I think Michael makes an excellent "big picture" point, which is that we should be using the single inclusive (and accurate) term "procedural sedation" regardless of the agent(s) chosen, rather than continuing to use multiple confusing (and ambiguous) terms such as "moderate sedation", "deep sedation", "conscious sedation" (the worst of all in my opinion) and even possibly "dissociative sedation".

Peter Auerbach, MD, FAAEM, FAAP
Randall Children's Hospital 
Portland, OR

On Nov 22, 2011, at 10:04 AM, Michael Verive <[log in to unmask]> wrote:

> As a Pediatric Intensivist, sedation provider, and member of the Society for Pediatric Sedation, I feel it important to clarify that the ASA does not have a "carve-out" for ketamine, just because it is a dissociative anesthetic agent.  If you look at the sedation continuum, there is no mention of "dissociative sedation" as a distinct classification.
> I think sometimes we pay too much attention to the labels we place on our intended sedation/anesthesia levels.  And, from a practical standpoint (and a medico-legal one), if you are using ketamine (or any other agent) to provide procedural sedation, it doesn't matter what you call the sedation level.  What matters is that you are prepared to handle the adverse events, including laryngospasm, inadvertent deeper-than-intended sedation/anesthesia, apnea (yes, it can happen even with ketamine, especially if a bolus is given rapidly), hypertension, hypotension, tachyarrhythmias, etc...
> Michael J. Verive, MD, FAAP
> Medical Director - Pediatric Intensive Care
> St. Mary's Hospital for Women and Children
> 3700 Washington Ave
> Evansville, IN 47750
> --- On Mon, 11/21/11, Jackson, Benjamin F <[log in to unmask]> wrote:
>> From: Jackson, Benjamin F <[log in to unmask]>
>> Subject: Ketamine Sedation Classification: Moderate vs Deep vs Dissociative?
>> To: [log in to unmask]
>> Date: Monday, November 21, 2011, 3:03 PM
>> Question for the group regarding
>> procedural sedation in the Pediatric ED setting specifically
>> involving ketamine:
>> I'm sure most of you have seen the 2011 update to the
>> Clinical Practice Guideline for Emergency Department
>> Ketamine Dissociative Sedation by Drs Green, Roback,
>> Kennedy, and Krauss, that ran in the May edition of Annals
>> EM (abstract below) in which the authors treat the unique
>> qualities of ketamine as an agent distinct from the
>> conventional dose-dependent sedation continuum and thus
>> argue for a specific dissociative sedation classification.
>> This assertion was referenced without contention by Drs
>> Cravero and Havidich in a review article on Pediatric
>> Sedation that ran in Pediatric Anesthesia (abstract below).
>> Have any of your groups navigated and/or successfully
>> developed a dissociative sedation classification for
>> procedural sedation with ketamine in your emergency
>> department?  If not, how are you classifying ketamine
>> sedations? (Question mirrored on Pediatric Sedation
>> listserv)
>> Please respond to the list or to me personally. 
>> Thanks so much.
>> Ben Jackson
>> Benjamin F. Jackson, MD, FAAP
>> Assistant Professor of Pediatrics
>> Pediatric Emergency Medicine
>> Medical University of South Carolina
>> 135 Rutledge Avenue, PO Box 250566
>> Charleston, SC 29425
>> Phone: 843-792-0269
>> Fax: 843-876-0962
>> [log in to unmask]
>> Ann Emerg Med. 2011 May;57(5):449-61. Epub 2011 Jan 21.
>> Clinical practice guideline for emergency department
>> ketamine dissociative sedation: 2011 update.
>> Green SM, Roback MG, Kennedy RM, Krauss B.
>> SourceDepartment of Emergency Medicine, Loma Linda
>> University Medical Center and Children's Hospital, Loma
>> Linda, CA 92354, USA.
>> Abstract
>> We update an evidence-based clinical practice guideline for
>> the administration of the dissociative agent ketamine for
>> emergency department procedural sedation and analgesia.
>> Substantial new research warrants revision of the widely
>> disseminated 2004 guideline, particularly with respect to
>> contraindications, age recommendations, potential
>> neurotoxicity, and the role of coadministered
>> anticholinergics and benzodiazepines. We critically discuss
>> indications, contraindications, personnel requirements,
>> monitoring, dosing, coadministered medications, recovery
>> issues, and future research questions for ketamine
>> dissociative sedation.
>> Copyright © 2011 American College of Emergency Physicians.
>> Published by Mosby, Inc. All rights reserved.
>> PMID: 21256625 [PubMed - indexed for MEDLINE] 
>> Paediatr Anaesth. 2011 Jul;21(7):800-9. doi:
>> 10.1111/j.1460-9592.2011.03617.x. Epub 2011 May 18.
>> Pediatric sedation--evolution and revolution.
>> Cravero JP, Havidich JE.
>> SourceDepartment of Anesthesiology, Dartmouth Medical
>> School/Dartmouth Hitchcock Medical Center, Lebanon, NH
>> 03756, USA. [log in to unmask]
>> Abstract
>> Pediatric sedation continues to change in terms of the
>> professionals who provide this care, those who produce
>> original research on this topic, guidelines and literature
>> concerning risk, medications employed, and methods for
>> training for new providers. Some of the changes could be
>> categorized as 'evolutionary' or gradual in nature and
>> predictable - such as the changing role of anesthesiologists
>> in the field of pediatric sedation and the use of the
>> well-established dissociative sedative, ketamine. Other
>> changes in pediatric sedation are more radical or
>> 'revolutionary'. They include reconsideration of what is
>> defined as an 'adverse event' during sedation, the use of
>> propofol or dexmedetomidine, and the application of human
>> patient simulation for training. This review will highlight
>> the ongoing changes in the dynamic field of pediatric
>> sedation by focusing on some of the important progress (both
>> evolutionary and revolutionary) that has occurred across the
>> varied specialties that!
>>   provide this care.
>> © 2011 Blackwell Publishing Ltd.
>> PMID: 21585616 [PubMed - indexed for MEDLINE] 
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