The Dark Side of Ketamine: Brain, Bladder, and Beyond: a Focused Clinical Review for Emergency Medicine Clinicians
Anatolian Journal of Emergency Medicine June 28, 2026 DOI: 10.54996/anatolianjem.1923782 via OpenAlex
Summary
Ketamine, while essential in emergency medicine, can cause four specific adverse effects that clinicians must recognize. Acute psycho-perceptual effects occur in up to 92% of patients receiving sub-dissociative ketamine by intravenous push but can be reduced by about 40% with slow infusion. Ketamine-induced cystitis affects 25–27% of chronic users and is progressive but partially reversible with early cessation. Ketamine-induced cholangiopathy occurs in roughly 10% of chronic users and mimics primary sclerosing cholangitis. Recreational ketamine use has surged globally, with US seizures increasing over 1,100% between 2017 and 2022 and UK treatment admissions rising fivefold since 2015. Across all chronic toxicity syndromes, ketamine cessation is the single most important intervention.
Study at a glance
| Characteristics | Review Peer reviewed |
|---|---|
| Population | Emergency department patients and chronic users |
| Topics | Ketamine |
| Keywords | Adverse effect Emergency department Dissociative Chronic pain |
| Key finding | Ketamine can cause acute psycho-perceptual effects, ketamine-induced cystitis, ketamine-associated cholangiopathy, and ketamine use disorder, all of which emergency physicians should identify and manage, with cessation being the key intervention for chronic toxicity. |
Abstract
Ketamine is an indispensable therapeutic in emergency medicine, yet its pharmacologic profile carries a unique constellation of adverse effects that emergency medicine clinicians must recognize and manage. This focused clinical review examines four categories of these ketamine-specific adverse effects encountered in the emergency department (ED): acute psycho-perceptual adverse effects (PPAEs) (during analgesic use), ketamine-induced cystitis (KIC) (a progressive uropathy), ketamine-associated cholangiopathy (a sclerosing cholangitis–like syndrome), and ketamine use disorder (KUD) (encompassing dependence and withdrawal). The review summarizes current evidence addressing epidemiology, pathophysiology, clinical presentation, ED management, and disposition of patients experiencing these adverse effects and provides a practical approach for their management. Recreational ketamine use has surged globally, with illicit seizures in the United States increasing over 1,100% between 2017 and 2022 and UK treatment admissions rising fivefold since 2015. Psycho-perceptual effects occur in up to 92% of patients receiving sub-dissociative ketamine by intravenous push but can be reduced by approximately 40% with slow infusion. Ketamine-induced cystitis affects 25–27% of chronic users and is progressive yet partially reversible with early cessation. Ketamine-induced cholangiopathy occurs in roughly 10% of chronic users and mimics primary sclerosing cholangitis. Across all chronic toxicity syndromes, ketamine cessation is the single most important intervention. Emergency physicians are uniquely positioned to identify these conditions, initiate treatment, and connect patients to specialized care.