Ketamine.
This ought not surprise virtually anyone, considering the vast body of experience physicians have performing safe, effective procedural sedation with ketamine. However, medicine is prone to its dogmatic confirmation bias, so I applaud these authors for this important report.
This is a prospective, observational, multi-center cohort specifically evaluating all episodes of procedural sedation for serious adverse events and important interventions. These authors recorded medication cocktails used for sedation, any adjunctive use of medication, the procedure performed, fasting status, and underlying health risks, and then tracked the outcomes of each procedure performed.
Ultimately, they included 6,295 children and sedation events in this study. The most commonly used sedation medications were ketamine, propofol, and combinations of ketamine, propofol, and fentanyl. Serious events were rare, occurring in about 1% of sedations – and, likewise, so were important interventions. Furthermore, the vast majority of events and interventions were simply temporary use of positive pressure ventilation in response to periods of apnea. Importantly, no patients required intubation or unplanned hospital admission. Oxygen desaturation was tracked separately from serious events and, along with vomiting, occurred in approximately 5% of sedation procedures.
With regard to other contributing factors to serious events or interventions, any deviation from ketamine monotherapy increased such risks. Whether it be combining ketamine with another opiate or benzodiazepine, or whether propofol were used alone or in combination, all increased the risk of serious events a small absolute amount over the baseline. Several figures included in the manuscript describe the various risk factors associated with serious outcomes with generally predictable associations, including increased risks with periprocedural opiate use, and decreased vomiting when ketamine were excluded.
Overall, even though the short answer to the question posed in the title is “ketamine”, the slightly longer answer is “any choice is probably fine”. Even though the relative risks are increased, the absolute risks are small – and the severity of interventions required, despite their labeling, were essentially benign.
“Risk Factors for Adverse Events in Emergency Department Procedural Sedation for Children”
https://www.ncbi.nlm.nih.gov/pubmed/28828486
Please correct me if I’m wrong, I remember reading if used for procedural sedation if the patient starts to have emergence/reactions with Ketamine they are not disassociated enough and would benefit from additional ketamine to facilitate appropriate sedation?
If you’re suggesting the cure for not enough ketamine is … more ketamine … then I think we can be in agreement!
Generally speaking, yes, if the sedation is inadequate and the procedure is prolonged, any method of sedation can be supplemented with additional doses.