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