Bolus or titrated injection of Ketamine for procedural sedation of adults in the Emergency Department.

Report By: Dr Richard Bowman - Staff Grade, Emergency Medicine
Search checked by Dr Caroline Leech - Consultant in Emergency Medicine
Institution: University Hospitals Coventry & Warwickshire NHS Trust
Date Submitted: 20th June 2016
Last Modified: 20th June 2016
Status: Blue (submitted but not checked)

Three Part Question

[In adult patients undergoing procedural sedation in the emergency department] is [a bolus intravenous injection of ketamine (0.5mg/kg) with 10mg top up doses] better than [titrated 10mg doses] at [reducing emergence phenomenon and minimising adverse events]?

Clinical Scenario

A 39 year-old patient presents to the emergency department with a displaced angulated limb fracture that requires reduction under conscious sedation. It is decided that intravenous Ketamine is the best agent to use but doctors in the department recommend different dosage regimens. Some believe that administration of a bolus of 0.5mg/kg Ketamine and then topping up by 10mg boluses is safe, effective and reduces the risk of adverse events, especially emergence phenomenon. Others feel that giving small titrated boluses of 10mg from the beginning is safer. You wonder which is the most effective method?

Search Strategy

Medline 1960 to June 2016 using PubMed interface.

1 - (((sedation) AND ketamine) AND regimen) AND adverse events with addition or substitution of adult, complications, bolus dosage, titrated dosage and emergence phenomenon for some terms and filtered to human and English.
2 - ((optimal dosing) AND sedation) AND ketamine with filter for human and English.

Search Outcome

1 - 54 papers were found of which none were directly relevant in answering the above question regarding adult sedation.
2 – 8 papers were found of which none were directly relevant.

Comment(s)

There is no published research to directly answer the clinical question. More research has been performed on the use of ketamine in the paediatric setting, particularly when it is used in combination with other agents. Some paediatric studies suggest that higher initial dosage regimes of Ketamine require less re-dosing and provides increased physician satisfaction without increasing adverse effects. It is not known if these results can be extrapolated to the adult population.

Clinical Bottom Line

There is no current evidence available on whether a bolus injection of Ketamine in adult procedural sedation is better than titrated dosage in reducing adverse events or emergence phenomenon.