Some kids were a bit anxious after they broke their arm and had to have it fixed in the ED.
Why is it thought that ketamine was the causal agent of this anxiety??!!?
Perhaps ketamine was protective and they would have had worse anxiety without it? This was not an experimental trial and there was no comparator arm.
AT BEST, this might raise a hypothesis for future study. We should NOT conclude ANYTHING from this study. Not even a HINT of anything. We should not change out practice in any way. We have no idea if ketamine was harmful or beneficial...
Very fair. And, to your point, the one study mentioned in the podcast looking at ketamine vs fentanyl/ midazolam (Ann EM 2009) showed more behavioral issues with the latter. Your point is valid and well-taken, and I did try to make that point clear in the second half of the podcast. Regardless, it is probably fair to let the parents know there is a reasonable chance of behavior issues following discharge and this is higher in kids who were anxious before sedation, but you are right that we may not be able to entirely pin it on the ketamine.
Dr, Behar states "at worst you might get some vomiting" with ketamine.......anyone that has seen laryngospasm with ketamine would disagree and need for intubation is also a known risk. Granted the risk of intubation is 1 in 4000, but given the frequency of it's use, everyone should be prepared for this complication when using this medication. I am not suggesting that Dr. Behar isn't. I am just concerned that such statements would lead others into a false sense that ketamine is completely benign.
-324 Pediatric Laryngospasm and Airway Interventions During Ketamine Procedural Sedation in the Emergency Department Anderson, J.L. ; Puls, H.A. ; Gilani, W.I. ; Barrionuevo, P. ; Hess, E.P. ; Erwin, P. ; Murad, M.H. ; Bellolio, M.F. Annals of Emergency Medicine, October 2015, Vol.66(4), pp.S117-S117
Fair point. I do tend to get a bit cavalier with ketamine- it's always better to be prepared! I do also feel strongly about administering it slowly (30-60 seconds). The one time I've had to intubate emergently with ketamine was in an adult when it was pushed quickly. But regardless, you are correct- we should be prepared to manage the airway whenever we sedate.
Great point on the infusion rate. I am pretty religious with a 2 minute stop watch. My only real scare with ketamine was under similar circumstances where the patient got it too quickly.
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Brian D., M.D. - November 3, 2018 1:29 PM
Some kids were a bit anxious after they broke their arm and had to have it fixed in the ED.
Why is it thought that ketamine was the causal agent of this anxiety??!!?
Perhaps ketamine was protective and they would have had worse anxiety without it? This was not an experimental trial and there was no comparator arm.
AT BEST, this might raise a hypothesis for future study. We should NOT conclude ANYTHING from this study. Not even a HINT of anything. We should not change out practice in any way. We have no idea if ketamine was harmful or beneficial...
ilene c. - November 5, 2018 11:41 AM
Very fair. And, to your point, the one study mentioned in the podcast looking at ketamine vs fentanyl/ midazolam (Ann EM 2009) showed more behavioral issues with the latter. Your point is valid and well-taken, and I did try to make that point clear in the second half of the podcast. Regardless, it is probably fair to let the parents know there is a reasonable chance of behavior issues following discharge and this is higher in kids who were anxious before sedation, but you are right that we may not be able to entirely pin it on the ketamine.
Sid Williamson - January 23, 2019 5:41 AM
Dr, Behar states "at worst you might get some vomiting" with ketamine.......anyone that has seen laryngospasm with ketamine would disagree and need for intubation is also a known risk. Granted the risk of intubation is 1 in 4000, but given the frequency of it's use, everyone should be prepared for this complication when using this medication. I am not suggesting that Dr. Behar isn't. I am just concerned that such statements would lead others into a false sense that ketamine is completely benign.
-324 Pediatric Laryngospasm and Airway Interventions During Ketamine Procedural Sedation in the Emergency Department
Anderson, J.L. ; Puls, H.A. ; Gilani, W.I. ; Barrionuevo, P. ; Hess, E.P. ; Erwin, P. ; Murad, M.H. ; Bellolio, M.F.
Annals of Emergency Medicine, October 2015, Vol.66(4), pp.S117-S117
ilene c. - January 23, 2019 12:05 PM
Fair point. I do tend to get a bit cavalier with ketamine- it's always better to be prepared! I do also feel strongly about administering it slowly (30-60 seconds). The one time I've had to intubate emergently with ketamine was in an adult when it was pushed quickly. But regardless, you are correct- we should be prepared to manage the airway whenever we sedate.
Sid Williamson - February 7, 2019 6:24 AM
Great point on the infusion rate. I am pretty religious with a 2 minute stop watch. My only real scare with ketamine was under similar circumstances where the patient got it too quickly.