Ketamine sedation for the reduction of children's fractures in the emergency department

Comparing the Safety and Effectiveness of Ketamine Versus Benzodiazepine/Opioid Combination for Procedural Sedation in Emergency Medicine: A Comprehensive Review and Meta-Analysis

Procedural sedation is essential in the ED to conduct painful procedures effectively. Ketamine and benzodiazepines/opioids are commonly used, with ketamine providing adequate analgesia and preserving airway muscle tone. However, ketamine is associated with adverse effects while benzodiazepines/opioids can lead to respiratory depression. This study compares the safety and efficacy of ketamine and midazolam/fentanyl. Two search methods were used to identify studies related to our topic, including a database search and a manual search involving screening reference lists of articles retrieved by the database search. A methodological quality appraisal was conducted on the articles suitable for inclusion using Cochrane's risk of bias tool in the Review Manager software (Review Manager (RevMan) (Computer program). Version 5.4, The Cochrane Collaboration, 2020). Moreover, pooled analysis was performed using the Review manager software. The study analyzed 1366 articles, of which seven were included for analysis. Pooled data showed that ketamine and midazolam/fentanyl had similar effects on pain scores during procedures and sedation depth measured by the University of Michigan sedation scale. However, the Modified Ramsay Sedation Score showed significantly more profound sedation in the ketamine group. The only significant adverse events were vomiting and nausea, which had a higher incidence in the ketamine group. Our data suggest that ketamine is as effective as the midazolam/fentanyl combination for procedural sedation but is associated with higher incidences of adverse events. Therefore, midazolam/fentanyl can be recommended for procedural sedation in the ED. However, it should be provided in the presence of a physician comfortable with airway management due to high incidences of oxygen desaturation.

The use of esketamine sedation in the emergency department for manipulation of paediatric forearm fractures: A 5 year study

The purpose of this study is to assess the use of esketamine as procedural sedation for the reduction of paediatric forearm fractures in the emergency department (ED). A retrospective analysis was undertaken of forearm fractures between 1^st January 2012 to 31^st December 2016 which were treated with manipulation in ED using esketamine sedation. Patient demographics and fracture configuration were collected. Patient radiographs were evaluated and cast index calculated. 151 patients (103 male, 48 female) were included (average age of 8.5 [1 to 15]). Four (2.6%) patients were lost to final follow up. 11 (7%) fractures were not accepted after initial manipulation and required formal surgical management under general anaesthetic. At one week follow up, a further 5 (3%) fractures displaced requiring operative management. 100% of patients who slipped at one week had a cast index greater than 0.8 [average 0.86, 95% CI 0.80-0.92]. At final follow up successful reduction was achieved in 89.1% (131/144) of patients. No adverse events occurred following administration of esketamine. This study provides evidence that manipulation of paediatric forearm fractures using esketamine as procedural sedation in the ED is comparable to other methods in achieving acceptable outcomes. This is in addition to the potential for cost savings. However, future studies formally assessing cost effectiveness and patient outcomes are needed.

Use of ketamine sedation for the management of displaced paediatric forearm fractures

AIM

To determine if ketamine sedation is a safe and cost effective way of treating displaced paediatric radial and ulna fractures in the emergency department.

METHODS

Following an agreed interdepartmental protocol, fractures of the radius and ulna (moderately to severely displaced) in children between the age of 2 and 16 years old, presenting within a specified 4 mo period, were manipulated in our paediatric emergency department. Verbal and written consent was obtained prior to procedural sedation to ensure parents were informed and satisfied to have ketamine. A single attempt at manipulation was performed. Pre and post manipulation radiographs were requested and assessed to ensure adequacy of reduction. Parental satisfaction surveys were collected after the procedure to assess the perceived quality of treatment. After closed reduction and cast immobilisation, patients were then followed-up in the paediatric outpatient fracture clinic and functional outcomes measured prospectively. A cost analysis compared to more formal manipulation under a general anaesthetic was also undertaken.

RESULTS

During the 4 mo period of study, 10 closed, moderate to severely displaced fractures were identified and treated in the paediatric emergency department using our ketamine sedation protocol. These included fractures of the growth plate (3), fractures of both radius and ulna (6) and a single isolated proximal radius fracture. The mean time from administration of ketamine until completion of the moulded plaster was 20 min. The mean time interval from sedation to full recovery was 74 min. We had no cases of unacceptable fracture reduction and no patients required any further manipulation, either in fracture clinic or under a more formal general anaesthetic. There were no serious adverse events in relation to the use of ketamine. Parents, patients and clinicians reported extremely favourable outcomes using this technique. Furthermore, compared to using a manipulation under general anaesthesia, each case performed under ketamine sedation was associated with a saving of £1470, the overall study saving being £14700.

CONCLUSION

Ketamine procedural sedation in the paediatric population is a safe and cost effective method for the treatment of displaced fractures of the radius and ulna, with high parent satisfaction rates.

Pharmacologic Considerations for Pediatric Sedation and Anesthesia Outside the Operating Room: A Review for Anesthesia and Non-Anesthesia Providers

Understanding the pharmacologic options for pediatric sedation outside the operating room will allow practitioners to formulate an ideal anesthetic plan, allaying anxiety and achieving optimal immobilization while ensuring rapid and efficient recovery. The authors identified relevant medical literature by searching PubMed, MEDLINE, Embase, Scopus, Web of Science, and Google Scholar databases for English language publications covering a period from 1984 to 2017. Search terms included pediatric anesthesia, pediatric sedation, non-operating room sedation, sedation safety, and pharmacology. As a narrative review of common sedation/anesthesia options, the authors elected to focus on studies, reviews, and case reports that show clinical relevance to modern day sedation/anesthesia practice. A variety of pharmacologic agents are available for sedation/anesthesia in pediatrics, including midazolam, fentanyl, ketamine, dexmedetomidine, etomidate, and propofol. Dosing ranges reported are a combination of what is discussed in the reviewed literature and text books along with personal recommendations based on our own practice. Several reports reveal that ketofol (a combination of ketamine and propofol) is quite popular for short, painful procedures. Fospropofol is a newer-generation propofol that may confer advantages over regular propofol. Remimazolam combines the pharmacologic effects of remifentanil and midazolam. A variety of etomidate derivatives such as methoxycarbonyl-etomidate, carboetomidate, methoxycarbonyl-carboetomidate, and cyclopropyl-methoxycarbonyl metomidate are in development stages. The use of nitrous oxide as a mild sedative, analgesic, and amnestic agent is gaining popularity, especially in the ambulatory setting. Utilizing a dedicated and experienced team to provide sedation enhances safety. Furthermore, limiting sedation plans to single-agent pharmacy appears to be safer than using multi-agent plans.

Paediatric fractures in a sub-saharan tertiary care center: a cohort analysis of demographic characteristics, clinical presentation, therapeutic patterns and outcomes

Introduction

Paediatric fractures are often of good prognosis due to auto-correction of insufficient fracture reduction by bone remodeling. In sub-Saharan Africa, traditional healers are renowned for managing fractures and there is a neglect for specialized pediatric fracture care. We aimed to determine the demographic characteristics, clinical presentation, treatment patterns and outcomes of paediatric fractures in a tertiary health care centre in Yaoundé.

Methods

We conducted a prospective cohort study of all consenting consecutive cases of fractures in patients younger than 16 years managed between January 2011 and June 2015 at the University Teaching Hospital, Cameroon. We analysed demographic data, injury characteristics, fracture patterns, treatment details, therapeutic challenges and outcome of treatment at 12 months of follow-up.

Results

We enrolled 147 fractures from 145 children with a mean age of 7 years and male-to-female sex ratio of 2.5:1. The main mechanisms of injury were games (53%) and accidental falls (20.7%). Forearm fractures were the most common fractures (38%). The mainstay of management was non-operative in 130 (88.5%) fractures, with 29.3% manipulations under anesthesia and 17 (11.5%) open reductions with internal fixation. The most surgically reduced fractures were supracondylar humeral fractures. Major difficulties were long therapeutic delay, lack of diligent anaesthesia and the lack of fluoroscopy. The outcome of treatment was favorable in 146 (99.3%) paediatric fractures.

Conclusion

With the growing population of sub-Saharan Africa and the objective of becoming an emergent region, public policies should match the technical realities.

Etomidate Versus Ketamine: Effective Use in Emergency Procedural Sedation for Pediatric Orthopedic Injuries

OBJECTIVES

The aim of this study was to compare the induction and recovery times, postsedation observation durations, and adverse effects of etomidate and ketamine in pediatric patients with fractures and/or dislocations requiring closed reduction in the emergency department.

METHODS

Forty-four healthy children aged 7 to 18 years were included. The patients were randomly divided into 2 groups. Group 1 (24 patients) received etomidate and fentanyl, and group 2 (20 patients) received ketamine intravenously. The Ramsay Sedation Scale and American Pediatric Association discharge criteria were used to evaluate the patients.

RESULTS

There were 70 fractured bones and 3 joint dislocations. Except in 1 case (2.3%), all of the injuries were reducted successfully. The mean amount of drugs used to provide adequate sedation and analgesia were 0.25 mg/kg of etomidate and 1.30 μg/kg of fentanyl in group 1 and 1.25 mg/kg of ketamine in group 2. Fourteen patients (31.8%) reported adverse effects, and none required hospitalization. There was no difference between the groups in the recovery times, occurrence of adverse effects, and postsedation observation durations (P > 0.05). The mean (SD) induction time for the patients in group 1 was 4.3 (1.0) minutes, whereas it was 2.2 (1.6) minutes in group 2 (P < 0.001).

CONCLUSIONS

Etomidate induces effective and adequate sedation in the pediatric emergency department for painful orthopedic procedures. Ketamine, which has longer action times, might be preferred for reductions because orthopedic procedures could be lengthy.

Intubation of Profoundly Agitated Patients Treated with Prehospital Ketamine

Background

Profound agitation in the prehospital setting confers substantial risk to patients and providers. Optimal chemical sedation in this setting remains unclear.

Objective

The goal of this study was to describe intubation rates among profoundly agitated patients treated with prehospital ketamine and to characterize clinically significant outcomes of a prehospital ketamine protocol.

Methods

This was a retrospective cohort study of all patients who received prehospital ketamine, per a predefined protocol, for control of profound agitation and who subsequently were transported to an urban Level 1 trauma center from May 1, 2010 through August 31, 2013. Identified records were reviewed for basic ambulance run information, subject characteristics, ketamine dosing, and rate of intubation. Emergency Medical Services (EMS) ambulance run data were matched to hospital-based electronic medical records. Clinically significant outcomes are characterized, including unadjusted and adjusted rates of intubation.

Results

Overall, ketamine was administered 227 times in the prehospital setting with 135 cases meeting study criteria of use of ketamine for treatment of agitation. Endotracheal intubation was undertaken for 63% (85/135) of patients, including attempted prehospital intubation in four cases. Male gender and late night arrival were associated with intubation in univariate analyses (χ2=12.02; P=.001 and χ2=5.34; P=.021, respectively). Neither ketamine dose, co-administration of additional sedating medications, nor evidence of ethanol (ETOH) or sympathomimetic ingestion was associated with intubation. The association between intubation and both male gender and late night emergency department (ED) arrival persisted in multivariate analysis. Neither higher dose (>5mg/kg) ketamine nor co-administration of midazolam or haloperidol was associated with intubation in logistic regression modeling of the 120 subjects with weights recorded. Two deaths were observed. Post-hoc analysis of intubation rates suggested a high degree of provider-dependent variability.

Conclusions

Prehospital ketamine is associated with a high rate of endotracheal intubation in profoundly agitated patients; however, ketamine dosing is not associated with intubation rate when adjusted for potential confounders. It is likely that factors not included in this analysis, including both provider comfort with post-ketamine patients and anticipated clinical course, play a role in the decision to intubate patients who receive prehospital ketamine.

OlivesTD, NystromPC, ColeJB, DoddKW, HoJD. Intubation of profoundly agitated patients treated with prehospital ketamine. Prehosp Disaster Med. 2016;31(6):593–602.

Optimal dosing of intravenous ketamine for procedural sedation in children in the ED-a randomized controlled trial

OBJECTIVE

The objective of the study is to compare need for redosing, sedation efficacy, duration, and adverse events between 3 commonly administered doses of parenteral ketamine in the emergency department (ED).

METHODS

We conducted a prospective, double-blind, randomized controlled trial on a convenience sample of children 3 to 18years who received intravenous ketamine for procedural sedation. Children from each age group (3-6, 7-12, and 13-18years) were assigned in equal numbers to 3 dosing groups (1, 1.5, and 2mg/kg) using random permuted blocks. The primary outcome measure was need for ketamine redosing to ensure adequate sedation. Secondary outcome measures were sedation efficacy, sedation duration, and sedation-related adverse events.

RESULTS

A total of 171 children were enrolled of whom 125 (1mg/kg, 50; 1.5mg/kg, 35; 2mg/kg, 40) received the randomized dose and were analyzed. The need for ketamine redosing was higher in the 1mg/kg group (8/50; 16.0% vs 1/35; 2.9% vs 2/40; 5.0%). There was no significant difference in the median Ramsay sedation scores (5.5 [interquartile range {IQR}, 4-6] vs 6 [IQR, 4-6] vs 6 [IQR, 5-6]), FACES-R score (0 [IQR, 0-4] vs 0 [IQR, 0-0] vs 0 [IQR, 0-0]), sedation duration in minutes (23 [IQR, 19-38] vs 24.5 [IQR, 17.5-34.5] vs 23 [IQR, 19-29]), and adverse events (10.0% vs 14.3% vs 10.0%) between the 3 dosing groups. Physician satisfaction was lower in the 1mg/kg group (79.6% vs 94.1% vs 97.3%).

CONCLUSIONS

Adequate sedation was achieved with all 3 doses of ketamine. Higher doses did not increase the risk of adverse events or prolong sedation. Ketamine administered at 1.5 or 2.0mg/kg intravenous required less redosing and resulted in greater physician satisfaction.

Ameliorating treatment-refractory depression with intranasal ketamine: potential NMDA receptor actions in the pain circuitry representing mental anguish

This article reviews the antidepressant actions of ketamine, an N-methyl-D-aspartame glutamate receptor (NMDAR) antagonist, and offers a potential neural mechanism for intranasal ketamine's ultra-rapid actions based on the key role of NMDAR in the nonhuman primate prefrontal cortex (PFC). Although intravenous ketamine infusions can lift mood within hours, the current review describes how intranasal ketamine administration can have ultra-rapid antidepressant effects, beginning within minutes (5-40 minutes) and lasting hours, but with repeated treatments needed for sustained antidepressant actions. Research in rodents suggests that increased synaptogenesis in PFC may contribute to the prolonged benefit of ketamine administration, beginning hours after administration. However, these data cannot explain the relief that occurs within minutes of intranasal ketamine delivery. We hypothesize that the ultra-rapid effects of intranasal administration in humans may be due to ketamine blocking the NMDAR circuits that generate the emotional representations of pain (eg, Brodmann Areas 24 and 25, insular cortex), cortical areas that can be overactive in depression and which sit above the nasal epithelium. In contrast, NMDAR blockade in the dorsolateral PFC following systemic administration of ketamine may contribute to cognitive deficits. This novel view may help to explain how intravenous ketamine can treat the symptoms of depression yet worsen the symptoms of schizophrenia.

Comparison of two analgesia protocols for the treatment of pediatric orthopedic emergencies

SummaryObjective:to compare the efficacy of two analgesia protocols (ketamine versus morphine) associated with midazolam for the reduction of dislocations or closed fractures in children.Methods:randomized clinical trial comparing morphine (0.1mg/kg; max 5mg) and ketamine (2.0mg/kg, max 70mg) associated with midazolam (0.2mg/kg; max 10mg) in the reduction of dislocations or closed fractures in children treated at the pediatrics emergency room (October 2010 and September 2011). The groups were compared in terms of the times to perform the procedures, analgesia, parent satisfaction and orthopedic team.Results:13 patients were allocated to ketamine and 12 to morphine, without differences in relation to age, weight, gender, type of injury, and pain scale before the intervention. There was no failure in any of the groups, no differences in time to start the intervention and overall procedure time. The average hospital stay time was similar (ketamine = 10.8+5.1h versus morphine = 12.3+4.4hs; p=0.447). The median pain (faces pain scale) scores after the procedure was 2 in both groups. Amnesia was noted in 92.3% (ketamine) and 83.3% (morphine) (p=0.904). Parents said they were very satisfied in relation to the analgesic intervention (84.6% in the ketamine group and 66.6% in the morphine group; p=0.296). The satisfaction of the orthopedist regarding the intervention was 92.3% in the ketamine group and 75% in the morphine group (p=0.222).Conclusion:by producing results similar to morphine, ketamine can be considered as an excellent option in pain management and helps in the reduction of dislocations and closed fractures in pediatric emergency rooms.

The design of a multicentre Canadian surveillance study of sedation safety in the paediatric emergency department

INTRODUCTION

Procedural sedation and analgesia have become standard practice in paediatric emergency departments worldwide. Although generally regarded as safe, serious adverse events such as bradycardia, asystole, pulmonary aspiration, permanent neurological injury and death have been reported, but their incidence is unknown due to the infrequency of their occurrence and lack of surveillance of sedation safety. To improve our understanding of the safety, comparative effectiveness and variation in care in paediatric procedural sedation, we are establishing a multicentre patient registry with the goal of conducting regular and ongoing surveillance for adverse events in procedural sedation.

METHODS

This multicentre, prospective cohort study is enrolling patients under 18 years of age from six paediatric emergency departments across Canada. Data collection is fully integrated into clinical care and is performed electronically in real time by the healthcare professionals caring for the patient. The primary outcome is the proportion of patients who experience a serious adverse event as a result of their sedation. Secondary outcomes include the proportion of patients who experience an adverse event that could lead to a serious adverse event, proportion of patients who receive a significant intervention in response to an adverse event, proportion of patients who experience a successful sedation, and proportion of patients who experience a paradoxical reaction to sedation. There is no predetermined end date for data collection.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from participating sites. Results will be disseminated using a multifaceted knowledge translation strategy by presenting at international conferences, publication in peer-reviewed journals, and through established networks.

Procedural sedation in the emergency department

Procedural sedation options in the emergency department now allow for more effective and safer care and facilitate the delivery of orthopaedic care that would otherwise require operating room anesthesia. Traditional sedation agents, such as nitrous oxide, midazolam, fentanyl, and ketamine, have a persistent role. Etomidate and propofol are relatively recent additions that are highly effective. Combination regimens, such as ketamine-midazolam and ketamine-propofol, may be superior because they benefit from synergistic traits. Despite these sedation regimens, use of local blocks in adults continues to be effective, and intranasal delivery in children has emerged as a viable option. Orthopaedic surgeons should be aware of the appropriateness of different sedation regimens and other options for specific clinical scenarios.

Contribution of NMDA receptors to dorsolateral prefrontal cortical networks in primates

Cognitive disorders such as schizophrenia and Alzheimer's disease are associated with dysfunction of the highly evolved dorsolateral prefrontal cortex (dlPFC), and with changes in glutamatergic N-methyl-D-aspartate receptors (NMDARs). Recent research on the primate dlPFC discovered that the pyramidal cell circuits that generate the persistent firing underlying spatial working memory communicate through synapses on spines containing NMDARs with NR2B subunits (GluN2B) in the post-synaptic density. This contrasts with synapses in the hippocampus and primary visual cortex, where GluN2B receptors are both synaptic and extrasynaptic. Blockade of GluN2B in the dlPFC markedly reduces the persistent firing of the Delay cells needed for neuronal representations of visual space. Cholinergic stimulation of nicotinic α7 receptors within the glutamate synapse is necessary for NMDAR actions. In contrast, α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptors have only subtle effects on the persistent firing of Delay cells, but contribute substantially to the firing of Cue and Response cells. Systemic administration of the NMDAR antagonist ketamine reduces the persistent firing of Delay cells, but increases the firing of some Response cells. The reduction in persistent firing produced by ketamine may explain why this drug can mimic or worsen the cognitive symptoms of schizophrenia. Similar actions in the medial PFC circuits representing the emotional aspects of pain may contribute to the rapid analgesic and anti-depressant actions of ketamine.

Development of an optimal sampling schedule for children receiving ketamine for short-term procedural sedation and analgesia

BACKGROUND

Intravenous racemic ketamine is commonly administered for procedural sedation, although few pharmacokinetic studies have been conducted among children. Moreover, an optimal sampling schedule has not been derived to enable the conduct of pharmacokinetic studies that minimally inconvenience study participants.

METHODS

Concentration-time data were obtained from 57 children who received 1-1.5 mg·kg(-1) of racemic ketamine as an intravenous bolus. A population pharmacokinetic analysis was conducted using nonlinear mixed effects models, and the results were used as inputs to develop a D-optimal sampling schedule.

RESULTS

The pharmacokinetics of ketamine were described using a two-compartment model. The volume of distribution in the central and peripheral compartments were 20.5 l∙70 kg(-1) and 220 l∙70 kg(-1), respectively. The intercompartmental clearance and total body clearance were 87.3 and 87.9 l·h(-1) ∙70 kg(-1), respectively. Population parameter variability ranged from 34% to 98%. Initially, blood samples were drawn on 3-6 occasions spanning a range of 14-152 min after dosing. Using these data, we determined that four optimal sampling windows occur at 1-5, 5.5-7.5, 10-20, and 90-180 min after dosing. Monte Carlo simulations indicated that these sampling windows produced precise and unbiased ketamine pharmacokinetic parameter estimates.

CONCLUSION

An optimal sampling schedule was developed that allowed assessment of the pharmacokinetic parameters of ketamine among children requiring short-term procedural sedation.

Hematoma block versus sedation for the reduction of distal radius fractures in children

PURPOSE

To determine which mode of anesthesia, hematoma block (HB) or procedural sedation (PS), was preferable for distal radius fracture (DRF) reduction in children.

METHODS

Fifty-two children (mean age, 12 y; range, 5-16 y) presenting with DRFs requiring reduction were prospectively enrolled and offered either PS or HB for anesthesia. Following reduction, families completed a satisfaction survey regarding mode of anesthesia and overall care (rated 0-10, with 10 being the best score) and an assessment of discomfort (rated 0-10, with 0 being no pain). Length of stay in the emergency department (ED) and complications related to procedure and method of anesthesia were recorded. Radiographic alignment was evaluated before and after reduction.

RESULTS

Twenty-six patients underwent reduction with either PS or HB. Midazolam was used in addition to HB in 8 patients. One patient was converted from HB to PS due to inadequate block. There was no significant difference in prereduction and postreduction angulation between the groups, and reductions maintained satisfactory alignment. Overall satisfaction and satisfaction with anesthesia were excellent for both groups, with respective means of 9.5 and 9.5 for PS and 9.3 and 9.6 for HB. Patient discomfort was minimal in both groups, with a mean of 1.6 for PS and 2.2 for HB. Length of stay was significantly shorter for HB patients, with patients spending a mean of 2.2 hours less in the ED. Three patients required further intervention following initial reduction. One patient in each group required revision reduction, and 1 PS patient underwent closed reduction and pinning.

CONCLUSIONS

Use of HB for the reduction of pediatric DRFs provided radiographic alignment, patient satisfaction, and pain control comparable with that of PS, while significantly decreasing ED time and resources.

Ketamine for management of acute exacerbations of asthma in children

BACKGROUND

Asthma is the most common chronic disease in children, and children with asthma frequently visit the paediatric emergency departments with acute exacerbations. Some of these children fail to respond to standard therapy (aerosol beta(2)-agonist with or without aerosol anticholinergic and oral or parenteral corticosteroids) for acute asthma leading to prolonged emergency department stay, hospitalisation, morbidity (e.g. barotrauma, intubation) and death, albeit rarely. Ketamine may relieve bronchospasm and is a potentially promising therapy for children with acute asthma who fail to respond to standard treatment.

OBJECTIVES

To evaluate the efficacy of ketamine compared to placebo, no intervention or standard care for management of severe acute asthma in children who had not responded to standard therapy.

SEARCH METHODS

We identified trials from the Cochrane Airways Group Specialised Register of trials (CAGR) and ClinicalTrials.gov. We reviewed reference lists of all primary studies and review articles for additional references. We contacted authors of identified trials and asked them to identify other published and unpublished studies. The latest search was in July 2012.

SELECTION CRITERIA

Randomised controlled trials comparing ketamine to placebo or standard care in children (up to 18 years of age) presenting with an acute asthma exacerbation who had not responded to standard therapy.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies. The data were extracted in pre-defined proforma and were analysed independently by two review authors. The data analysis was performed using Review Manager 5.1.

MAIN RESULTS

A single study enrolling 68 non-intubated children was found eligible for inclusion in review. The study had low or unclear risk of bias. It demonstrated no significant difference in respiratory rate, oxygen saturation, hospital admission rate (odds ratio (OR) 0.77; 95% confidence interval (CI) 0.23 to 2.58) and need for mechanical ventilation between ketamine (0.2 mg/kg intravenous bolus over one to two minutes, followed by a 0.5 mg/kg per hour continuous infusion for two hours) and placebo group. There were no significant side effects of ketamine in the study. There was also no difference in need for other adjuvant therapy (OR 2.19; 95% CI 0.19 to 25.40) and in Pulmonary Index Score (mean difference (MD) -0.40; 95% CI -1.21 to 0.41) between the groups.

AUTHORS' CONCLUSIONS

The single study on non-intubated children with severe acute asthma did not show significant benefit and does not support the case studies and observational reports showing benefits of ketamine in both non-ventilated and ventilated children. There were no significant side effects of ketamine. We could not find any trials on ventilated children. To prove that ketamine is an effective treatment for acute asthma in children, there is need for sufficiently powered randomised trials of high methodological quality with objective outcome measures of clinical importance. Future trials should also explore different doses of ketamine and its role in children needing ventilation because of severe acute asthma.

Do children with high body mass indices have a higher incidence of emesis when undergoing ketamine sedation?

OBJECTIVES

The objective of this study was to determine if overweight children are more likely than normal-weight children to require ondansetron when undergoing ketamine sedation in a pediatric emergency department.

METHODS

Patients between the ages of 2 and 18 years with an American Society of Anesthesiologists classification of I or II who underwent intravenous procedural sedation with ketamine with or without midazolam for uncomplicated forearm fracture reduction in an urban pediatric emergency department during the year 2007 were included. A review of sedation records was conducted for each visit. Data collected included demographics, sedation time, and doses of medications administered. Body mass index (BMI) was calculated using an estimated height for the 50th percentile for age and sex. In 2007, all patients underwent procedural sedation per protocol. Per protocol, patients did not prophylactically receive ondansetron during procedural sedations.

RESULTS

During the study period, 141 patients were identified who met inclusion criteria. Of these, 110 had an estimated BMI less than 25 kg/m; 31 had an estimated BMI of 25 kg/m or greater. Ten patients (7.1%) received ondansetron. Patients in the high-BMI group were more likely to have received ondansetron than those in the normal-BMI group (16.1% vs 4.5%, P = 0.04).

CONCLUSIONS

Our data suggest that pediatric patients with high BMIs are at greater risk for nausea or emesis during ketamine sedation. Clinicians should consider prophylactic administration of ondansetron to this group of patients before performing ketamine sedation.

Pediatric fractures: temporal trends and cost implications of treatment under general anesthesia

PURPOSE

Pediatric fractures are common and are often managed by manipulation under general anesthesia (MUA). This study's aim was to assess the changing pattern of pediatric fractures over 6 years and use this data to perform a workload forecast and estimate cost implications of treatment under general anesthesia.

METHODS

The Emergency Department (ED), operating theater and ward admissions data of children aged 1-11 years presenting with fractures was analyzed. We calculated caseload trends, delay to operation, various parameters of service provision, and the current cost of treating each fracture. We then performed predictive cost analysis for the next 3 years to estimate potential savings by manipulating fractures in ED under ketamine sedation.

RESULTS

The case load has increased >350% in 6 years (total fractures increasing at 23% and MUAs increasing at 17% per year, respectively). The summer months and evenings have been consistently busier. 72% of fractures were managed by pure reduction alone (MUA), 22% by reduction + K-wires, and various other procedures were performed in 1%. The median delays from ED presentation to admission, definitive procedure and discharge were 4, 21 and 33 h, respectively. Each MUA took 52 min and cost the hospital £723. Assuming that the current trends continue, the expenditures would be £101 K, £114 K, and £128 K for 2010, 2011 and 2012, respectively.

DISCUSSION

Fracture manipulation in children under general anesthesia often requires an overnight hospital stay, which is not only uncomfortable for the child and inconvenient for the parents but it also increases the burden on the limited National Health Service (NHS) resources. There is a 23% annual increase in fractures and children have to wait for 21 h before the definitive procedure. Using ketamine to manipulate children's fractures in the ED could offer potential service and cost improvements.

Intravenous vs intramuscular ketamine for pediatric procedural sedation by emergency medicine specialists: a review

Ketamine is a general anesthetic agent widely used for pediatric procedural sedation outside the operating theater by nonanesthesiologists. In a setting where efficacy and safety of the agent are paramount, there are conflicting recommendations in terms of optimal mode of parenteral administration, as well as optimal dosage and need for the coadministration of adjunctive agents to decrease side effects. We investigated existing evidence to determine whether ketamine should be best administered intravenously or intramuscularly. This analysis was made difficult by limited direct comparisons of both modes of parenteral administration and a lack of consistent definitions for key outcomes such as 'effectiveness,''adverse events,''hypoxia,''ease of completion of the procedure,' and 'satisfaction' across studies that have evaluated ketamine. Based on large data sets, the safety and efficacy of both modes of administration are broadly similar. Although data on head to head comparisons of intravenous and intramuscular ketamine is limited, based on our analysis, we conclude that the trends indicate ketamine is ideally administered intravenously.

The evolution of ketamine applications in children

Ketamine has found many applications in pediatric anesthetic practice. Insights into the mechanism of action and the pharmacokinetics and pharmacodynamics of its isomers have led to a re-evaluation of this drug, expanding the range of applications in children. Ketamine is a remarkably versatile drug that can be administered through almost any route. It can also be used for different purposes. The aim of this review is to look at the possible applications of this drug in children.

What is the nature of the emergence phenomenon when using intravenous or intramuscular ketamine for paediatric procedural sedation?

OBJECTIVE

Ketamine has become the drug most favoured by emergency physicians for sedation of children in the ED. Some emergency physicians do not use ketamine for paediatric procedural sedation (PPS) because of concern about emergence delirium on recovery. The present study set out to determine the true incidence and nature of this phenomenon.

METHODS

Prospective data relating to any emergence agitation, crying, hallucinations, dreams, altered perceptions, delirium and necessary interventions were recorded in consecutive cases of ketamine PPS from March 2002 to June 2007, and analysed. Standard inclusion and exclusion criteria for the use of ketamine were followed.

RESULTS

A total of 745 prospective data collection records were available for analysis over the 5 year period. Of all, 93 (12.5%) children cried on awakening when recovering from PPS, 291 (39%) experienced pleasant altered perceptions and 16 (2.1%) experienced what was called 'emergence delirium'. None required any active treatment and all except one settled within 20 min. There was no evidence of an increased rate of nightmares on telephone follow up in the weeks post procedure.

CONCLUSION

The belief that ketamine, in the doses used for ED PPS, causes frequent emergence delirium is flawed. A pleasant emergence phenomenon is common, but is not distressing for the child, and has no long-term (up to 30 days) negative sequelae. Rarely, there is anxiety or distress on awakening from ketamine sedation, which settles spontaneously. This should not deter emergency physicians from using ketamine for PPS.

Behavioural assessment of pediatric pain

Behavioural assessment methods have been used to signal the need for intervention and to evaluate treatment effectiveness. Direct observation and rating scales have been used to assess pain and distress associated with acute medical procedures, postoperative pain, critical care, analogue pain induction procedures and other sources. Two recent scholarly reviews of behavioural assessment methods were conducted by the Society of Pediatric Psychology Evidence-Based Assessment Task Force and the Pediatric Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials, which classified various instruments as well established, approaching well established or promising. The characteristics of the eight behavioural assessment scales that were recommended by one of these task forces are further reviewed in the present paper. The results indicate that behavioural assessment scales have been used flexibly to assess pain in a wide variety of situations, across different pediatric populations and for patients of different ages. In the present review, there appears to be no basis for designating the scales as measures of distress versus pain; both emotional and sensory components of pain seem to be assessed by each of the scales. There is considerable overlap among the behavioural indicators of pain used in the different scales. Furthermore, the behavioural codes indicative of pain may occur before, during and after painful events. Recommendations for future research are provided, including using behavioural assessment to focus on children's coping and adults' behaviours, as well as pain.

Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children

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.

Use of Continuous Intravenous Ketamine for End-Stage Cancer Pain in Children

Children in the terminal stage of cancer may experience intractable pain despite the use of high doses of opioids. The resultant sedating effect of the opioids limits the child's ability to communicate and participate in activities, thereby negatively affecting quality of life. Ketamine, an intravenous (IV) anesthetic with analgesic properties, when used in low doses, may be useful in managing pediatric cancer pain at the end of life. Ketamine can prevent the development of opioid tolerance and provide additional analgesia without an increase in sedating effects. At the authors' institution, 2 children with end-stage cancer were started on continuous infusion low-dose ketamine to help achieve adequate pain control and allow the children to be home and interactive for the last weeks of their lives. Each case illustrates the complexities of achieving and maintaining adequate pain control and promoting care of the child and family in a setting that is most appropriate for them.

Adverse events associated with ketamine for procedural sedation in adults

STUDY OBJECTIVES

Ketamine is widely used as a procedural sedation agent in pediatrics, where its safety and efficacy are supported by numerous studies. Emergency physicians use ketamine infrequently in adults, as it is believed to have a more significant side effect profile in this population. However, adult data on ketamine use in the emergency medicine literature are sparse. Our objective was to determine ketamine's adverse effect profile in adults when used for procedural sedation.

METHODS

We performed a literature review based on adverse effect research methodology recommendations. PubMed, EMBASE, TOXNET, and a variety of specialized databases were queried without regard to publication date or language. Experts were contacted to locate additional data. Inclusion criteria included adult study; ketamine used to facilitate the performance of painful procedures; dose of at least 1 mg/kg intravenous or at least 2 mg/kg intramuscular; original data and adverse events reported; spontaneously breathing patient, and no continuous cotherapies. Studies that met inclusion criteria were abstracted onto structured forms and their results qualitatively summarized.

RESULTS

Of the 5512 unique citations that were evaluated, 87 met criteria for inclusion. Most studies were performed in the 1970s and published in the anesthesia literature. Contexts, end points, and methodological quality varied widely across studies. Ketamine reliably produces conditions that facilitate the performance of painful procedures. Pharyngeal reflexes are generally preserved and cardiovascular tone stimulated, including a rise in blood pressure and myocardial oxygen demand. Laryngospasm and airway obstruction are reported, and though ketamine is a respiratory stimulant, a brief period of apnea around the time of injection is common. Reports of significant cardiorespiratory adverse events are rare, despite ketamine's frequent use in austere, poorly monitored settings. Dysphoric emergence phenomena occur in 10% to 20% of cases; sedating medications are effective in preventing and managing these reactions.

CONCLUSION

When ketamine is used for procedural sedation in adults, emergence phenomena occur in 10% to 20% of patients. Although providers must be prepared to recognize and manage airway obstruction, cardiorespiratory adverse events are rare and typically do not affect outcomes.

Ultrasound as an aid for reduction of paediatric forearm fractures

BACKGROUND

Displaced distal forearm fractures are frequently reduced in emergency departments. Not infrequently, some are not done adequately and require the tedious process of repeating the procedure, with repeated X-rays and radiation exposure, and inconvenience to patient and staff. The use of ultrasound (US) in its expanding role in the practice of emergency medicine has been proposed to visualise bone positioning.

AIM

Our department embarked on this proof of concept study to assess the usefulness of this tool.

METHOD

By way of convenience sampling, we looked at whether our US interpretation correlated with the corresponding X-ray findings, pre and post manipulation of suitable fractures.

RESULTS

Out of 42 patients recruited over a 1-year period, we were successful in 38 (90%). Four were "unsuccessful" (10%) due to technique rather than equipment or patient factors.

CONCLUSION

Whilst before we were blind prior to a post-reduction X-ray, this "new" additional role of the ultrasound (very accessible, cost effective and safe) can now aid us in our decision making, thereby enhancing the work flow of this group of patients through the department.

Effect of ondansetron on the incidence of vomiting associated with ketamine sedation in children: a double-blind, randomized, placebo-controlled trial

STUDY OBJECTIVE

We investigate the effect of ondansetron on the incidence of vomiting in children who receive intravenous (IV) ketamine for procedural sedation and analgesia in the emergency department (ED).

METHODS

In this double-blind, randomized, placebo-controlled trial in a children's hospital ED, patients receiving IV ketamine (1 mg/kg) for ED procedures were randomized to receive either IV ondansetron (0.15 mg/kg; maximum 4 mg) or identical placebo. We recorded whether vomiting occurred in the ED postsedation or up to 12 hours after discharge with telephone follow-up and compared ED length of stay and parental satisfaction.

RESULTS

One hundred twenty-seven children were randomized to placebo and 128 to ondansetron. The groups were similar in age, sex, and fasting duration. ED vomiting was less common with ondansetron: 6 of 128 (4.7%) versus 16 of 127 (12.6%), P=.02, difference 7.9% (95% confidence interval 1.1% to 14.7%), number needed to treat 13. Follow-up was successful in 82.7%, with vomiting in the ED or after discharge less frequent with ondansetron: 10 of 128 (7.8%) versus 24 of 127 (18.9%), P=.01, difference 11.1% (95% confidence interval 2.7% to 19.5%), number needed to treat 9. ED length of stay and parental satisfaction were similar between groups.

CONCLUSION

IV ondansetron significantly reduces the incidence of vomiting associated with IV ketamine procedural sedation in children.

Validity and reliability of the Behavioural Observational Pain Scale for postoperative pain measurement in children 1-7 years of age

OBJECTIVE

Pain measurement is a necessity in pain treatment but can be difficult in young children. The aim of this study was to evaluate the validity and reliability of the Behavioural Observational Pain Scale (BOPS) as a postoperative pain measurement scale for children aged 1-7 yrs. The scale assesses three elements of pain behaviors: facial expression, verbalization, and body position.

DESIGN

A prospective study.

SETTING

A day surgery care unit for children and a neurosurgical postoperative care unit.

PATIENTS

Seventy-six children aged 1-7 yrs (4.5 +/- 1.8) undergoing elective surgical procedures were observed.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The study was divided into interrater reliability, concurrent validity, and construct validity. The interrater reliabilities of the observers were very good with a high agreement between the different nurses' BOPS scores. Each item of the BOPS scale ranged from kappa(w) 0.86 to 0.95. In the concurrent validity, BOPS and Children's Hospital of Eastern Ontario Pain Scale scores had a positive correlation indicating that both tools described similar behaviors (r(s) = .871, p < .001). In construct validity, the effect of analgesic was tested before analgesic administration and at 15, 30, and 60 mins after analgesic administration. The differences in BOPS score between the time intervals were significant (p < .01) before administration of analgesia and at 15, 30, and 60 mins. There was also statistical significance in the BOPS score (p < .01) between 15 and 60 mins after administration of analgesia.

CONCLUSIONS

With BOPS, the caretaker can evaluate and document pain with high reliability and validity and thereby improve postoperative pain treatment in preschool children. The simple scoring system makes BOPS easy to incorporate in a postoperative unit.

A randomized comparison of nitrous oxide plus hematoma block versus ketamine plus midazolam for emergency department forearm fracture reduction in children

OBJECTIVES

Ketamine provides effective and relatively safe sedation analgesia for reduction of fractures in children in the emergency department. However, prolonged recovery and adverse effects suggest the opportunity to develop alternative strategies. We compared the efficacy and adverse effects of ketamine/midazolam to those of nitrous oxide/hematoma block for analgesia and anxiolysis during forearm fracture reduction in children.

METHODS

Children 5 to 17 years of age were randomly assigned to receive intravenous ketamine (1 mg/kg)/midazolam (0.1 mg/kg; max: 2.5 mg) or 50% nitrous oxide/50% oxygen and a hematoma block (2.5 mg/kg of 1% buffered lidocaine). All of the children received oral oxycodone 0.2 mg/kg (max: 15 mg) at triage > or = 45 minutes before reduction. Videotapes were obtained before (baseline), during (procedure), and after (recovery) reduction and scored using the Procedure Behavioral Checklist by an observer blinded to study purpose. The primary outcome measure was the mean change in Procedure Behavioral Checklist score from baseline to procedure, with greater change indicating greater procedure distress. Other outcome measures of efficacy included recovery times and visual analog scale scores to assess patient distress, parent report of child distress, and orthopedic surgeon satisfaction with sedation. Adverse effects were assessed during the emergency visit and by telephone 1 day after reduction. Data were analyzed using repeated measures, that is, analysis of variance, chi2, and t tests.

RESULTS

There were 102 children (mean age: 9.0 +/- 3.0 years) who were randomly assigned. There was no difference in age, race, gender, and baseline Procedure Behavioral Checklist scores between ketamine/midazolam (55 subjects) and nitrous oxide/hematoma block (47 subjects). Mean changes in Procedure Behavioral Checklist scores were very small for both groups. The mean change in Procedure Behavioral Checklist was less for nitrous oxide/hematoma block, and patients and parents reported less pain during fracture reduction with nitrous oxide/hematoma block. Recovery times were markedly shorter for nitrous oxide/hematoma block compared with ketamine/midazolam. Orthopedic surgeons were similarly satisfied with the 2 regimens. Of the ketamine/midazolam subjects, 11% had O2 saturations < 94%. Other adverse effects occurred in both groups, but more often in ketamine/midazolam both during the emergency visit and at 1-day follow-up.

CONCLUSIONS

In children who had received oral oxycodone, both nitrous oxide/hematoma block and ketamine/midazolam resulted in minimal increases in distress during forearm fracture reduction at the doses studied. The nitrous oxide/hematoma block regimen had fewer adverse effects and significantly less recovery time.

Intravenöse Midazolam-Ketamin-Anästhesie zur geschlossenen Reposition der Vorderarmfraktur bei Kindern

BACKGROUND

The aim of this study was to compare ketamine requirements in children undergoing closed reduction of forearm fractures under midazolam-ketamine anaesthesia with or without axillary plexus anaesthesia.

METHODS

With hospital ethical committee approval, we retrospectively analyzed the records of children who received midazolam-ketamine anaesthesia in the years 2000-2001 (group A) and midazolam-ketamine anaesthesia combined with axillary plexus anaesthesia in the years 2002-2004 (group B) for closed reduction of forearm fractures. Requirements for ketamine and postoperative analgesics were noted. Groups were compared with the Mann-Whitney U-test or T-test and the chi2-test (p<0.05).

RESULTS

A total of 455 children (group A 225/group B 230) were included in this study. The total amounts of ketamine were not statistically different between the two groups (p=0.154). However, ketamine requirements became less if the time interval between start of axillary plexus anaesthesia and start of intervention became more than 15 min (p<0.05). Patients in group B requested fewer analgesics in the postoperative period (p<0.01).

CONCLUSIONS

In the clinical routine of an emergency department the combination of midazolam-ketamine anaesthesia with axillary plexus anesthesia for closed reduction of forearm fractures in children did not result in lower requirements of ketamine.

A randomized, controlled trial of i.v. versus i.m. ketamine for sedation of pediatric patients receiving emergency department orthopedic procedures

STUDY OBJECTIVE

We compare adverse events, efficacy, and length of sedation of intravenous (i.v.) versus intramuscular (i.m.) ketamine procedural sedation and analgesia for orthopedic procedures in the emergency department (ED).

METHODS

Pediatric patients receiving ketamine for orthopedic procedures were enrolled in a prospective, randomized, controlled trial in a children's hospital ED. All patients were initially randomized to receive ketamine either 1 mg/kg i.v. or 4 mg/kg i.m. Demographics, adverse events, sedation efficacy, and length of sedation were recorded.

RESULTS

Two hundred twenty-five patients were randomized (116 i.v., 109 i.m.). Two hundred eight patients, aged 14 months to 15 years, completed the study, 109 i.v. and 99 i.m. Respiratory adverse events were similar between groups (i.v. 8.3% versus i.m. 4.0%; odds ratio [OR] 0.47; 95% confidence interval [CI] 0.14 to 1.6). Vomiting in the ED was more common in the i.m. group (26.3% versus 11.9%; OR 2.60; 95% CI 1.2 to 5.9). Using the Faces Pain Scale, patients in the i.m. group reported significantly less pain from the procedure. Video observers reported significantly lower distress in the i.m. group during the painful procedure (Observation Score of Behavioral Distress scores 0.35 i.m. versus 0.74 i.v.; mean difference 0.38; 95% CI 0.04 to 0.72). Length of sedation was significantly longer in the i.m. group (median 129 versus 80 minutes). Satisfaction of sedation was high in parents and physicians, with no difference in reported satisfaction between groups. This study was terminated early because of nursing resistance based on the longer recovery times observed in patients receiving ketamine i.m.

CONCLUSION

In this study of pediatric sedation for orthopedic procedures, we found that ketamine 4 mg/kg i.m. was more effective than 1 mg/kg i.v. but demonstrated significantly longer recovery times and more vomiting.

Ketamine for rapid sequence induction in patients with head injury in the emergency department

OBJECTIVE

To examine the evidence regarding the use of ketamine for induction of anaesthesia in patients with head injury in the ED.

METHOD

A literature review using the key words ketamine, head injury and intracranial pressure.

RESULTS

Advice from early literature guiding against the use of ketamine in head injury has been met with widespread acceptance, as reflected by current practice. That evidence is conflicting and inconclusive in regards to the safety of using ketamine in head injury. A review of the literature to date suggests that ketamine could be a safe and useful addition to our available treatment modalities. The key to this argument rests on specific pharmacological properties of ketamine, and their effects on the cerebral haemodynamics and cellular physiology of brain tissue that has been exposed to traumatic injury.

CONCLUSION

In the modern acute management of head-injured patients, ketamine might be a suitable agent for induction of anaesthesia, particularly in those patients with potential cardiovascular instability.

Ketamine for Conscious Sedation in Pediatric Emergency Care

The literature concerning the efficacy and safety of ketamine for conscious sedation during procedures in pediatric emergency departments was reviewed. Data were obtained from the Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures developed by the American Academy of Pediatrics Committee on Drugs, and from a MEDLINE search (January 1966-July 2004). Search terms were conscious sedation, ketamine, and emergency department; articles relevant to pediatric age group were selected. Clinical end points were efficacy and adverse effects associated with ketamine. Ketamine was effective for conscious sedation in 89-100% of patients in various studies using intravenous, intramuscular, or oral routes of administration. The efficacy of ketamine was similar to or greater than that of other drugs, such as midazolam and the combination of meperidine, promethazine, and chlorpromazine. The main adverse effects of ketamine were emesis, recovery agitation, and emergence phenomena. Ketamine appears to be an effective and well-tolerated agent for conscious sedation in pediatric patients. Overall physician and parent satisfaction with the administration of this agent for conscious sedation was high.

A Method for Measuring System Safety and Latent Errors Associated with Pediatric Procedural Sedation

The practice of sedating patients in the hospital for diagnostic and therapeutic procedures may be associated with life-threatening respiratory depression. We describe a method that uses a simulated event to identify latent system failures. A simulated scenario was developed that was reproducible with realistic physiology that degraded over time if no interventions occurred and improved when treated appropriately. Management of the scenario was observed in an ideal setting, a radiology department, and an emergency department. Event management was videotaped. The simulator's physiological data were saved automatically at 5-s intervals. Deviations from "best practice" were measured by using a set of video markers for event detection, diagnosis, and treatment. The simulator data files were used to calculate time out of range for critical variables. Hypoxia and hypotension lasted 4.5 and 5.5 min in the radiology and emergency departments, respectively, compared with 0 min in the gold standard setting. Many latent failures were identified by reviewing the video. This study supports the feasibility of using available human simulation as a crash-test dummy to more objectively quantify rescue system performance in actual sedation care settings. This method revealed vulnerabilities in personnel and in care systems even though sedation care regulatory requirements were met.

Clinical practice guideline for emergency department ketamine dissociative sedation in children

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.

Ketamine for paediatric sedation/analgesia in the emergency department

This review investigates the use of ketamine for paediatric sedation and analgesia in the emergency department.

The Lancaster experience of 2.0 to 2.5 mg/kg intramuscular ketamine for paediatric sedation: 501 cases and analysis

OBJECTIVES

To report the experience of using intramuscular ketamine 2.0 or 2.5 mg/kg for minor painful procedures in children in a medium sized district general hospital accident and emergency department. To demonstrate the safety and acceptability of ketamine and determine if the incidence of adverse effects is related to dose or other variables.

METHODS

Prospective data collection and analysis using Statsdirect and SPSS software.

RESULTS

501 consecutive cases were collected from August 1996 to April 2002. A total of 310 children received 2.0 mg/kg and 191 received 2.5 mg/kg. Twenty six received a second dose. In seven cases oxygen saturation fell below 93%, three of these fell below 90%. There was one case of laryngospasm. Eight cases received airway suctioning, five of these were mouth or lip wounds. Seventeen per cent vomited in recovery or at home for which one child required admission. Muscle hypertonicity was observed in 6.8%, disturbed sleep or nightmares in 2%. The median time to discharge was 85 minutes. Ninety seven per cent of parents' experiences were "the same as" or "better than" expected. No children suffered any lasting or troublesome complications.

CONCLUSIONS

2.0 - 2.5 mg/kg intramuscular ketamine sedation is a safe and acceptable technique when used within a defined protocol. Lower dose ketamine (2 mg/kg) warrants further study in view of potentially less airway complications and quicker discharge times than previously reported.