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Esketamine parenteral


Solution for injection containing esketamine hydrochloride.

Drugs List

  • esketamine 250mg/10ml solution for injection ampoule
  • esketamine 25mg/5ml solution for injection ampoule
  • esketamine 50mg/2ml solution for injection ampoule
  • Therapeutic Indications


    Analgesia for painful procedures
    Analgesia in artificial respiration
    Analgesia in emergency medicine
    Induction and maintenance of anaesthesia


    The individual response to esketamine varies. The doses recommended are not fixed and should be titrated for patient's requirements.


    Induction and maintenance of general anaesthesia
    Intermittent dosing
    Induction: 0.5 to 1mg/kg given by slow intravenous injection or 2 to 4mg/kg given by intramuscular injection.
    Maintenance: Half the initial dose to be given as needed, every 10 to 15 minutes.

    Continuous dosing
    0.5 to 3mg/kg/hour given by continuous intravenous infusion.

    Analgesia in emergency medicine
    0.125 to 0.25mg/kg by slow intravenous injection or 0.25 to 0.5mg/kg by intramuscular injection.

    Analgesic supplementation of regional and local anaesthesia
    0.125 to 0.25mg/kg/hour by intravenous infusion.

    Analgesia in artificial respiration (intubated intensive care patients)
    Initial dosing
    0.25mg/kg by bolus injection.

    Continuous dosing
    0.2 to 0.5 (up to 1.5) mg/kg/hour given by continuous intravenous infusion with benzodiazepine.

    Maximum 4 to 6 weeks use for permanent infusion.


    Specific doses are not provided by the manufacturer. Dosage in children has not been adequately studied but is not expected to differ substantially from adult doses.

    Additional Dosage Information

    Dose reduction is required in patients with multiple injuries and in patients with poor general health e.g. shock, approximately half the normal dose should be used as a guideline.


    Slow intravenous injection, intramuscular injection or intravenous infusion only.

    Intravenous injection should be administered slowly to reduce risk of respiratory depression.

    Fast 4 to 6 hours before administration if possible.


    Raised intracranial pressure
    Severe hypertension
    Umbilical cord prolapse
    Uncontrolled hypertension
    Uterine rupture

    Precautions and Warnings

    Acute alcohol intoxication
    Predisposition to increased intracranial pressure
    Upper respiratory tract surgery
    Central nervous system disorder
    Chronic alcoholism
    Decompensated cardiac failure
    Hepatic cirrhosis
    Hepatic impairment
    History of angina
    History of drug misuse
    History of psychiatric disorder
    Ischaemic heart disease
    Ocular surgery
    Penetrating ocular injury
    Severe psychiatric disorder
    Unstable angina
    Within 6 months of a myocardial infarction

    Dose adjustment may be necessary in patients with hepatic impairment
    Advise patient ability to drive or operate machinery may be impaired
    Advise patient not to drive until they know how the medicine affects them
    Advise patient not to drive/operate machinery within 24 hours of treatment
    Advise patient this medicine is subject to driving restrictions
    Not all available brands are licensed for all indications
    Resuscitation facilities must be immediately available
    Treatment to be administered by or under supervision of specialist
    Ventilatory support facilities must be immediately available
    May cause respiratory depression
    Monitor vital signs, respiration & cardiac function
    Potential for drug abuse
    Hospital use only
    Advise patient not to take alcohol during and for 24 hours after therapy

    Emergence reactions may occur, including flashbacks, hallucinations, dysphoria, anxiety, insomnia or disorientation. The risk of emergence reactions during recovery from anaesthesia can be reduced by co-administration of benzodiazepine.

    Increased salivation can occur, atropine or another anticholinergic can be used as a prophylaxis.

    Muscle relaxants and supplemental analgesia are indicated when esketamine is used in a procedure that causes visceral pain.

    Esketamine is not suitable for long term use, haemorrhagic cystitis and hepatotoxicity has been reported in long term racemic ketamine use.

    Caution is advised if intracranial pressure is elevated or in patients with damage or diseases of the central nervous system, as elevation of cerebrospinal pressure has been reported with ketamine anaesthesia.

    Caution is advised if used during ocular examination or surgery where intraocular pressure should not increase.

    Avoid in situations which require relaxed uterus myometrium such as threatening uterus rupture.

    Muscle relaxants and controlled ventilation may be necessary in procedures on the pharynx larynx and bronchi.

    Patient should be accompanied home after use of anaesthesia as an outpatient.

    Esketamine should not be used as the sole anaesthetic agent in patients with manifest ischaemic cardiac disorders.

    Cardiac function should be monitored continuously in hypertensive or cardiac decompensation patients.

    Pregnancy and Lactation


    Use esketamine with caution during pregnancy.

    The manufacturer recommends that esketamine use should be restricted in pregnancy and only be used if the potential benefits outweigh the risks for the infant. Animal studies have not shown teratogenic effects and do not indicate any adverse effects. There is limited published information regarding the use of esketamine during pregnancy. Potential risks are unknown, however esketamine crosses the placental barrier and may cause respiratory depression in the neonate if used during delivery.


    Use esketamine with caution during breastfeeding.

    The manufacturer advises caution if esketamine is used when breastfeeding. There is limited published information regarding the use of esketamine during breastfeeding. Esketamine is excreted into breast milk. The manufacturer states that adverse effects seem unlikely following the use of therapeutic doses.

    Effects on Ability to Drive and Operate Machinery

    This class of medicine is in the list of drugs included in regulations under 5a of the Road Traffic Act 1988 (England and Wales). This medicine may be subject to police testing and has specified maximum blood levels for driving.
    When prescribing this medicine: Advise patient the medicine can affect cognitive function and is likely to affect ability to drive. Advise patient not to drive until they know how the medicine affects them.
    It is an offence to drive while under the influence of this medicine. However, a patient is not committing an offence (called 'statutory defence') if: 1. The medicine has been prescribed to treat a medical or dental problem and 2. The medicine has been taken according to the instructions given by the prescriber and/or in the information provided with the medicine, and 3. The medicine was not affecting the ability to drive safely. For further guidance see

    Side Effects

    Abnormal liver function tests
    Acute hepatic injury
    Anaphylactoid reaction
    Blurred vision
    Decrease in blood pressure
    Erythema at injection site
    Haemorrhagic cystitis
    Increased blood pressure
    Increased heart rate
    Increased intra-ocular pressure
    Increased mucus secretions
    Increased pulmonary vascular resistance
    Morbilliform eruption
    Pain on injection
    Psychomotor restlessness
    Respiratory depression
    Tonic-clonic spasms
    Vivid dreams


    It is strongly recommended that the UK National Poisons Information Service be consulted on cases of suspected or actual overdose where there is doubt over the degree of risk or about appropriate management.

    The following number will direct the caller to the relevant local centre (0844) 892 0111

    Information may be obtained if you have access to ToxBase the primary clinical toxicology database of the National Poisons Information Service. This is available via password on the internet ( ) or if this is unavailable at the backup site ( ).

    Further Information

    Last full review date: December 2021

    Reference Sources

    Summary of Product Characteristic: Esketamine Sintetica 25mg/ml solution for injection/infusion. Sintetica Limited. Revised February 2021.
    Summary of Product Characteristic: Esketamine Sintetica 5mg/ml solution for injection/infusion. Sintetica Limited. Revised February 2021. Government departments. Department for Transport. Publications. Drug driving and medicine: Advice for healthcare professionals. Drug driving: Guidance for healthcare professionals on drug driving. Available at:
    Last accessed: 9 December 2021

    NICE Evidence Services Available at: Last accessed: 16 December 2021

    The Norwegian Porphyria Centre (NAPOS).
    Available at:
    Last revised: 22 September 2018
    Last accessed: 16 December 2021

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