I disagree with Dr. Verive.

I agree that the important issue is whether the person doing the sedation is able to handle complications, particularly the airway. 

However, in the real world, away for the "big picture," the problem is measuring and credentialing that ability. From a medicolegal standpoint, that credentialing is very important and it will come up when adverse events and bad outcomes occur. 

If you are an intensivist or boarded in emergency medicine, you are probably credentialed (regardless of recently demonstrated ability) to provide any level of sedation. This reinforces Dr. Verive's viewpoint that it is all a continuum. 

However, if you are a pediatrician not boarded in those specialties, most hospitals (or specifically the anesthesia departments within them) have taken a tiered approach to credentialing. Propofol sedation typically requires credentialing at a higher tier than midazolam. In the "little picture" at each hospital, the issue of whether ketamine requires as much training (initial and on-going) as propofol is very important to the pediatric hospitalists providing sedation. I find ketamine to be safer than using midazolam/fentanyl at doses high enough to achieve appropriate "procedural sedation," for pediatric patients. I would be very happy to eliminate the distinction between moderate and deep sedation (and even happier to be paid accordingly.) Until that happens, I think there are good arguments for carving out ketamine sedation as different than deep sedation with propofol. 

This has been an issue since the "sedation continuum" was inaccurately redefined to eliminate "conscious sedation" and replace it with the inaccurate concept that sedation is a simple, single, linear spectrum of minimal, moderate, and deep "levels."

Kevin Powell MD PhD
Saint Louis University  

-----Original Message-----
From: Pediatric Emergency Medicine Discussion List
[mailto:[log in to unmask]]On Behalf Of Peter Auerbach
Sent: Tuesday, November 22, 2011 2:57 PM
To: [log in to unmask]
Subject: Re: Ketamine Sedation Classification: Moderate vs Deep vs

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

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