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Here's my vote for IV ketamine for:
 
        brief deep sedation/analgesia
        in toddlers and young children
        when you really need more than anxiolysis
 
Technique
        Room with suction, BVM, airways etc.
        IV (saline lock and T-connector)
        Monitors:  our protocol mandates pulse oximetry, ECG and q5min BP
                The pulse oximeter is critical.  The rest of the monitors
                irritate the child.  We are discussing adding side-stream ETCO2
                via nasal cannula.
        Somebody to record vital signs, somebody to do procedure, somebody to
             give drugs and continuously assess the airway (in our place an
             attending or fellow)
        Papoose board (may have some motor activity)
        pretreat with atropine 0.01 mg/kg
        midazolam 0.1 mg/kg first, then
        parents to waiting room!
        initial dose of ketamine 0.5 mg/kg
        Adequate local anesthesia!
        titrate subsequent increments of 0.25 mg/kg to need
Advantages over Narcotic plus Benzo
       * Less respiratory depression/airway obstruction
       *Airway reflexes at least somewhat better preserved in theory
       * More reliably effective at lower relative doses
        (some kids just seem to get wilder and wilder with
        fentanyl and midazolam until they are _very_ deep)
       * street ready sooner
Disadvantages
       *Labor intensive
       *Can't reverse ketamine
       (I would suggest you are doing something wrong if find yourself regularly
        reversing short acting narcotics or benzos given for sedation.)
       *Laryngospasm
       (Haven't seen it yet, but when it happens I take some comfort of knowing
        I have IV access for succinylcholine.  Children tolerate well some
        tachycardia and flushing from atropine.  Why deal with excessive
        secretions if you can decrease them.
       *Dysphoria/crazy on arousal -- good argument for using midazolam,
        avoiding adolescents and other crazy types
       *Seductive:  works too well.  All these impressionable trainees around
        likely to try it in even less controlled settings, in higher initial
        doses (labor intensive to give small frequent doses) and by easier but
        less optimal routes such as IM,PO,rectal or IN. These alternate routes
        prolong the duration of action of the drug, cannot be titrated to effect
        and thus prolong the at risk period from deep sedation.
 
Dale W. Steele M.D.                    | Assistant Prof. of Pediatrics
Pediatric Emergency Medicine           | Brown University
Davol 141, Rhode Island Hospital       | VOICE: [work]  (401) 444-6236
593 Eddy St                            | Office FAX     (401) 444-4307
Providence, RI  02903                  | Digital Pager  (401) 784-0322