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Ketamine is a safe, effective, and appropriate technique for emergency department paediatric procedural sedation
  1. S M Green1,
  2. B Krauss2
  1. 1Department of Emergency Medicine, Loma Linda University Medical Center and Children’s Hospital, Loma Linda, California, USA
  2. 2The Division of Emergency Medicine, Children’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
  1. Correspondence to:
 Dr S M Green
 Loma Linda University Medical Center A-108, 11234 Anderson Street, Loma Linda, CA 92354, USA; stevegreentarascon.com

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Ketamine has an important role in the management of acutely injured children

Three reports in this issue of the journal substantively advance the status of ketamine for paediatric procedural sedation in the emergency department (ED). McGlone et al1 and Ellis et al2 report a total of 590 ketamine administrations, together noting a high level of sedation efficacy, strong degrees of parental and staff satisfaction, and an adverse effect profile readily manageable by trained emergency physicians. In a third report, Howes3 capably reviews the now abundant literature supporting the safety of this dissociative sedative technique.

These reports are entirely consistent with many previous ED series from the United Kingdom4–7 and elsewhere8–18 reporting the safety of ketamine in literally thousands of children. The exceptional track record for this drug in various non-ED settings has also been well reported.19

Ketamine is now widely accepted as a standard of care for ED paediatric procedural sedation in the United States.8–22 The unique dissociative state induced by ketamine is inconsistent with all accepted definitions of general anaesthesia, and thus any allegation that this drug is an “anaesthetic”—and thus somehow dangerous—is an exercise in semantics rather than in safety or appropriateness.21 The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)—the United States accrediting body for hospitals—has confirmed that ED ketamine administration is fully compliant with their standards when administered according to protocol.22 The Executive Committee of the American Academy of Pediatrics’ Section on Anesthesiology has acknowledged that “ketamine has had wide and safe use by nonanesthesiologists”,23 and perhaps no non-anaesthetists are better trained to manage sedation and its complications than are emergency physicians given their skill set. Resistance from American chiefs of anaesthesia to ED ketamine protocols—common in the 1990s—has now all but evaporated attributable in large part to the robust data showing the safety and efficacy of ketamine use for children by emergency physicians.

Yes, ketamine is extremely safe. However, its administration requires skilled practitioners well versed in its unique action, aware of its many contraindications, and fully prepared to manage its potential complications with confidence. Airway malalignment (0.7% incidence), laryngospasm (0.4%), and apnea/respiratory depression (0.3%) do rarely occur in the ED setting; however no adverse outcomes relating to these complications have been reported.1–18 In 33 years of regular use there have been no reported reports of ketamine associated clinically significant aspiration in patients without established contraindications.18–20 Indeed, the unique retention of protective airway reflexes with ketamine despite full dissociation makes this drug especially well suited for urgent and emergent procedures commonly performed in the ED on non-fasted patients.24

ED use of ketamine should optimally occur only in strict accordance with a protocol such as that sanctioned by the JCAHO.22 Ketamine is not the perfect ED sedative, as emesis well into recovery is not uncommon (6.7% incidence)8 and recovery times (median 110 minutes)8 are substantially longer than with newer ultra-short acting agents such as propofol.20

If ketamine is not already in widespread use in EDs in the United Kingdom, it is not because the drug is unsafe, ineffective, or that its experience has not been rigorously reported. It is probably because of the qualifications of the practitioners to whom responsibility for its management would rest. Ketamine is not an appropriate agent for unsupervised use by junior house officers. In the United States ketamine is administered by senior registrar or consultant level career emergency physicians (or by trainees under their direct supervision) who supervise the ED 24 hours per day and are immediately available to manage potential sedation complications. American emergency physicians undergo at least three years of postgraduate training in emergency medicine, including expert level skills in procedural sedation and its component skills: advanced airway management, vascular access, pharmacology, and resuscitation.

Emergency physicians in the United Kingdom who possess the above requisites should not be hindered from enacting ketamine protocols and administering this drug to select patients. Indeed it would seem the duty of anaesthetists and hospital leadership to—whenever and however appropriate—assist emergency physicians in providing such state of the art management of procedural pain and anxiety for the benefit of the acutely injured children we serve.

Ketamine has an important role in the management of acutely injured children

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