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WHAT IS KETAMINE?
It is a dissociative anaesthetic that has some hallucinogenic effects. It distorts perceptions of sight and sound and makes the user feel disconnected and not in control. It is an injectable, short-acting anaesthetic for use in humans and animals.
It is referred to as a “dissociative anaesthetic” because it makes patients feel detached from their pain and environment. Ketamine can induce a state of sedation (feeling calm and relaxed), immobility, relief from pain, and amnesia (no memory of events while under the influence of the drug).
It is abused for its ability to produce dissociative sensations and hallucinations. Ketamine has also been used to facilitate sexual assault.
WHAT IS ITS ORIGIN?
Originally Ketamine is produced commercially in a number of countries, including the United States. Most of the ketamine illegally distributed in the United States is diverted or stolen from legitimate sources, particularly veterinary clinics, or smuggled into the United States from Mexico.
Distribution of ketamine typically occurs among friends and acquaintances, most often at raves, nightclubs, and at private parties; street sales of ketamine are rare.
What are the common street names?
Common street names include: t Cat Tranquilizer, Cat Valium, Jet K, Kit Kat, Purple, Special K, Special La Coke, Super Acid, Super K, and Vitamin K What does it look like? Ketamine comes in a clear liquid and a white or off-white powder.
Powdered ketamine (100 milligrams to 200 milligrams) typically is packaged in small glass vials, small plastic bags, and capsules as well as paper, glassine, or aluminium foil folds.
Slang for experiences related to Ketamine or effects of ketamine include:
t “K-land” (refers to a mellow & colourful experience) t “K-hole” (refers to the out-of-body, near-death experience) t “Baby food” (users sink into blissful, infantile inertia) t “God” (users are convinced that they have met their maker).
The onset of effects is rapid and often occurs within a few minutes of taking the drug, though taking it orally results in a slightly slower onset of effects.
Flashbacks have been reported several weeks after ketamine is used. Ketamine may also cause agitation, depression, cognitive difficulties, unconsciousness, and amnesia. What is its effect on the body?.
A couple of minutes after taking the drug, the user may experience an increase in heart rate and blood pressure that gradually decreases over the next 10 to 20 minutes.
Ketamine can make users unresponsive to stimuli. When in this state, users experience: t Involuntarily rapid eye movement, dilated pupils, salivation, tear secretions, and stiffening of the muscles This drug can also cause nausea.
What are its overdose effects? An overdose can cause unconsciousness and dangerously slowed breathing. Which drugs cause similar effects? Other hallucinogenic drugs such as LSD, PCP, and mescaline can cause hallucinations.
There are also several drugs such as GHB, Rohypnol, and other depressants that are misused for their amnesiac or sedative properties to facilitate sexual assault.
As an anaesthetic agent for diagnostic and surgical procedures. When used by intravenous or intramuscular injection, Ketamine is best suited for short procedures.
With additional doses, or by intravenous infusion, Ketamine can be used for longer procedures. If skeletal muscle relaxation is desired, a muscle relaxant should be used and respiration should be supported.
For the induction of anaesthesia prior to the administration of other general anaesthetic agents. To supplement other anaesthetic agents.
Specific areas of application or types of procedures:
When the intramuscular route of administration is preferred.
Debridement, painful dressings, and skin grafting in burned patients, as well as other superficial surgical procedures.
Neurodiagnostic procedures such as pneumoencephalograms, ventriculograms, myelograms, and lumbar punctures.
Diagnostic and operative procedures of the eye, ear, nose, and mouth, including dental extractions.
Note: Eye movements may persist during ophthalmological procedures.
Anaesthesia in poor-risk patients with depression of vital functions or where depression of vital functions must be avoided, if at all possible.
Orthopaedic procedures such as closed reductions, manipulations, femoral pinning, amputations, and biopsies.
Sigmoidoscopy and minor surgery of the anus and rectum, circumcision and pilonidal sinus.
Cardiac catheterization procedures.
Caesarean section; as an induction agent in the absence of elevated blood pressure.
Anaesthesia in the asthmatic patient, either to minimise the risks of an attack of bronchospasm developing, or in the presence of bronchospasm where anaesthesia cannot be delayed.
Posology and method of administration
For intravenous infusion, intravenous injection or intramuscular injection.
NOTE: All doses are given in terms of ketamine base
Adults, elderly (over 65 years) and children:
For surgery in elderly patients, ketamine has been shown to be suitable either alone or supplemented with other anaesthetic agents.
Ketamine has been safely used alone when the stomach was not empty. However, since the need for supplemental agents and muscle relaxants cannot be predicted, when preparing for elective surgery it is advisable that nothing be given by mouth for at least six hours prior to anaesthesia.
Premedication with an anticholinergic agent (e.g. atropine, hyoscine or glycopyrrolate) or another drying agent should be given at an appropriate interval prior to induction to reduce ketamine-induced hypersalivation.
Midazolam, diazepam, lorazepam, or flunitrazepam used as a premedical or as an adjunct to ketamine, have been effective in reducing the incidence of emergence reactions.
Onset and duration
As with other general anaesthetic agents, the individual response to Ketamine is somewhat varied depending on the dose, route of administration, age of the patient, and concomitant use of other agents, so that dosage recommendation cannot be absolutely fixed. The dose should be titrated against the patient’s requirements.
Because of rapid induction following intravenous injection, the patient should be in a supported position during administration. An intravenous dose of 2 mg/kg of body weight usually produces surgical anaesthesia within 30 seconds after injection and the anaesthetic effect usually lasts 5 to10 minutes.
An intramuscular dose of 10 mg/kg of body weight usually produces surgical anaesthesia within 3 to 4 minutes following injection and the anaesthetic effect usually lasts 12 to 25 minutes. Return to consciousness is gradual.
- Ketamine as the sole anaesthetic agent
The use of Ketamine by continuous infusion enables the dose to be titrated more closely, thereby reducing the amount of drug administered compared with intermittent administration. This results in shorter recovery time and better stability of vital signs.
A solution containing 1 mg/ml of ketamine in dextrose 5% or sodium chloride 0.9% is suitable for administration by infusion.
The initial dose of Ketamine administered intravenously may range from 1 mg/kg to 4.5 mg/kg (in terms of ketamine base). The average amount required to produce 5 to 10 minutes of surgical anaesthesia has been 2.0 mg/kg.
It is recommended that intravenous administration be accomplished slowly (over a period of 60 seconds). More rapid administration may result in respiratory depression and enhanced pressor response.
Dosage in Obstetrics
In obstetrics, for vaginal delivery or in caesarean section, intravenous doses ranging from 0.2 to 1.0 mg/kg are recommended (see section 4.6 Fertility, pregnancy and lactation).
The initial dose of Ketamine administered intramuscularly may range from 6.5 mg/kg to 13 mg/kg (in terms of ketamine base). A low initial intramuscular dose of 4 mg/kg has been used in diagnostic manoeuvres and procedures not involving intensely painful stimuli. A dose of 10 mg/kg will usually produce 12 to 25 minutes of surgical anaesthesia.
Dosage in Hepatic Insufficiency:
Dose reductions should be considered in patients with cirrhosis or other types of liver impairment. (see section 4.4 Special Warnings and Special Precautions for Use)
Dosage in Obstetrics
Data are lacking for intramuscular injection and maintenance infusion of ketamine in the parturient population, and recommendations cannot be made. Available data are presented in Section 5.2.
Maintenance of general anaesthesia
Lightening of anaesthesia may be indicated by nystagmus, movements in response to stimulation, and vocalization. Anaesthesia is maintained by the administration of additional doses of Ketamine by either the intravenous or intramuscular route.
Each additional dose is from ½ to the full induction dose recommended above for the route selected for maintenance, regardless of the route used for induction.
The larger the total amount of Ketamine administered, the longer will be the time to complete recovery.
Purposeless and tonic-clonic movements of extremities may occur during the course of anaesthesia. These movements do not imply a light plane and are not indicative of the need for additional doses of the anaesthetic.
- Ketamine as induction agent prior to the use of other general anaesthetics
Induction is accomplished by a full intravenous or intramuscular dose of Ketamine as defined above. If Ketamine has been administered intravenously and the principal anaesthetic is slow-acting, a second dose of Ketamine may be required 5 to 8 minutes following the initial dose.
If Ketamine has been administered intramuscularly and the principal anaesthetic is rapid-acting, administration of the principal anaesthetic may be delayed up to 15 minutes following the injection of Ketamine.
- Ketamine as a supplement to anaesthetic agents
Ketamine is clinically compatible with the commonly used general and local anaesthetic agents when an adequate respiratory exchange is maintained. The dose of Ketamine for use in conjunction with other anaesthetic agents is usually in the same range as the dosage stated above; however, the use of another anaesthetic agent may allow a reduction in the dose of Ketamine
Special warnings and precautions for use
To be used only in hospitals by or under the supervision of experienced medically qualified anaesthetists except under emergency conditions.
As with any general anaesthetic agent, resuscitative equipment should be available and ready for use.
Respiratory depression may occur with overdosage of Ketamine, in which case supportive ventilation should be employed. Mechanical support of respiration is preferred to the administration of analeptics.
The intravenous dose should be administered over a period of 60 seconds. More rapid administration may result in transient respiratory depression or apnoea and enhanced pressor response.
Because pharyngeal and laryngeal reflexes usually remain active, mechanical stimulation of the pharynx should be avoided unless muscle relaxants, with proper attention to respiration, are used.
Although aspiration of contrast medium has been reported during Ketamine anaesthesia under experimental conditions (Taylor, P A and Towey, R M, Brit. Med. J. 1971, 2: 688), in clinical practice aspiration is seldom a problem.
In surgical procedures involving visceral pain pathways, Ketamine should be supplemented with an agent which obtunds visceral pain.
When Ketamine is used on an outpatient basis, the patient should not be released until recovery from anaesthesia is complete and then should be accompanied by a responsible adult.
Ketamine for sale, should be used with caution in patients with the following conditions:
- Use with caution in the chronic alcoholic and the acutely alcohol-intoxicated patient.
- Ketamine is metabolised in the liver and hepatic clearance is required for termination of clinical effects. A prolonged duration of action may occur in patients with cirrhosis or other types of liver impairment.
- Dose reductions should be considered in these patients. Abnormal liver function tests associated with ketamine use have been reported, particularly with extended use (>3 days) or drug abuse.
- Since an increase in cerebrospinal fluid (CSF) pressure has been reported during Ketamine anaesthesia, Ketamine should be used with special caution in patients with pre-anaesthetic elevated cerebrospinal fluid pressure.
- Use with caution in patients with globe injuries and increased intraocular pressure (e.g. glaucoma) because the pressure may increase significantly after a single dose of ketamine.
- Use with caution in patients with neurotic traits or psychiatric illness (e.g. schizophrenia and acute psychosis)
- Use in caution in patients with acute intermittent porphyria.
- Use in caution in patients with seizures.
- Use in caution in patients with hyperthyroidism or patients receiving thyroid replacement (increased risk of hypertension and tachycardia)
- Use in caution in patients with a pulmonary or upper respiratory infection (ketamine sensitises the gag reflex, potentially causing laryngospasm)
- Use in caution in patients with intracranial mass lesions, a presence of head injury, or hydrocephalus.
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The psychological manifestations vary in severity between pleasant dream-like states, vivid imagery, hallucinations, nightmares and emergence delirium (often consisting of dissociative or floating sensations).
In some cases, these states have been accompanied by confusion, excitement, and irrational behaviour which a few patients recall as an unpleasant experience. (See section 4.8 Undesirable Effects).
Emergence delirium phenomena may occur during the recovery period. The incidence of these reactions may be reduced if verbal and tactile stimulation of the patient is minimised during the recovery period. This does not preclude the monitoring of vital signs.
Because of the substantial increase in myocardial oxygen consumption, ketamine should be used in caution in patients with hypovolemia, dehydration or cardiac disease, especially coronary artery disease (e.g. congestive heart failure, myocardial ischemia and myocardial infarction).
In addition, ketamine should be used with caution in patients with mild-to-moderate hypertension and tachyarrhythmias.
Cardiac function should be continually monitored during the procedure in patients found to have hypertension or cardiac decompensation.
Elevation of blood pressure begins shortly after the injection of Ketamine, reaches a maximum within a few minutes and usually returns to pre-anaesthetic values within 15 minutes after injection.
The median peak rise of blood pressure in clinical studies has ranged from 20 to 25 per cent of pre-anaesthetic values. Depending on the condition of the patient, this elevation of blood pressure may be considered a beneficial effect, or in others, an adverse reaction.
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Cases of cystitis including haemorrhagic cystitis, acute kidney injury, hydronephrosis, and ureteral disorders have been reported in patients being given ketamine on a long term basis, especially in the setting of ketamine abuse.
These adverse reactions develop in patients receiving long term ketamine treatment after a time ranging from 1 month to several years. Ketamine is not indicated nor recommended for long term use.
Hepatotoxicity has also been reported in patients with extended use (> 3 days).
Drug Abuse and Dependence
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Ketamine has been reported as being a drug of abuse. Reports suggest that ketamine produces a variety of symptoms including, but not limited to, flashbacks, hallucinations, dysphoria, anxiety, insomnia, or disorientation. Adverse effects have also been reported: see “Long-Term Use”.
Ketamine dependence and tolerance may develop in individuals with a history of drug abuse or dependence. Therefore, ketamine should be prescribed and administered with caution.
4.5 Interaction with other medicinal products and other forms of interaction
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Prolonged recovery time may occur if barbiturates and/or narcotics are used concurrently with Ketamine.
Diazepam is known to increase the half-life of ketamine and prolongs its pharmacodynamic effects. Dose adjustments may, therefore, be needed.
Ketamine is chemically incompatible with barbiturates and diazepam because of precipitate formation. Therefore, these should not be mixed in the same syringe or infusion fluid.
Ketamine may potentiate the neuromuscular blocking effects of atracurium and tubocurarine including respiratory depression with apnoea.
The use of halogenated anaesthetics concomitantly with ketamine can lengthen the elimination half-life of ketamine and delay recovery from anaesthesia. Concurrent use of ketamine (especially in high doses or when rapidly administered) with halogenated anaesthetics can increase the risk of developing bradycardia, hypotension or decreased cardiac output.
Ketamine for sale. The use of ketamine with other central nervous systems (CNS) depressants (e.g. ethanol, phenothiazines, sedating H1 – blockers or skeletal muscle relaxants) can potentiate CNS depression and/or increase risk of developing respiratory depression. Reduced doses of ketamine may be required with concurrent administration of other anxiolytics, sedatives and hypnotics.
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Ketamine has been reported to antagonise the hypnotic effect of thiopental.
Patients taking thyroid hormones have an increased risk of developing hypertension and tachycardia when given ketamine.
Concomitant use of antihypertensive agents and ketamine increases the risk of developing hypotension.
Sympathomimetics (directly or indirectly acting) and vasopressin may enhance the sympathomimetic effects of ketamine.
Concomitant use with ergometrine may lead to an increase in blood pressure.
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When ketamine and theophylline or aminophylline are given concurrently, a clinically significant reduction in the seizure threshold may be observed. Unpredictable extensor-type seizures have been reported with concurrent administration of these agents.
Drugs that inhibit CYP3A4 enzyme activity generally decrease hepatic clearance, resulting in increased plasma concentration of CYP3A4 substrate medications, such as ketamine. Coadministration of ketamine with drugs that inhibit CYP3A4 enzyme may require a decrease in ketamine dosage to achieve the desired clinical outcome.
Ketamine for sale. Drugs that induce CYP3A4 enzyme activity generally increase hepatic clearance, resulting in decreased plasma concentration of CYP3A4 substrate medications, such as ketamine.
Coadministration of ketamine with drugs that induce CYP3A4 enzyme may require an increase in ketamine dosage to achieve the desired clinical outcome.
4.6 Fertility, pregnancy and lactation
Ketamine for sale. Ketamine crosses the placenta. This should be borne in mind during operative obstetric procedures in pregnancy. No controlled clinical studies in pregnancy have been conducted.
The use in pregnancy has not been established and such use is not recommended, with the exception of administration during surgery for abdominal delivery or vaginal delivery.
Some neonates exposed to ketamine at maternal intravenous doses ≥ 1.5 mg/kg during delivery have experienced respiratory depression and low Apgar scores requiring newborn resuscitation.
Marked increases in maternal blood pressure and uterine tone have been observed at intravenous doses greater than 2 mg/kg.
Data are lacking for intramuscular injection and maintenance infusion of ketamine in the parturient population, and recommendations cannot be made.
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The following Adverse Events have been reported:
System Organ Class
|Immune system disorders||Rare||Anaphylactic reaction*|
|Metabolism and nutrition disorders||Uncommon||Anorexia|
|Psychiatric disorders||Common||Hallucination, Abnormal dreams, Nightmare, Confusion, Agitation, Abnormal behaviour|
|Rare||Delirium* Flashback*, Dysphoria*, Insomnia, Disorientation*|
|Nervous system disorders||Common||Nystagmus, Hypertonia, Tonic-clonic movements|
|Not Known||Intraocular pressure increased|
|Cardiac disorders||Common||Blood pressure increased, Heart rate increased|
|Respiratory, thoracic and Mediastinal disorders||Common||Respiratory rate increased|
|Uncommon||Respiratory depression, Laryngospasm|
|Rare||Obstructive airway disorder*, Apnoea*|
|Gastrointestinal disorders||Common||Nausea, Vomiting|
|Hepatobiliary disorders||Not known||Liver function test abnormal, Drug-induced liver injury**|
|Skin and subcutaneous tissue disorders||Common||Erythema, Rash morbilliform|
|Renal and urinary disorders||Rare||Cystitis*, Haemorrhagic cystitis*|
|General disorders and administration site conditions||Uncommon||Injection site pain, Injection site rash|
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