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Ketamine for Conscious Sedation in Pediatric Emergency Care

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Ketamine for Conscious Sedation in Pediatric Emergency Care

Abstract


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.

Introduction


Conscious sedation is a controlled state of depressed consciousness that preserves protective reflexes, allows maintenance of a patent airway independently and continuously, and permits the patient to respond appropriately to physical stimulation and verbal command. Conscious sedation has traditionally been used in inpatient settings, such as the operating room, where skilled anesthesia personnel are available to titrate drugs and maintain airway patency. An increasing need to accomplish procedures outside the operating room has led to the use of conscious sedation in outpatient settings, such as emergency departments. Many procedures in the pediatric emergency department are well tolerated with a local anesthetic and an acceptable level of sedation and analgesia achievable with conscious sedation.

Most agents for conscious sedation have traditionally been used by anesthesiologists in the controlled environment of an operating room. Thus, the use of these agents in a less controlled environment, such as the emergency department, requires practitioners to be cognizant about possible adverse effects and apply the skills necessary to manage these effects as needed. Guidelines for monitoring and managing pediatric patients during and after conscious sedation were developed by the American Academy of Pediatrics Committee on Drugs to ensure the safe and effective management of conscious sedation in the outpatient setting. The goals of pediatric sedation are to protect the patient's safety and welfare, minimize physical discomfort or pain, provide analgesia to minimize negative physiologic responses and maximize the potential for amnesia, control behavior, and return the patient to a state in which safe discharge from the emergency department is possible.

The ideal sedative agent can be described as having a relatively fast and consistent onset; short duration; uniform efficacy; an effective combination of analgesia, sedation, and amnesia; ease of administration without unnecessary pain or anxiety; and minimal contraindications, adverse effects, and cost. It is important to identify an agent or combination of agents that maximizes these properties. Classes of drugs used for conscious sedation are the benzodiazepines (e.g., midazolam, lorazepam), opioids (e.g., morphine, fentanyl), and sedative-hypnotics (e.g., chloral hydrate, ketamine).

One report suggested that ketamine for conscious sedation prevents excessive pain and discomfort for the child, avoids hospital admissions, and offers economy of time and resources for surgeons, anesthetists, pediatricians, and operating room and ward staff. Ketamine's relative cardiovascular stability and limited effects on the respiratory system make it a suitable alternative to other agents that can cause more deleterious effects.

Ketamine for conscious sedation has been studied in children in various emergency departments in the United States and other countries using a variety of routes and doses, both alone and in combination with other drugs.

Source...
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