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Definitive studies are needed
In the United Kingdom, there is very little formal competency based training in the techniques of paediatric procedural sedation except in the specialty of dentistry.1,2 Procedural sedation is often delegated to junior medical staff using a local protocol. The procedures for informed consent, documentation, monitoring, recovery, follow up, and audit are varied and often non-existent. This situation is changing as new clinical governance and training systems are put in place. In Scotland, the Scottish Intercollegiate Guidelines Network (SIGN) has produced a multidisciplinary, evidence based, peer reviewed guideline for the management of paediatric procedural sedation.3 The consensus view of this group was that, in Scotland, ketamine (and agents such as propofol, fentanyl, alfentanil, and remifentanil) should only be used by those trained in and with adequate on-going experience of paediatric anaesthesia and/or intensive care. It should only be used in a hospital setting. The product licence (and indeed the vial) states that ketamine is an intravenous general anaesthetic agent that should only be used by a trained anaesthetist.
The specialty of accident and emergency medicine is developing rapidly in the UK and consultant led and consultant based 24 hour services are becoming more common. The Faculty of Accident and Emergency Medicine were formally involved in the development and peer review of the SIGN guidelines and were represented on the working group by one of the few specialist paediatric A&E consultants in the UK. However, some members of that Faculty feel they were not adequately consulted, that their practice was being undermined, and that the guidelines apply only in Scotland. SIGN guidelines are living documents and can be changed in the light of new evidence. The National Audit of paediatric ketamine use in emergency departments in the UK mentioned in this issue is welcome and any further research on the utility of ketamine when given by non-anaesthetists in the UK hospital setting is also to be welcomed.
Before this technique can be widely supported for use in paediatric A&E practice in the UK several issues need to be addressed. The most important provision is adequate training and on-going experience in paediatric sedation and analgesic techniques. Better communication and links between specialties that have to deal with children would also be of great benefit. The Academy of Royal Colleges in the UK has observed guidelines for safe sedation were not being implemented and proposed some actions to improve adherence to good practice.3 Their advice was that every hospital should have a multidisciplinary sedation group led jointly by an anaesthetist and another specialist. They should monitor sedation activity, assess the need for sedation, oversee the local implementation of national guidelines, and audit the safety and adverse effects of sedation practices in their unit. Where children are involved, paediatric specialist expertise and advice should form part of these groups. In many hospitals these recommendations have still not been implemented and dialogue between specialties such as A&E and anaesthesia in some hospitals can be zero!
Children and families must be given informed choices based on clear information on risks and benefits, efficacy, and safety. If you are going to promote widespread adoption of a technique with a questionable adverse effect profile in children, you need to be sure that adequate controlled comparisons have been made of the alternatives. For ketamine, the definitive controlled and randomised studies compared with modern general anaesthesia have yet to be carried out in an A&E setting. In paediatric radiology general anaesthesia has recently been shown to be safer, more reliable, more efficient, and more cost effective than sedation of children for MRI scans.5 Until proper comparative studies are done, I think the jury is out despite arguments in favour of ketamine presented in this issue.
We do have a duty to collaborate and cooperate across the specialties to produce quality evidence. One benefit of this is to gain an understanding of what different specialties regard as a standard of care. A recent study in Dartmouth USA where procedural sedation undertaken by non-anaesthetists was videotaped and reviewed by an independent panel revealed major problems with the perceptions of those carrying out the procedures as to the efficacy and safety of their technique.6 I hope such projects and this type of debate will help promote cross specialty understanding and collaboration in the best interests of children.
Definitive studies are needed
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