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Re: Ketamine sedation - safe and effective

Dear Editor

I read with great interest the article by MC Howes. It concerns me that much current practice in Emergency Medicine in the UK is still dictated by those outside the speciality, who have little or no idea of the needs of our patients, or the settings in which we work.

I was not surprised to read that, while ketamine sedation has been accepted both in the US and Australia as a part of modern emergency medicine practice, the UK still cautions that use of general anaesthetic (presumably including ketamine) should only be practiced by those trained in paediatric or neonatal anaesthesia.

In our own (third world) department, ketamine is often used to sedate children who need to undergo short, painful operations, including manipulation of fractures and some suturing and incision and drainage procedures.

We have a well written protocol (developed by my predecessor) which has stood the test of time (it has been in force for the past 4 years with no serious complications to date).

The key to safe and effective sedation hinges on the following: careful selection of patients (including premorbid history, airway assessment and fasting history); properly trained staff (for each procedure, ther must be at least one person responsible for the airway who can manage an emergent airway problem - this is NOT necessarily a paediatric anaesthetist) and careful selection of drugs (we use ketamine for all our younger children, with the addition of a small dose of midazolam and atropine). Finally, the patient MUST be monitored carefully until awake. In our department, pulse oximetry is mandatory, but the importance of clinical observation is stressed to all staff.