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Procedural sedation and analgesia involve the use of one or more sedative and analgesic agents to relieve pain and anxiety and to control motor activity in patients undergoing diagnostic and therapeutic procedures.1–4 Administration of effective procedural sedation can maximise patient comfort, thus leading to a higher frequency of procedural success and it is also often linked with increased parental satisfaction with the emergency department (ED) experience, even though the administration of sedation can be associated with increased length of stay.1–4 Typical indications for procedural sedation include diagnostic imaging, fracture or dislocation reduction, wound care and repair of a laceration, incision and drainage of an abscess, lumbar puncture and placement of a central venous catheter.1–4 This paper will discuss the safety profile of ketamine when used in procedural sedation and how to prevent or manage ketamine sedation-related adverse events.
Ketamine: pharmacology and actions
Ketamine is N-methyl-D-aspartate receptor blocker, a dissociative agent chemically related to phencyclidine. It produces a trance-like cataleptic state of sensory isolation characterised by profound analgesia, sedation and amnesia while maintaining cardiovascular stability and preserving spontaneous respirations and airway reflexes.4 Ketamine undergoes hepatic metabolism to norketamine, an active metabolite with one-third of the analgesic potency of ketamine. It has a short duration of action and can be administered intravenously, intramuscularly or intranasally. The intravenous route is highly preferred in procedural sedation using ketamine. The onset of action of ketamine is rapid (1–2 min), the duration is brief (10–15 min) and the recovery time is short (30–60 min). The initial dose is 1–1.5 mg/kg, and an additional 0.5 mg/kg doses can be administered within the next 4 min and titrated to effect. The dose given should achieve and maintain dissociation. This is an important concept. Other drugs used for sedation in the ED will demonstrate a dose-response continuum, which generally involve more drug to achieve deeper …
Contributors DJ has completed the literature search and shared the analysis and write up of the review with CP who edited and re-edited the paper.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Commissioned; externally peer reviewed.
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