Ujuzi means skills in Swahili and is intended to be a regular feature for colleagues to share practical interventions, innovations and novelties that have proved useful in the management of patients in the prehospital environment or Emergency Centre. You can let Ujuzi know about your practical ideas by emailing practicalpearl@afjem.com.
Ketamine procedural sedation in low resource settings
Procedural sedation and analgesia (PSA) is a core competency in emergency medicine (EM). As EM develops in low resource settings, it is incumbent upon the emergency medicine community to ensure that evidence based trainings are developed to enable providers in these setting to safely provide PSA. This will avert unnecessary delays and patient suffering from inadequate pain management and sedation during painful procedures.
In addition to lack of providers trained in PSA, the other usual limiting factors in low resource settings are lack of proper monitoring equipment and supplemental oxygen.1 This makes ketamine the ideal choice for PSA in these settings. Ketamine is a dissociative anesthetic that has both amnestic and analgesic properties. Its effects do not fit into the typical continuum of sedation discussed for other agents. If administered properly, ketamine is associated with exceedingly low risk of respiratory depression or hemodynamic instability. Additionally, patients under ketamine anesthesia maintain protective airway reflexes.
Ketamine has a long history of extensive use in low resource settings.1, 2, 3 However, ketamine can cause adverse events if used incorrectly or administered to an improperly selected patient. Practical pearls for ketamine use can be divided into patient selection, administration and rescue from adverse events.
Patient selection:
- 1.
In terms of severity, the major adverse event is laryngospasm (incidence 0.3%).4 Patients with active upper respiratory tract infections may be at increased risk, although the evidence for this is not strong.5 Given the difficulty of managing prolonged laryngospasm in resource limited settings, providers without advanced airway expertise should strongly consider alternatives to ketamine in patients with upper respiratory tract infections.
- 2.
Concerns about ketamine increasing intracranial pressure (ICP) are likely overstated and some evidence exists that ketamine actually lowers ICP.4, 6 We do not restrict ketamine use in patients with possible intracranial pathology in our setting.
- 3.
In some settings there was hesitancy to administer ketamine to adults for fear of unacceptably high rates of emergence reaction. Thi