Pain management and sedation/concept
Clinical Practice Guideline for Emergency Department Ketamine Dissociative Sedation: 2011 Update

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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.

Introduction

The dissociative agent ketamine has been the single most popular agent to facilitate painful emergency department (ED) procedures in children for nearly 2 decades.1, 2, 3 Current ketamine protocols, including indications, contraindications, and dosing, are frequently based on a widely cited 2004 clinical practice guideline,1 which in turn was an update of a 1990 protocol.4 This latter article was cited in 1999 as an “example of compliance” by The Joint Commission.5 The 2004 guideline, however, is now substantially out of date and in need of revision because subsequent ketamine investigations have questioned, disproved, or refined several of its assertions and recommendations. During this same period, there has also been sufficient ED research in adults to support expansion of ketamine use beyond children. In addition, animal research describing neurotoxicity with ketamine raises important new questions that must be considered and further investigated in humans.

To describe the best available evidence and perspectives about optimal dissociative sedation practice, we reviewed the newer ketamine literature and updated the 2004 clinical practice guideline.

Section snippets

Why a Separate Clinical Practice Guideline for Ketamine?

Emergency physicians already have access to various standards,6 policies,7 guidelines,8, 9 and review articles10, 11 dealing with the general practice of procedural sedation and analgesia. However, ketamine displays unique features that warrant considering it separately from other sedatives.

The underlying pharmacology of ketamine is fundamentally different from that of other procedural sedation and analgesia agents. This drug exerts its effect by “disconnecting” the thalamocortical and limbic

Materials and Methods

We assembled a clinical practice guideline update committee of 4 senior ketamine researchers, including the 2 authors of the previous version. We limited our panel to emergency physicians because the ED is the exclusive focus of this guideline, emergency physicians have a widely accepted leadership role in procedural sedation and analgesia,10, 11, 21 and emergency physicians have a natural reluctance to permit other specialists to dictate emergency medical practice.22

To perform this update, we

Explanation of Clinical Practice Guideline Content

The updated clinical practice guideline is shown in Figure 1, with major changes from the previous version summarized in Figure 2. The following is explanatory information and evidence in support of its sequential elements. A general approach to ketamine dissociative sedation is shown in Figure 3.

Future Research Questions

The ED ketamine literature in children is robust, with few major issues remaining unstudied. Although larger, multicenter studies would always be welcome, there is already a strong evidentiary basis in place for indications, dosing, route, and adjunctive medications and for the safety of this drug in the ED.

The high-priority study questions at this time are as follows.

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  • Cited by (0)

    Supervising editors: Kelly D. Young, MD, MS; Donald M. Yealy, MD

    Dr. Young and Dr. Yealy were the supervising editors on this article. Dr. Green did not participate in the editorial review or decision to publish this article.

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Dr. Krauss is a consultant for Oridion Medical, a capnography company, and holds 2 patents in the area of capnography.

    Earn CME Credit: Continuing Medical Education is available for this article at http://www.ACEP-EMedhome.com.

    Publication date: Available online January 21, 2011.

    Reprints not available from the authors.

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