Intravenous Ketamine and Kids
ABSTRACT & COMMENTARY
Source: Green SM, et al. Intravenous ketamine for pediatric sedation in the emergency department: safety profile with 156 cases. Acad Emerg Med 1998;5:971-976.
Green and colleagues, in this retrospective consecutive case series, sought to determine the safety of IV ketamine in the emergency department (ED) when it was used for procedural sedation in pediatric patients. Of the 156 children studied, only two had airway complications. One had a transient period of apnea that responded to bag-valve-mask ventilation. The other had transient respiratory depression with desaturation, again responding to non-invasive treatment. One patient had excessive salivation. Six patients had uncomplicated emesis. Two patients had what was characterized as "mild" recovery agitation. Forty percent of the children studied required only one dose of 1.5 mg/kg. The remainder required repeat doses with a mean total dose of 2.5 mg/kg. Concurrent atropine was given in 88% of the cases, and concurrent midazolam in 31%. Green et al conclude that IV ketamine has a very good safety profile when used in the ED in pediatric patients.
Comment by Glenn C. Freas, MD, JD, FACEP
This study caught my eye soon after one of my senior residents declared that ketamine was the "perfect" agent for conscious sedation in the ED. Seemingly, he had read an article that I missed. However, this was not the one. This study does show that the feared complications of airway compromise and/or excessive secretions are rare. The concomitant administration of atropine certainly decreased the hypersalivation attributed to ketamine. The adverse reaction that continues to concern me is the emergence phenomenon. In sixties parlance, this is apparently similar to a "bad trip" on LSD. The incidence of this reaction is higher in adults but not insignificant in children. Despite the authors’ reassurances that their chart abstractors would have picked up mild, moderate, and severe recovery agitation, I remain skeptical. How does one document such reactions in children, particularly very young children? Do a few whimpers really mean the recovery agitation is merely "mild?" Most of the pediatric emergency medicine specialists that I know routinely use midazolam with ketamine to blunt the emergence phenomenon.
Another issue is whether IV ketamine offers any advantage over IM ketamine. Green et al admit that recovery times were similar for both routes. They also acknowledge that IM ketamine is efficacious. At our institutions, we routinely use a ketamine "dart" (ketamine, midazolam, and atropine in a single IM injection) for pediatric sedation. It works quickly, lasts long enough for most ED procedures, and is safe. Green et al admit that IV ketamine is probably best reserved for children who already have an IV in place, or for children who require prolonged, titrated sedation. If you do use it, it appears safe.
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