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Bali A, Dang AK, Gonzalez DA, Kumar R, Asif S. Clinical Uses of Ketamine in Children: A Narrative Review. Cureus 2022; 14:e27065. [PMID: 35989801 PMCID: PMC9389002 DOI: 10.7759/cureus.27065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2022] [Indexed: 11/05/2022] Open
Abstract
Ketamine is a phencyclidine derivative that acts as a noncompetitive N-methyl-D-aspartate as well as a glutamate receptor antagonist. It also has other minor mechanisms that contribute to its extensive drug profile. Ketamine is a bronchodilator and maintains normal airway reflexes and, thus, permits spontaneous respiration. This, coupled with the fact that it produces potent analgesia, makes it highly suitable for children. Despite its many merits, the drug’s side effects, along with its cultural image of being a drug of abuse, a drug used in veterinary medicine, or a “date-rape drug” have sullied its reputation within the armamentarium of medicine. Even though it is widely used in developing countries, its use in Western nations has diminished. We have strived to explore the various clinical uses of ketamine in children through this article. In addition, the article also highlights how some of the fears associated with using the drug are unfounded and provides ways by which the drug’s side effects can be prevented and managed.
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Bhargava R, Brown L. Esophageal coin removal by emergency physicians: a continuous quality improvement project incorporating rapid sequence intubation. CAN J EMERG MED 2015; 13:28-33. [DOI: 10.2310/8000.2011.100298] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
ABSTRACTObjective:The objective of this study was to describe our experience removing esophageal coins from children in a tertiary care pediatric emergency department over a 4-year period.Methods:We retrospectively reviewed a continuous quality improvement data set spanning October 1, 2004, through September 30, 2008.Results:In 96 of 101 cases (95%), emergency physicians successfully retrieved the coin. The median age of the children was 19 months (interquartile range [IQR] 13–43 months; range 4 months–12.8 years). The median time to removal of coin from initiation of intubation was 8 minutes (IQR 4–14 minutes; range 1–60 minutes). Coins were extracted using forceps only in 56 cases, whereas forceps and a Foley catheter were used in the remainder. Succinylcholine and etomidate were used in almost all cases for rapid sequence intubation prior to coin removal. Complications were identified in 46 cases: minor bleeding (13), lip laceration (7), multiple attempts (5), hypoxia (3), accidental extubation (3), dental injuries (3), bradycardia (2), coin advanced (1), right main-stem bronchus intubation (1), and other (8).Conclusions:Emergency physicians successfully removed esophageal coins following rapid sequence intubation in most cases. Our approach may be considered for the management of pediatric esophageal coins, particularly in an academic pediatric emergency department.
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Cevik E, Bilgic S, Kilic E, Cinar O, Hasman H, Acar AY, Eroglu M. Comparison of ketamine-low-dose midozolam with midazolam-fentanyl for orthopedic emergencies: a double-blind randomized trial. Am J Emerg Med 2012; 31:108-13. [PMID: 22944555 DOI: 10.1016/j.ajem.2012.06.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Revised: 05/31/2012] [Accepted: 06/01/2012] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE Most of the fractures and dislocations are reduced in the emergency setting. Many drugs are available for procedural sedation and analgesia in the emergency department (ED); however, the adverse effects are still a common problem. The aim of our study was to compare the 2 drug combinations. METHOD We performed a prospective, randomized, double-blinded, placebo-controlled trial of patients presenting to the ED after a traumatic event and required urgent reduction either for a fracture or dislocation. Patients were randomized to midazolam-fentanyl (MF) group or ketamine-low-dose midazolam (KM) group. Hypoxia, duration of hypoxia, need for oxygen, time to onset of sedation, recovery time, pain scores during reduction, and sedation depth were set as primary outcome measures and were recorded. RESULTS A total of 498 patients who presented to ED with extremity injury and required closed reduction were assessed; 130 of them were approached for eligibility and 69 patients were excluded. The remaining 61 patients were randomized to either KM group (n = 31) or MF group (n = 30). Hypoxia and duration of hypoxia were significantly lower in the KM group compared with the MF group. Patients in the KM group reported significantly lower pain scores during reduction; however, adverse effects were higher compared with MF group. CONCLUSION Both drug combinations can be effectively used for procedural sedation and analgesia; however, with lower risk for hypoxia and lower pain scores, KM combination stands as a reasonable choice for orthopedic interventions in the emergency unit.
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Affiliation(s)
- Erdem Cevik
- Department of Emergency Medicine, Gulhane Military Medical Academy, GATA Acil Tip Anabilim Dalı, Etlik, Ankara 06010, Turkey.
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Dolansky G, Shah A, Mosdossy G, Rieder M. What is the evidence for the safety and efficacy of using ketamine in children? Paediatr Child Health 2011; 13:307-8. [PMID: 19337601 DOI: 10.1093/pch/13.4.307] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2008] [Indexed: 11/13/2022] Open
Affiliation(s)
- G Dolansky
- Department of Paediatrics, Children's Hospital at the London Health Sciences Centre
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El Koraichi A, Lamkinsi T, Ghannam A, Tadili J, Benchekroun K, El Haddoury M, El Kettani SE. Extraction des pièces de monnaie à partir du tractus oesophagien supérieur chez les enfants par la pince de Magill sous sédation en ventilation spontanée. ACTA ACUST UNITED AC 2011. [DOI: 10.1007/s13546-011-0265-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abstract
OBJECTIVE The objective of this study was to assess predictors of emergency department (ED) ketamine-associated laryngospasm using case-control techniques. METHODS We performed a matched case-control analysis of a sample of 8282 ED ketamine sedations (including 22 occurrences of laryngospasm) assembled from 32 prior published series. We sequentially studied the association of each of 7 clinical variables with laryngospasm by assigning 4 controls to each case while matching for the remaining 6 variables. We then used univariate statistics and conditional logistic regression to analyze the matched sets. RESULTS We found no statistical association of age, dose, oropharyngeal procedure, underlying physical illness, route, or coadministered anticholinergics with laryngospasm. Coadministered benzodiazepines showed a borderline association in the multivariate but not univariate analysis that was considered anomalous. CONCLUSIONS This case-control analysis of the largest available sample of ED ketamine-associated laryngospasm did not demonstrate evidence of association with age, dose, or other clinical factors. Such laryngospasm seems to be idiosyncratic, and accordingly, clinicians administering ketamine must be prepared for its rapid identification and management. Given no evidence that they decrease the risk of laryngospasm, coadministered anticholinergics seem unnecessary.
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Green SM, Roback MG, Krauss B. Anticholinergics and ketamine sedation in children: a secondary analysis of atropine versus glycopyrrolate. Acad Emerg Med 2010; 17:157-62. [PMID: 20370745 DOI: 10.1111/j.1553-2712.2009.00634.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Adjunctive anticholinergics are commonly administered during emergency department (ED) ketamine sedation in children under the presumption that drying oral secretions should decrease the likelihood of airway and respiratory adverse events. Pharmacologic considerations suggest that glycopyrrolate might exhibit a superior adverse effect profile to atropine. The authors contrasted the adverse events noted with use of each of these anticholinergics in a large multicenter observational database of ketamine sedations. METHODS This was a secondary analysis of an observational database of 8,282 ED ketamine sedations assembled from 32 prior series. The authors compared the relative incidence of six adverse events (airway and respiratory adverse events, laryngospasm, apnea, emesis, recovery agitation, and clinically important recovery agitation) between children who received coadministered atropine, glycopyrrolate, or no anticholinergic. Multivariable analysis using the specific anticholinergic as a covariate was performed, while controlling for other known predictors. RESULTS Atropine was associated with less vomiting (5.3%) than either glycopyrrolate (10.7%) or no anticholinergic (11.4%) in both unadjusted and multivariable analyses. Glycopyrrolate was associated with significantly more airway and respiratory adverse events (6.4%) than either atropine (3.3%) or no anticholinergic (3.0%) and similarly more clinically important recovery agitation (2.1% vs. 1.2 and 1.3%). There were, however, no differences noted in odds of laryngospasm and apnea. CONCLUSIONS This secondary analysis unexpectedly found that the coadministered anticholinergic atropine exhibited a superior adverse event profile to glycopyrrolate during ketamine sedation. Any such advantage requires confirmation in a separate trial; however, our data cast doubt on the traditional premise that glycopyrrolate might be superior. Further, neither anticholinergic showed efficacy in decreasing airway and respiratory adverse events.
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Affiliation(s)
- Steven M Green
- Department of Emergency Medicine, Loma Linda University Medical Center & Children's Hospital, Loma Linda, CA, USA.
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Green SM, Coté CJ. Ketamine and Neurotoxicity: Clinical Perspectives and Implications for Emergency Medicine. Ann Emerg Med 2009; 54:181-90. [DOI: 10.1016/j.annemergmed.2008.10.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2008] [Revised: 09/23/2008] [Accepted: 10/01/2008] [Indexed: 10/21/2022]
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Green SM, Roback MG, Krauss B, Brown L, McGlone RG, Agrawal D, McKee M, Weiss M, Pitetti RD, Hostetler MA, Wathen JE, Treston G, Garcia Pena BM, Gerber AC, Losek JD. Predictors of emesis and recovery agitation with emergency department ketamine sedation: an individual-patient data meta-analysis of 8,282 children. Ann Emerg Med 2009; 54:171-80.e1-4. [PMID: 19501426 DOI: 10.1016/j.annemergmed.2009.04.004] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2009] [Revised: 03/13/2009] [Accepted: 04/01/2009] [Indexed: 11/26/2022]
Abstract
STUDY OBJECTIVE Ketamine is widely used in emergency departments (EDs) to facilitate painful procedures; however, existing descriptors of predictors of emesis and recovery agitation are derived from relatively small studies. METHODS We pooled individual-patient data from 32 ED studies and performed multiple logistic regression to determine which clinical variables would predict emesis and recovery agitation. The first phase of this study similarly identified predictors of airway and respiratory adverse events. RESULTS In 8,282 pediatric ketamine sedations, the overall incidence of emesis, any recovery agitation, and clinically important recovery agitation was 8.4%, 7.6%, and 1.4%, respectively. The most important independent predictors of emesis are unusually high intravenous (IV) dose (initial dose of > or =2.5 mg/kg or a total dose of > or =5.0 mg/kg), intramuscular (IM) route, and increasing age (peak at 12 years). Similar risk factors for any recovery agitation are low IM dose (<3.0 mg/kg) and unusually high IV dose, with no such important risk factors for clinically important recovery agitation. CONCLUSION Early adolescence is the peak age for ketamine-associated emesis, and its rate is higher with IM administration and with unusually high IV doses. Recovery agitation is not age related to a clinically important degree. When we interpreted it in conjunction with the separate airway adverse event phase of this analysis, we found no apparent clinically important benefit or harm from coadministered anticholinergics and benzodiazepines and no increase in adverse events with either oropharyngeal procedures or the presence of substantial underlying illness. These and other results herein challenge many widely held views about ED ketamine administration.
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Affiliation(s)
- Steven M Green
- Department of Emergency Medicine, Loma Linda University Medical Center and Children's Hospital, Loma Linda, CA
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Green SM, Roback MG, Krauss B, Brown L, McGlone RG, Agrawal D, McKee M, Weiss M, Pitetti RD, Hostetler MA, Wathen JE, Treston G, Garcia Pena BM, Gerber AC, Losek JD. Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children. Ann Emerg Med 2009; 54:158-68.e1-4. [PMID: 19201064 DOI: 10.1016/j.annemergmed.2008.12.011] [Citation(s) in RCA: 185] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2008] [Revised: 11/18/2008] [Accepted: 12/09/2008] [Indexed: 02/07/2023]
Abstract
STUDY OBJECTIVE Although ketamine is one of the most commonly used sedatives to facilitate painful procedures for children in the emergency department (ED), existing studies have not been large enough to identify clinical factors that are predictive of uncommon airway and respiratory adverse events. METHODS We pooled individual-patient data from 32 ED studies and performed multiple logistic regressions to determine which clinical variables would predict airway and respiratory adverse events. RESULTS In 8,282 pediatric ketamine sedations, the overall incidence of airway and respiratory adverse events was 3.9%, with the following significant independent predictors: younger than 2 years (odds ratio [OR] 2.00; 95% confidence interval [CI] 1.47 to 2.72), aged 13 years or older (OR 2.72; 95% CI 1.97 to 3.75), high intravenous dosing (initial dose > or =2.5 mg/kg or total dose > or =5.0 mg/kg; OR 2.18; 95% CI 1.59 to 2.99), coadministered anticholinergic (OR 1.82; 95% CI 1.36 to 2.42), and coadministered benzodiazepine (OR 1.39; 95% CI 1.08 to 1.78). Variables without independent association included oropharyngeal procedures, underlying physical illness (American Society of Anesthesiologists class >or = 3), and the choice of intravenous versus intramuscular route. CONCLUSION Risk factors that predict ketamine-associated airway and respiratory adverse events are high intravenous doses, administration to children younger than 2 years or aged 13 years or older, and the use of coadministered anticholinergics or benzodiazepines.
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Affiliation(s)
- Steven M Green
- Department of Emergency Medicine, Loma Linda University Medical Center and Children's Hospital, Loma Linda, CA, USA.
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Xue FS, Liao X, Xu YC, Yang QY. Sedation and anesthesia for fiberoptic intubation in management of pediatric difficult airways. Paediatr Anaesth 2008; 18:1239-41. [PMID: 18717797 DOI: 10.1111/j.1460-9592.2008.02741.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Green SM, Krauss B. Clinical practice guideline for emergency department ketamine dissociative sedation in children. Ann Emerg Med 2005. [PMID: 15520705 DOI: 10.1016/j.annemergmed.2004.06.006] [Citation(s) in RCA: 122] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
We present an evidence-based clinical practice guideline for the administration of the dissociative agent ketamine for emergency department pediatric procedural sedation and analgesia. Substantial research in recent years has necessitated updates and revisions to the widely disseminated 1990 recommendations. We critically discuss indications, contraindications, personnel requirements, monitoring, dosing, coadministered medications, recovery issues, and future research questions for dissociative sedation.
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Affiliation(s)
- Steven M Green
- Department of Emergency Medicine, Loma Linda University Medical Center and Children's Hospital, Loma Linda, CA 92354, USA.
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Mace SE, Barata IA, Cravero JP, Dalsey WC, Godwin SA, Kennedy RM, Malley KC, Moss RL, Sacchetti AD, Warden CR, Wears RL. Clinical policy: evidence-based approach to pharmacologic agents used in pediatric sedation and analgesia in the emergency department. J Pediatr Surg 2004; 39:1472-84. [PMID: 15486890 DOI: 10.1016/j.jpedsurg.2004.07.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Mace SE, Barata IA, Cravero JP, Dalsey WC, Godwin SA, Kennedy RM, Malley KC, Moss RL, Sacchetti AD, Warden CR, Wears RL. Clinical Policy: Evidence-based Approach to Pharmacologic Agents Used in Pediatric Sedation and Analgesia in the Emergency Department. J Emerg Nurs 2004; 30:447-61. [PMID: 15452523 DOI: 10.1016/j.jen.2004.07.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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