>I am interested in everyone's opinion about the following protocol
>and any experience you have had with this medication ...
I am a ketamine fan, but your "protocol" raises some concerns. This
is good outline of information about the drug, but _is not_ a protocol. I
assume you have a general sedation protocol which addresses the critical
-When is it appropriate?
It is hard to defend deep sedation of an child with a full
stomach for a 5 minute laceration repair. What should be done in the OR?
-What monitoring is appropriate?
The concept "Conscious Sedation" is an oxymoron. This is
"deep" sedation...the AAP Guidelines suggest continuous pulse oximetry,
cardio-respiratory monitor, frequent bp's and _most_ important, a physician
with no other responsibility than monitoring the patient continuously
present during the period of time the child is deeply sedated.
-NPO status of the patient?
How many of our patients have an "empty stomach" by even
the most liberal guidelines as defined for anesthesia? This fact is
generally ignored in the published ED studies.
-Need for an IV?
In my opinion ketamine should be given IV with _rare_
exceptions . The other routes (intramuscular, rectal, oral, intranasal)
cannot be easily titrated to effect. The duration of action (and therefore
duration of risk and need for intensive monitoring) is _much_ longer. If
you think it is hard to put IV's in kids and use other routes because they
are "easier", you are not likely to be successful in placing an IV when you
really need it. The Annals article you cite describes a scary episode of
I agree with concommittent use of midazolam (lowers dose of
ketamine required, may help with emergence) and an anticholinergic agent.
My experience has been with atropine (0.01 mg/kg).
>7. Nystagmus: Vertical nystagmus will be universally noted
>in patients in the dissociative anesthetic state.
This state is disturbing to parents. I think less drug is used and
things go better if you then send the parents out after the midazolam takes
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Dale Steele,MD <[log in to unmask]> Listowner: PED-EM-L