Ketamine sedation – what do like with your special K?

I must declare a “conflict of interest”.  I love ketamine, therefore anything you read from here on in is likely seriously biased.  Ketamine has had a big resurgence in popularity over the past 5 years in anaesthesia and ED practice.  There have been plenty of papers looking at its use for procedural sedation in the last few years. Last week I got into a minor Twitter-debate with @jvrbntz @keeweedoc and @PBSherren about current practice and evidence.

But when I look around my ED, and talk to colleagues in other places I find that there is a wide range of practice when it comes to using ketamine for procedural sedation.  So I thought I would open up a forum for discussion and link in some evidence for us all to consider and try to reach some consensus.

Here are the basic ways I see people using ketamine, and the drugs that get used with it in order to reduce side-effects or improve the sedation.

  1. Straight ketamine.   Do you like it IMI or IV (or maybe even intranasal?)
  2. Ketafol (K + propofol): What is the ratio to use? What dose? In one or 2 syringes?
  3. Antisialogogue ?  Atropine or glycopyrrolate
  4. Benzos – midazolam (or other) – before, with or after K?
  5. Antiemetics: ondansetron, droperidol, metoclopramide? Routine or as required?
  6. Monitoring – what do you use as a standard?
  7. Oxygen or no oxygen during sedation?
  8. Strategies for avoiding emergence phenomena – how do you do it?

Here is a link to the great, free-full text review of ketamine sedation from the Annals of Emergency Medicine, May 2011.  It is worth a read and might change your practice.  It has references to pretty much all the latest data out there on ketamine in the ED.

For the record – my current ketamine sedation routine (based on some evidence and a lot of guesswork and bias) is as  follows:

  • IV access – try to keep the kid as calm as possible, or allow hem to settle down before starting sedation
  • No IMI ketamine unless the IV is really tough or causing lots of distress.
  • Preload with ondansetron – NNT = 13, but not much downside to this other than cost.
  • No antisialogogues
  • Preference for Ketofol ( 1:1 ratio) for painful, brief procedures
  • Benzos – I use midazolam on a PRN basis if emergence is happening – just hang around as the sedation wears off and watch them closely.
  • Oximetry and continuous waveform capnography via nasal prongs
  • Oxygen via nasal prongs with a BVM on standby if they have a prolonged apnoea.
  • Keep the room quiet, turn off unnecessary lights and have mum nearby for the recovery phase

Ok, let me hear your current practice and idiosynchracies  – do you follow guidelines, evidence or just do what you find works well in your shop?

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