At 07:08 PM 8/19/2004, Evan Mahl wrote:
>I was concerned about sedation for this child. I am a
>bit weary about sedating a child (with something like
>ketamine) who needs oral surgery. My only bad adverse
>event in the past was with a tongue lac/ketamine with
>bronchospasm. Perhaps a bit of fluid got on the cords
>and caused this spasm.
Ketamine is well known to both preserve and exaggerate protective airway
reflexes, and there is evidence that stimulation of the larynx during
dissociative sedation will increase the risk of laryngospasm. (1) In a
large series of ketamine for pediatric gastroenterology procedures, for
example, laryngospasm was encountered in 9.4% of those undergoing upper
endoscopy but in none of those undergoing colonoscopy. (2) Since
laryngospasm only occurs in 0% to 3% of upper endoscopy patients sedated
using benzodiazepines and opioids, (2) it is reasonable to assume that
ketamine presents additional independent risk as a sedative choice during
procedures with substantial laryngeal stimulation. Several authors have
reported no airway complications using ketamine for dentistry and other
intra-oral procedures; (3-6) however others have. (7-8)
Based on this presumed higher risk of laryngospasm, it seems reasonable to
regard procedures which stimulate the posterior pharynx either directly or
with secretions as relative contraindications to ketamine. How rigorously
one enforces this relative contraindication would be based upon one’s
relative comfort in dealing with laryngospasm. Clinicians preferring to do
all possible to minimize laryngospasm risk should likely pass. I would fall
in this category.
Clinicians less wary of ketamine-associated laryngospasm can be reassured
that it is relatively uncommon (0.4% incidence) for non-oral procedures (9)
and that essentially all reported occurrences have been transient and
responded quickly to assisted ventilation and oxygen. (1) In a systematic
review of all ketamine series in children prior to 1990 totaling 11,589
ketamine administrations, there were only two reported cases in which
ketamine-associated laryngospasm led to intubation (0.02% incidence, 95%
confidence interval 0.002% to 0.06%). (1, 10,11) In both cases it is not
clear whether the intubation was required, or rather employed for
anesthesiologist convenience. There is currently no evidence to suggest
that practitioners skilled in both dissociative sedation and advanced
airway management cannot consistently manage laryngospasm without a greater
than minimal risk of adverse outcome.
Steve Green, MD
Professor of Emergency Medicine & Pediatrics
Loma Linda University
1. Green SM, Johnson NE: Ketamine sedation for pediatric procedures: Part
2, Review and implications. Ann Emerg Med 1990; 19:1033-1046.
2. Green SM, Klooster M, Harris T, Lynch EL, Rothrock SG: Ketamine sedation
for pediatric gastroenterology procedures. J Pediatr Gastroent Nutr 2001;
3. Luhmann JD, Kennedy RM, McAllister JD, Jaffe DM: Sedation for
peritonsilar abscess drainage in the pediatric emergency
department. Pediatr Emerg Care 2002; 18:1-3.
4. Pruitt JW, Goldwasser MS, Sabol SR, Prstojevich SJ: Intramuscular
ketamine, midazolam, and glycopyrrolate for pediatric sedation in the
emergency department. J Oral Maxillofac Surg 1995; 53:13-17.
5. Susskind DL, Park J, Piccirillo JF, Lusk RP, Muntz HR: Conscious
sedation – A new approach for peritonsillar abscess drainage in the
pediatric population. Arch Otolaryngol Head Neck Surg 1999; 125:1197-1200.
6. Corssen G, Hayward JR, Gunter JW, et al: A new parenteral anesthesia
for oral surgery. J Oral Surgery 1969; 27:627-632.
7. Bryant WM: Ketamine anesthesia and intranasal or intraoral
operations. Plast Reconstr Surg 1973; 51:562-564.
8. Chuden HG: Klinische erfahrungen mit ketamine bei der
adenotonsillektomie. Anaesthesist 1971; 20(4):155-157.
9. Green SM, Rothrock SG, Lynch EL, et al: Intramuscular ketamine for
pediatric sedation in the emergency department: Safety profile with 1,022
cases. Ann Emerg Med 1998; 31:688-697.
10. Phillips LA, Seruvatu SG, Rika PN: Anaesthesia for the
surgeon-anaesthetist in difficult situations. Anaesthesia 1970; 25:36-45.
11. Walker AK: Intramuscular ketamine in a developing
country. Anaesthesia 1972; 27:408-414.
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