Ketamine sedation for pediatric gastroenterology procedures

Background: Although the dissociative sedative ketamine is used commonly fo r pediatric procedural sedation in other settings, the safety of this agent in pediatric gastroenterology is not well-studied. A 5-year experience wit h ketamine sedation for pediatric gastroenterology procedures was reviewed to document the safety profile of this agent and to identify predictors of laryngospasm during esophagogastroduodenoscopy (EGD). Methods: The study was a retrospective consecutive case series of children receiving ketamine administered by pediatric gastroenterologists skilled in basic airway management to facilitate pediatric gastrointestinal procedure s during a 5-year period. Patient's records were reviewed to determine indi cation, dosage, adverse effects, drugs, inadequate sedation, and recovery t ime for each sedation. A multiple logistic regression analysis was performe d to identify predictors of laryngospasm during EGD. Outcome measures were descriptive features of sedation, including adverse effects and predictors of laryngospasm during EGD. Results: During the study period pediatric gastroenterologists administered ketamine 636 times, primarily for EGD (86%) and primarily by the intraveno us route (98%). The median loading dose and total dose were 1.00 mg/kg and 1.34 mg/kg, respectively. Inadequate sedation was noted in seven (1.1%) pro cedures. Adverse effects included transient laryngospasm (8.2%), emesis (4. 1%), recovery agitation (2.4%), partial airway obstruction (1.3#), apnea an d respiratory depression (0.5%), and excessive salivation (0.3%). There wer e no adverse outcomes attributable to ketamine. Nearly half (46%) the subje cts had severe underlying illness (American Society of Anesthesiologists [A SA] class greater than or equal to3). All instances of laryngospasm occurre d during EGD (9.5% incidence), and the only independent predictor of laryng ospasm in this sample was decreasing age. The incidence of laryngospasm was 13.9% in preschool-aged (less than or equal to6 years) children and was 3. 6% in school-aged (>6 years) children (difference 10.3%, 95% confidence int ervals 5.5-14.9%). No dose relationship was noted with laryngospasm, and th e risk did not increase with underlying illness. Conclusion: Pediatric gastroenterologists skilled in ketamine administratio n and basic airway management can effectively administer this drug to facil itate gastrointestinal procedures. Transient laryngospasm occurred in 9.5% of children receiving ketamine for EGD, and its incidence was greater in pr eschool than in school-aged children.