INTRODUCTION

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.1-3 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however, is now substantially out of date and in need of revision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.