—including cardiovascular strain, emergence reactions, and potential neurotoxicity—require cautious application. Despite these challenges, the utility of ketamine in patients with hemodynamic instability, particularly in sepsis and during tracheal intubation, highlights its potential as a versatile agent in critical care pharmacotherapy. Current guidelines recommend restrained, adjunctive use pending further high-quality evidence. This review emphasizes the need for large-scale, multicenter randomized controlled trials to define the role of ketamine, refine dosing strategies, and assess safety across diverse ICU populations. As clinical interest expands, the integration of ketamine into ICU practice must be guided by both innovation and vigilant safety monitoring.

Keywords

Intensive care unit / Ketamine / Mechanical ventilation / Opioid consumption / Rapid sequence intubation / Sepsis

Conflict of interest statement

The authors declare no conflict of interest.

Author contributions

Zeng S, Li Y, Zheng J, and Wang H conceived the study. Zeng S, Yao Z, Guan C, Cui S, and Quan Z conducted the literature search and data collection. Zeng S drafted the manuscript, and Wang H and Zheng J revised it. All authors have read and approved the final version of the manuscript.

Funding

This work was funded by the National Key Research and Development Program of China (No. 2021YFC2501800), the National Natural Science Foundation of China (No. 82472184), the Outstanding Youth Project of HeilongjiangNatural Science Foundation (No. JQ2021H002), the Key R&D Plan Project in Heilongjiang Province (No.GY2023ZB0075), the Harbin MedicalUniversity Foundation Youth Project (No. PYQN2023-9), theWuJiepingMedical Foundation (No. 320.6750.2021-4-60), and the Research Project of Heilongjiang Provincial Health Commission (No. 20241717010028).

Ethical approval of studies and informed consent

Not applicable.

Acknowledgments

We thank the Department of Critical Care Medicine at the Second Affiliated Hospital of Harbin Medical University for its support of this study.

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