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The incidence of peri-procedural amnesia following procedural sedation in children is unclear and difficult to determine. This study aimed to apply quantitative and qualitative approaches to better understand amnesia following dental sedation of children. After Institutional Review Board Approval, children scheduled for sedation for dental procedures with oral midazolam (OM), oral midazolam and ketamine (OMK), or intranasal midazolam and ketamine (IMK) were recruited for examination of peri-procedural amnesia. Amnesia during the dental session was assessed using a three-stage method, using identification of pictures and an animal toy. On the day following the sedation, primary caregivers answered two questions about their children’s memory. One week later, the children received a semi-structured interview. Behavior and level of sedation during the dental session were recorded. Quantitative data were analyzed using descriptive statistics and comparison tests. Qualitative data were analyzed using content analysis. Triangulation was used. Thirty-five children (age: 36 to 76 months) participated in the quantitative analysis. Most children showed amnesia for the dental procedure (82.9%, n = 29/35) and remembered receiving the sedation (82.1%, n = 23/28 for oral administration, 59.3%, n = 16/27 for intranasal administration). The occurrence of amnesia for the dental procedure was slightly higher in the oral midazolam group compared with the other groups (44.8%, n = 13/29 for OM, 13.8%, n = 4/29 for OMK, and 41.4%, n = 12/29 for IMK). Twenty-eight children participated in the qualitative approach. The major theme identified was that some children could remember their procedures in detail. We conclude that peri-procedural amnesia of the dental procedure was common following sedation.

We review the literature in regard to the accuracy, reliability, and feasibility of the Mallampati score as might be pertinent and applicable to emergency department (ED) airway management and procedural sedation. This 4-level pictorial tool was devised to predict difficult preoperative laryngoscopy and intubation, but is now also widely recommended as a routine screening element before procedural sedation. The literature evidence demonstrates that the Mallampati score is inadequately sensitive for the identification of difficult laryngoscopy, difficult intubation, and difficult bag-valve-mask ventilation, with likelihood ratios indicating a small and clinically insignificant effect on outcome prediction. Although it is important to anticipate that patients may have a difficult airway, there is no specific evidence that the Mallampati score augments or improves the baseline clinical judgment of a standard airway evaluation. It generates numerous false-positive warnings for each correct prediction of a difficult airway. The Mallampati score is not reliably assessed because independent observers commonly grade it differently. It cannot be evaluated in many young children and in patients who cannot cooperate because of their underlying medical condition. The Mallampati score lacks the accuracy, reliability, and feasibility required to supplement a standard airway evaluation before ED airway management or procedural sedation.

Procedural sedation is an integral part of emergency medicine (EM) practice in the USA, Canada, Australia and New Zealand. These countries have produced a large, robust literature supporting the safe and efficacious use of ketamine, propofol and other ED sedation agents for managing procedural pain and anxiety.1–3 In the UK and Ireland, EM and paediatric EM practitioners are striving to similarly establish procedural sedation as a fundamental part of their practice. McCoy et al describe, through a structured interview session with a group of EM consultants, the current issues impacting procedural sedation in the UK and the barriers to its adoption. Many of these same challenges and impediments were encountered in North America and Australia/New Zealand, and the lessons learned may be applicable and helpful in the UK and Ireland.4 As veterans of these challenges, here is our perspective. The capability of paediatric emergency physicians to administer timely procedural sedation directly benefits patients and their families by providing a safe, effective and efficient outpatient way of managing procedural pain and anxiety. Emergency physicians from North America, Australia and New Zealand reading the McCoy et al report will be surprised by the acceptance of hospitalisation as standard practice for management of simple forearm fractures in children, especially in the UK where EM is an established specialty. Such an approach transforms a brief ED procedure and a 30–90 min recovery into an overnight bed, an admitting paediatrician, a theatre room and an anaesthetist. Instead of promptly returning to the comforts of home, …

INTRODUCTION Procedural sedation refers to the technique of administering sedatives or dissociative agents with or without analgesics to induce an altered state of consciousness that allows the patient to tolerate unpleasant procedures while preserving cardiorespiratory function. Procedural sedation and analgesia is a core competency in emergency medicine and a daily part of emergency department (ED) practice. As noted by the United States Centers for Medicare & Medicaid Services (CMS): “The ED is a unique environment where patients present on an unscheduled basis with often very complex problems that may require several emergent or urgent interventions to proceed simultaneously to prevent further morbidity or mortality.” The CMS guidelines also state that “. . . emergency medicine–trained physicians have very specific skill sets to manage airways and ventilation that is necessary to provide patient rescue. Therefore, these practitioners are uniquely qualified to provide all levels of analgesia/sedation and anesthesia (moderate to deep to general).” Emergency medicine residency and pediatric emergency medicine fellowship core curricula include all of the requisite procedural sedation skills, eg, advanced airway management, resuscitation, critical care, monitoring, sedation pharmacology, pain management. Emergency physicians have a wellestablished track record of safe sedation and are important research and thought leaders in this multidisciplinary field. The American College of Emergency Physicians (ACEP) is an authoritative body that has established guidelines for the use of sedation, analgesia, and anesthesia by emergency physicians. CMS guidelines support the use of the ACEP guideline: “A hospital could use multiple guidelines, for example, ACEP for sedation in the ED and American Society of Anesthesiologists (ASA) for anesthesia/sedation in surgical services, etc.” ACEP convened this task force in 2011 to provide this update to guide hospital policy for the administration of analgesia, sedation, and anesthesia by emergency physicians.

The objective of this study was to assess predictors of emergency department (ED) ketamine-associated laryngospasm using case-control techniques.We performed a matched case-control analysis of a sample of 8282 ED ketamine sedations (including 22 occurrences of laryngospasm) assembled from 32 prior published series. We sequentially studied the association of each of 7 clinical variables with laryngospasm by assigning 4 controls to each case while matching for the remaining 6 variables. We then used univariate statistics and conditional logistic regression to analyze the matched sets.We found no statistical association of age, dose, oropharyngeal procedure, underlying physical illness, route, or coadministered anticholinergics with laryngospasm. Coadministered benzodiazepines showed a borderline association in the multivariate but not univariate analysis that was considered anomalous.This case-control analysis of the largest available sample of ED ketamine-associated laryngospasm did not demonstrate evidence of association with age, dose, or other clinical factors. Such laryngospasm seems to be idiosyncratic, and accordingly, clinicians administering ketamine must be prepared for its rapid identification and management. Given no evidence that they decrease the risk of laryngospasm, coadministered anticholinergics seem unnecessary.

IMPORTANCE: It is not clear whether adherence to preprocedural fasting guidelines prevent pulmonary aspiration and associated adverse outcomes during emergency department (ED) sedation of children. OBJECTIVE: To examine the association between preprocedural fasting duration and the incidence of sedation-related adverse outcomes in a large sample of children. DESIGN, SETTING, AND PARTICIPANTS: We conducted a planned secondary analysis of a multicenter prospective cohort study of children aged 0 to 18 years who received procedural sedation for a painful procedure in 6 Canadian pediatric EDs from July 2010 to February 2015. The primary risk factor was preprocedural fasting duration. Secondary risk factors were age, sex, American Society of Anesthesiologists classification, preprocedural and sedation medications, and procedure type. MAIN OUTCOMES AND MEASURES: Four outcomes were examined: (1) pulmonary aspiration, (2) the occurrence of any adverse event, (3) serious adverse events, and (4) vomiting. RESULTS: A total of 6183 children with a median age of 8.0 years (interquartile range, 4.0-12.0 years), of whom 6166 (99.7%) had healthy or mild systemic disease (American Society of Anesthesiologists levels I or II), were included in the analysis. Of these, 2974 (48.1%) and 310 (5.0%) children did not meet American Society of Anesthesiologists fasting guidelines for solids and liquids, respectively. There were no cases of pulmonary aspiration. There were 717 adverse events (11.6%; 95% CI, 10.8%-12.4%), of which 68 (1.1%; 95% CI, 0.9%-1.3%) were serious adverse events and 315 (5.1%; 95% CI, 4.6%-5.7%) were vomiting. The odds ratio (OR) of occurrence of any adverse event, serious adverse events, and vomiting did not change significantly with each additional hour of fasting duration for both solids (any adverse event: OR, 1.00; 95% CI, 0.98 to 1.02; serious adverse events, OR, 1.01; 95% CI, 0.95-1.07; vomiting: OR, 1.00; 95% CI, 0.97-1.03) and liquids (any adverse event: OR, 1.00; 95% CI, 0.98-1.02; serious adverse events: 1.01, 95% CI, 0.95-1.07; vomiting: OR, 1.00; 95% CI, 0.96-1.03). CONCLUSIONS AND RELEVANCE: In this study, there was no association between fasting duration and any type of adverse event. These findings do not support delaying sedation to meet established fasting guidelines.

Objectives: Adjunctive anticholinergics are commonly administered during emergency department (ED) ketamine sedation in children under the presumption that drying oral secretions should decrease the likelihood of airway and respiratory adverse events. Pharmacologic considerations suggest that glycopyrrolate might exhibit a superior adverse effect profile to atropine. The authors contrasted the adverse events noted with use of each of these anticholinergics in a large multicenter observational database of ketamine sedations. Methods: This was a secondary analysis of an observational database of 8,282 ED ketamine sedations assembled from 32 prior series. The authors compared the relative incidence of six adverse events (airway and respiratory adverse events, laryngospasm, apnea, emesis, recovery agitation, and clinically important recovery agitation) between children who received coadministered atropine, glycopyrrolate, or no anticholinergic. Multivariable analysis using the specific anticholinergic as a covariate was performed, while controlling for other known predictors. Results: Atropine was associated with less vomiting (5.3%) than either glycopyrrolate (10.7%) or no anticholinergic (11.4%) in both unadjusted and multivariable analyses. Glycopyrrolate was associated with significantly more airway and respiratory adverse events (6.4%) than either atropine (3.3%) or no anticholinergic (3.0%) and similarly more clinically important recovery agitation (2.1% vs. 1.2 and 1.3%). There were, however, no differences noted in odds of laryngospasm and apnea. Conclusions: This secondary analysis unexpectedly found that the coadministered anticholinergic atropine exhibited a superior adverse event profile to glycopyrrolate during ketamine sedation. Any such advantage requires confirmation in a separate trial; however, our data cast doubt on the traditional premise that glycopyrrolate might be superior. Further, neither anticholinergic showed efficacy in decreasing airway and respiratory adverse events.

Background: The prophylactic coadministration of atropine or other anticholinergics during dissociative sedation has historically been considered mandatory to mitigate ketamine-associated hypersalivation. Emergency physicians (EPs) are known to omit this adjunct, so a prospective study to describe the safety profile of this practice was initiated. Objectives: To quantify the magnitude of excessive salivation, describe interventions for hypersalivation, and describe any associated airway complications. Methods: In this prospective observational study of emergency department (ED) pediatric patients receiving dissociative sedation, treating physicians rated excessive salivation on a 100-mm visual analog scale and recorded the frequency and nature of airway complications and interventions for hypersalivation. Results: Of 1,090 ketamine sedations during the 3-year study period, 947 (86.9%) were performed without adjunctive atropine. Treating physicians assigned the majority (92%) of these subjects salivation visual analog scale ratings of 0 mm, i.e., “none,” and only 1.3% of ratings were ≥ 50 mm. Transient airway complications occurred in 3.2%, with just one (brief desaturation) felt related to hypersalivation (incidence 0.11%, 95% confidence interval = 0.003% to 0.59%). Interventions for hypersalivation (most commonly suctioning) occurred in 4.2%, with no occurrences of assisted ventilation or intubation. Conclusions: When adjunctive atropine is omitted during ketamine sedation in children, excessive salivation is uncommon, and associated airway complications are rare. Anticholinergic prophylaxis is not routinely necessary in this setting.

It has recently been suggested that peripheral nerve or plexus blocks performed with the use of a nerve stimulator at low currents (

Is propofol an appropriate agent for use as part of emergency department (ED) procedural sedation and analgesia? Few questions in emergency medicine are currently as controversial. No one disputes that propofol exhibits numerous exceptionally desirable characteristics as a procedural sedation and analgesia agent. First, its clinical effect is essentially immediate after intravenous administration (“one arm–brain circulatory time”). Second, its marked potency reliably produces effective procedural sedation and analgesia conditions, even for very painful procedures. Third, recovery after sedation is extremely short, typically between 5 and 15 minutes. Finally, patient satisfaction is high because propofol has anti-emetic and apparent euphoric properties. It is no wonder that this agent has revolutionized anesthesiology practice. Many emergency physicians have already extrapolated this proven operating room success to our setting, using propofol as a single agent or in combination with an opioid, to successfully induce brief but potent sedation for short, painful procedures such as orthopedic manipulations, cardioversion, and abscess drainage. However, this application is based on limited experience because, thus far, only 8 small series of ED propofol use have been formally reported (Table).1-8 Despite this, proponents believe that there are sufficient studies in the anesthesia literature demonstrating the safety and efficacy of propofol to justify its use in the ED.9 Although hypotension, apnea, pain on injection, and bacterial contamination of the lipid emulsion have been reported, the primary criticism of propofol for procedural sedation and analgesia has focused on the greater sedation depth that typically results from propofol. Using the traditional propofol for procedural sedation and analgesia combination of midazolam and fentanyl, emergency physicians can reliably (albeit laboriously) titrate patients to either a state of “moderate sedation” (ie, purposeful responsive to verbal or tactile stimulation)10 or “deep sedation” (ie, purposeful responsive to repeated or painful stimulation).10 It is widely accepted that such moderate sedation is unlikely to be associated with impairment of protective airway reflexes, and thus aspiration risk in this setting is minimized.11 In contrast, however, the ultrarapid onset and high potency of propofol make it more difficult to titrate and prone to potentially substantial overshoot. Within 30 seconds of a single intravenous dose of propofol, a patient’s sedation depth could, without always a high level of predictability, be compatible with moderate sedation, deep sedation, or perhaps general anesthesia.12 Although all nondissociative sedatives can induce depth at all levels of the sedation continuum, in practice, propofol is primarily used for deep sedation.3-8,13 Anesthesiologists have been especially concerned about propofol use by nonanesthesiologists14 and have not differentiated such practitioners by skill set, lumping together emergency physicians with dentists, radiologists, and gastroenterologists.15,16 Pharmacy and therapeutics committees in many hospitals have blocked use of propofol for ED procedural sedation and analgesia because of objection by anesthesiologists on the committee. The paucity of data on the safety of propofol for ED procedural sedation and analgesia has made it difficult at times to overcome these objections. Four years ago, one of us characterized propofol as “not yet ready for prime time” in emergency medicine.12 This cautionary commentary raised concerns regarding the risk of inadvertent oversedation with propofol, personnel requirements, Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards, and fasting in the setting of deep sedation. Large case P A I N M A N A G E M E N T / E D I T O R I A L

Objectives: It is unclear whether ketamine induces subclinical respiratory depression when administered in dissociative doses intravenously (IV). The authors report a pilot study of capnography in emergency department (ED) pediatric patients receiving ketamine alone for procedural sedation, and describe serial measures of ventilatory response [end-tidal carbon dioxide (EtCO 2 ), respiratory rate, pulse oximetry]. Methods: The authors performed continuous capnography on a convenience sample of 20 ED pediatric patients who received ketamine 1.5 mg/kg IV for procedural sedation. Results: Continuous EtCO 2 and pulse oximetry remained essentially unchanged following ketamine injection, and no EtCO 2 levels > 47 mm Hg were noted at any point throughout sedation. Conclusions: No hypoventilation was observed in 20 ED pediatric patients receiving ketamine 1.5 mg/kg administered IV over 1 minute. The authors found no evidence of respiratory depressant properties for this dissociative agent.

Ketamine is a safe and effective sedative for emergency department procedures in children. However, the use of ketamine sometimes is associated with airway complications, emesis, and recovery agitation. We wished to identify predictors of these adverse events that clinicians might use to risk-stratify children who are candidates for ketamine sedation.We analyzed data from 1,021 ED intramuscular ketamine sedations in children 15 years of age or younger at a university medical center and an affiliated county hospital over a 9-year period. Five potential predictor variables (age, gender, American Society of Anesthesiologists' [ASA] risk classification, quantity of first ketamine dose, and number of ketamine doses administered) were compared between children with and without complications. We used multiple logistic regression analyses to determine the association of these 5 variables with emesis and recovery agitation, and validated these analyses with bootstrap resampling techniques. We compared children with and without airway complications using univariate statistics alone, as there were too few patients with airway complications to support a multivariate analysis.No study variables had significant univariate associations with airway complications (all P values.40). We found emesis to be associated with increasing age in multivariate analysis (odds ratio [OR] 1.25 per year, bias-corrected 95% confidence interval [CI] 1.17 to 1.34, P.001). The incidence of emesis was 12. 1% in children aged 5 years or older, and 3.5% in those younger than 5 years (Delta8.6%, 95% CI 4.9% to 12.1%). Recovery agitation was associated with the presence of an underlying medical condition (ie, ASA classor =2, OR 3.05, bias-corrected 95% CI 1.65 to 7.30, P=.004) and inversely associated with increasing age (OR 0.79 per year, bias-corrected 95% CI 0.69 to 0.89, P.001). The incidence of recovery agitation was 17.9% in ASA class 1 children and 33.3% in children in ASA class 2 or greater (Delta-15.4%, 95% CI 0.0% to -30. 7%). The incidence of recovery agitation was 12.1% in children aged 5 years or older, and 22.5% in those younger than 5 years (Delta-10. 4%, 95% CI -3.0% to -17.7%). Bootstrap resampling techniques validated the importance of the significant variables identified in the regression analyses.No study variable was predictive of ketamine-associated airway complications. Emesis that occurred after ketamine administration was modestly associated with increasing age. Recovery agitation was modestly associated with decreasing age and the presence of an underlying medical condition. The discriminatory power of these variables was low enough as to be unlikely to alter clinical decisions regarding patient selection for ketamine administration. No evidence of a significant ketamine dose relationship was noted for airway complications, emesis, or recovery agitation.

Study objective : We sought to characterize the clinical manifestations, outcome, and etiology of inadvertent ketamine overdose in the emergency department. Methods : We investigated cases of inadvertent ketamine overdose in children seen in the ED solicited through electronic mail subscription lists or reported to the Institute for Safe Medication Practices. The clinical manifestations, outcome, and reported cause for each case are described. Results : We identified 9 cases of inadvertent ketamine overdose in children treated in the ED. Patients received either 5 (n=3), 10(n=5), or 100 (n=1) times the intended dose, either by the intramuscular (n=5) or intravenous (n=4) route. All 9 experienced prolonged sedation (3 to 24 hours). Four experienced brief respiratory depression shortly after administration, and assisted ventilation was performed in 2. Two children without respiratory difficulty or hypoxemia were intubated by their physicians as a precaution. In 5 children, the dosing error was not discovered until late in the sedation, often when the child was not waking at the expected time. No adverse outcomes were noted, and all children were normal neurologically on discharge and longer-term follow-up if available. Conclusion : No adverse outcomes were noted in 9 healthy children treated in the ED who inadvertently received 5 to 100 times the intended dose of ketamine. Toxicity manifested as prolonged sedation in all 9 and brief respiratory depression in 4. The margin of safety in ketamine overdose may be wide, although less common and more serious outcomes cannot be excluded by this small, self-reported sample.

Study objective: To determine the safety of intramuscular ketamine when administered by emergency physicians for pediatric procedures in accordance with a defined protocol. Methods: We assembled a consecutive case series of children aged 15 years or younger who were given ketamine in the emergency departments of a university medical center and an affiliated county hospital over a 9-year period. A protocol for ketamine use (4 mg/kg, intramuscularly) was followed. Treating physicians were instructed to complete data forms recording complications and adequacy of sedation concurrent with patient care. Subsequent chart review was used to determine indications, adjunctive drugs, time to discharge, and adverse reactions for all patients. Results: Intramuscular ketamine was administered 1,022 times, mainly for laceration repair and fracture reduction. Physicians completed data forms for 431 of treated children (42%). Transient airway complications occurred in 1.4%: airway malalignment (n=7), laryngospasm (n=4), apnea (n=2), and respiratory depression (n=1). All were quickly identified and treated without intubation or sequelae. Emesis occurred in 6.7%, without evidence of aspiration. Mild recovery agitation occurred in 17.6%, moderate to severe agitation in 1.6%. No child required hospitalization for complications caused by ketamine. Ketamine produced acceptable sedation in 98% of patients. The median time from injection to emergency department discharge was 110 minutes for children given a single dose of ketamine. Conclusion: Intramuscular ketamine may be administered safely by emergency physicians to facilitate pediatric procedures in accordance with a defined protocol and with appropriate monitoring. Ketamine is highly effective, has a wide margin of safety, does not require intravenous access, and uniquely preserves protective airway reflexes. [Green SM, Rothrock SG, Lynch EL, Ho M, Harris T, Hestdalen R, Hopkins GA, Garrett W, Westcott K: Intramuscular ketamine for pediatric sedation in the emergency department: Safety profile in 1,022 cases. Ann Emerg Med June 1998;31:688-697.]

Objective. It is frequently taught that lumbar puncture is a mandatory procedure in many or all children who have fever and a seizure, because the convulsion may represent the sole manifestation of bacterial meningitis. We attempted to determine the incidence of this occult manifestation of meningitis. Design. Retrospective case series. Setting and patients. 503 consecutive cases of meningitis in children aged 2 months to 15 years seen at two referral hospitals during a 20-year period. Main outcome measures. Signs and symptoms of meningitis in patients having associated seizures. Results. Meningitis was associated with seizures in 115 cases (23%), and 105 of these children were either obtunded or comatose at their first visit with a physician after the seizure. The remaining 10 had relatively normal levels of consciousness and either were believed to have viral meningitis (2) or possessed straightforward indications for lumbar puncture: nuchal rigidity (6), prolonged focal seizure (1), or multiple seizures and a petechial rash (1). No cases of occult bacterial meningitis were found. Conclusion. In our review of 503 consecutive children with meningitis, none were noted to have bacterial meningitis manifesting solely as a simple seizure. We suspect that this previously described entity is either extremely rare or nonexistent. Commonly taught decision rules requiring lumbar puncture in children with fever and a seizure appear to be unnecessarily restrictive.

This study evaluated the efficacy of a single dose of intramuscular ceftriaxone for acute otitis media in children, using amoxicillin as a control. (There is currently no established single-dose treatment for this condition.) In a prospective, randomized, double-blind, clinical trial, 233 children, aged 5 months to 5 years, with uncomplicated acute otitis media were randomly assigned to receive either a single intramuscular injection of ceftriaxone (50 mg/kg) plus placebo oral suspension for 10 days, or a placebo injection plus amoxicillin oral suspension (40 mg/kg per day divided three times per day) for 10 days in a double-blind fashion. Demographic and clinical characteristics were similar in both groups. Treatment was successful in 107 of 117 given amoxicillin (91%, 95% confidence interval 86% to 97%) and 105 of 116 given ceftriaxone (91%, 95% confidence interval 85% to 96%). Rates of improvement, failure, relapse, and reinfection were similar in both groups, as were the otoscopic and tympanometric evaluations at the 14- and 60-day follow-up visits. It is concluded that a single intramuscular injection of ceftriaxone (50 mg/kg) is as effective as 10 days of oral amoxicillin for the treatment of uncomplicated acute otitis media in children.

Study objective: To evaluate the efficacy of routine early administration of IV magnesium to patients with acute asthma. Design: Prospective, randomized clinical trial. Setting: Urban teaching hospital emergency department. Type of participants: One hundred twenty consecutive patients aged 18 to 65 years with acute asthma unresponsive to a single albuterol treatment. Interventions: All patients received oxygen, 125 mg IV methylprednisolone, and hourly albuterol inhalation therapy. The study group also received 2 g IV magnesium sulfate infused over 20 minutes. Measurements and main results: Demographic and clinical characteristics were similar in both groups. Hospitalization was necessary in 13 of 58 patients who received magnesium (22%; 95% confidence intervals [CI], 13% to 32%) and 11 of 62 control patients (17%; 95% CI, 10% to 26%; P = .523). Duration of ED treatment in discharged patients was 224 ± 75 minutes in the magnesium group (95% CI, 208 to 240 minutes) and 228 ± 90 minutes in the control group (95% CI, 209 to 247 minutes, P = .832). In addition, changes in peak expiratory flow were not statistically different. Conclusion: Routine early administration of IV magnesium in acute asthma does not alter treatment outcome.

[Green SM, Krauss B. The semantics of ketamine. Ann Emerg Med. November 2000;36:480-482.]

Objective Vomiting is a common adverse event after emergency department ketamine sedation in children. We sought to determine if the rate of vomiting is dose related to intravenous ketamine. Methods Treating physicians administered intravenous ketamine to children requiring sedation for a procedure in a pediatric emergency department using doses of their discretion in this prospective observational study. We compared initial and total ketamine doses between children with and without vomiting directly and after controlling for age and coadministered drugs using multiple logistic regression analysis. Results A wide range of initial (0.2 to 2.4 mg/kg) and total (0.3 to 23.8 mg/kg) ketamine doses were administered in the 1039 sedations studied. Vomiting occurred in 74 (7%) overall. Initial and total ketamine dose distributions were similar in children with and without vomiting (medians 1.6 vs 1.6 mg/kg and 2.2 vs 2.1 mg/kg, respectively). Our multivariate analysis found no significant association between emesis and initial dose; however, it did reveal an association with total dose that was explained by a minority (3.5%) of children who received high cumulative doses (>7 mg/kg). The rate of emesis was 7.0% when the total ketamine dose was 7 mg/kg or less and 11.1% when greater than 7 mg/kg. Conclusions Within a wide range of intravenous doses, ketamine-associated vomiting is not related to either the initial loading dose or the total dose--except for a modest increase for those receiving high cumulative doses (>7 mg/kg).

Study objective Although ketamine is one of the most commonly used sedatives to facilitate painful procedures for children in the emergency department (ED), existing studies have not been large enough to identify clinical factors that are predictive of uncommon airway and respiratory adverse events. Methods We pooled individual-patient data from 32 ED studies and performed multiple logistic regressions to determine which clinical variables would predict airway and respiratory adverse events. Results In 8,282 pediatric ketamine sedations, the overall incidence of airway and respiratory adverse events was 3.9%, with the following significant independent predictors: younger than 2 years (odds ratio [OR] 2.00; 95% confidence interval [CI] 1.47 to 2.72), aged 13 years or older (OR 2.72; 95% CI 1.97 to 3.75), high intravenous dosing (initial dose ≥2.5 mg/kg or total dose ≥5.0 mg/kg; OR 2.18; 95% CI 1.59 to 2.99), coadministered anticholinergic (OR 1.82; 95% CI 1.36 to 2.42), and coadministered benzodiazepine (OR 1.39; 95% CI 1.08 to 1.78). Variables without independent association included oropharyngeal procedures, underlying physical illness (American Society of Anesthesiologists class ≥3), and the choice of intravenous versus intramuscular route. Conclusion Risk factors that predict ketamine-associated airway and respiratory adverse events are high intravenous doses, administration to children younger than 2 years or aged 13 years or older, and the use of coadministered anticholinergics or benzodiazepines.

Ketamine produces rapid and consistent pediatric sedation with a predictable onset and recovery time. A wide margin of safety is afforded without the respiratory and cardiovascular depression commonly seen with alternative agents. The efficacy of ketamine is well established in anesthesia and dentistry and has extensive applications in other specialties. Ketamine sedation facilitates superior technical and cosmetic results while minimizing emotional trauma to distraught children. The much-feared complications of aspiration and laryngospasm are extremely rare when ketamine is used with proper precautions. Ketamine deserves increased use in the ED, and we advocate additional clinical investigation in this setting.

When reading a randomized controlled trial, we typically expect one of 2 outcomes. Either the trial is positive and demonstrates a difference between interventions or it is negative and suggests similarity. In this issue, Deitch et al report a methodologically rigorous evaluation of supplemental oxygen during propofol sedation in adults and describe an outcome that is not positive but yet not totally negative. The rate of hypoxia was less in those receiving oxygen at 3 L per minute compared with room air (8% versus 18%); however, this 10% difference was not statistically significant and with 95% confidence is consistent with anything from a 24% decrease in hypoxia to a 7% increase when adding oxygen. This range includes clinically important differences. One interpretation of this trial is that because it is statistically negative, there is likely no meaningful benefit from supplemental oxygen, and therefore propofol in adults can reasonably be administered with room air alone. Avoiding supplemental oxygen appears preferable when capnography is unavailable because desaturation is not delayed when respiratory complications begin, and thus oximetry can serve as a warning device. A second interpretation of this trial is that the 10% trend, although a weak point estimate, may be clinically if not statistically significant and that there is little to be lost and perhaps something to be gained by adding oxygen. The number needed to treat according to this point estimate is 10, ie, for every 10 patients receiving supplemental oxygen, perhaps 1 episode of hypoxia can be avoided. However, the imprecision of this point estimate must be recognized. If just 1 subject fewer in the room air group had experienced hypoxia, the trend drops to 8% (number needed to treat 13). If 2 fewer room air subjects experienced hypoxia, the trend is 6% (number needed to treat 17). Unfortunately, the practice variation that prompted this trial is unlikely to be resolved according to it. Admittedly, a larger sample might have lessened this ambiguity. A post hoc calculation of the number needed to convincingly rule out a 10% difference would be 392 total patients (assumptions 18% baseline, 0.05, power 0.80; Stata 9.1; StataCorp, College Station, TX). This would have required almost 4 years at the authors’ institution at their rate of enrollment.

Study objective The Glasgow Coma Scale (GCS) score is widely used in the initial evaluation of patients with traumatic brain injury. This 15-point score, however, has been criticized as unnecessarily complex. Recently, a 3-point Simplified Motor Score (defined as obeys commands=2; localizes pain=1; withdrawals to pain or worse=0) was developed from the motor component of the GCS and was found to have a similar test performance for predicting outcomes after traumatic brain injury when compared with the GCS score as the criterion standard. The purpose of this study was to validate the Simplified Motor Score in a large heterogeneous trauma population. Methods This was a secondary analysis of a prospectively maintained trauma registry with consecutive trauma patients who presented to a Level I trauma center from 1995 through 2004. Test performance of the GCS and the Simplified Motor Score relative to 4 clinically relevant traumatic brain injury outcomes (emergency intubation, clinically significant brain injury, neurosurgical intervention, and mortality) was evaluated with areas under the receiver operating characteristic curves (AUCs). Results Of 21,170 patients included in the analysis, 18% underwent emergency intubation, 14% had clinically significant brain injuries, 7% underwent neurosurgical intervention, and 5% died. The AUCs for the GCS and its components ranged from 0.76 to 0.92 across the 4 outcome measures. The AUCs for the Simplified Motor Score ranged from 0.71 to 0.89, and the relative differences from the GCS AUCs ranged from 3% to 7%, with a median difference of 5%. Conclusion In this external validation study, the 3-point Simplified Motor Score demonstrated similar test performance when compared with the 15-point GCS score and its components for the prediction of 4 clinically important traumatic brain injury outcomes.

Purposes Psychic recovery reactions after ketamine administration are not uncommon in adults, but yet are rare in children 15 years old and younger. The nature of such reactions has not been previously described in young adults, and accordingly we wished to quantify the incidence and severity of recovery agitation after ketamine sedation in patients aged 16 to 21 years. Basic Procedures We prospectively collected data on 26 young adults aged 16 to 21 years who received ketamine for emergency department procedures, and treating physicians rated recovery “agitation,” “crying,” and “unpleasant hallucinations or nightmares” each on a 100-mm visual analog scale (0 mm = “none,” 100 mm = “worst possible”). Main Findings Treating physicians rated agitation and crying as entirely absent (rating 0 mm) in 25 of the 26 patients, and unpleasant hallucinations or nightmares as entirely absent (0 mm) in all 26. The single occurrences each of agitation (rating 46 mm) and crying (rating 23 mm) were not severe and resolved spontaneously without treatment. Principal Conclusions In this small sample of young adults we observed no serious psychic recovery reactions, mirroring the low incidence of such responses well documented with children 15 years old and younger. This supports the expansion of ketamine use to young adults aged 16 to 21 years.

Background Acute mountain sickness (AMS) commonly occurs when unacclimatized individuals ascend to altitudes above 2000 m. Acetazolamide and Ginkgo biloba have both been recommended for AMS prophylaxis; however, there is conflicting evidence regarding the efficacy of Ginkgo biloba use. We performed a randomized, placebo-controlled trial of acetazolamide vs Ginkgo biloba for AMS prophylaxis. Methods We randomized unacclimatized adults to receive acetazolamide, Ginkgo biloba , or placebo in double-blind fashion and took them to an elevation of 3800 m for 24 hours. We graded AMS symptoms using the Lake Louise Acute Mountain Sickness Scoring System (LLS) and compared the incidence of AMS (defined as LLS score ≥3 and headache). Results Fifty-seven subjects completed the trial (20 received acetazolamide; 17, Ginkgo biloba , and 20, placebo). The LLS scores were significantly different between groups; the median score of the acetazolamide group was significantly lower than that of the placebo group ( P = .01; effect size, 2; and 95% confidence interval [CI], 0 to 3), unlike that of the Ginkgo biloba group ( P = .89; effect size, 0; and 95% CI, −2 to 2). Acute mountain sickness occurred less frequently in the acetazolamide group than in the placebo group (effect size, 30%; 95% CI, 61% to −15%), and the frequency of occurrence was similar between the Ginkgo biloba group and the placebo group (effect size, −5%; 95% CI, −37% to 28%). Conclusions In this study, prophylactic acetazolamide therapy decreased the symptoms of AMS and trended toward reducing its incidence. We found no evidence of similar efficacy for Ginkgo biloba .

Study objective The 15-point Glasgow Coma Scale (GCS) is extensively used in the initial evaluation of traumatic brain injury in emergency department (ED) settings. We hypothesized that the GCS might be unnecessarily complex and that a simpler scoring system might demonstrate similar accuracy in the prediction of traumatic brain injury outcomes. Methods We analyzed a prospectively maintained trauma registry of patients evaluated at our Level I trauma center from 1990 to 2002. We calculated the test performance of ED GCS scores relative to 4 clinically relevant traumatic brain injury outcomes (emergency intubation, neurosurgical intervention, brain injury, and mortality) using areas under their receiver operating characteristic (ROC) curves. We performed similar analyses for each of the 3 GCS components and for 2 simplified 3-point scores (simplified verbal score: oriented=2, confused conversation=1, inappropriate words or less=0; simplified motor score: obeys commands=2, localizes pain=1, withdrawal to pain or less=0). We then compared the test performance of each of these 5 to the total GCS score using a priori thresholds for clinically important differences. Results Each of the 3 GCS components alone and the 2 simplified 3-point scores demonstrated ROC areas within 9% of that of the GCS score for the 4 outcomes, with a median difference of 3.0% (interquartile range 1.6% to 4.5%). These differences were all below our a priori definitions of clinical importance. Conclusion The 3 individual GCS components alone and two 3-point simplified scores demonstrated test performance similar to the total GCS score for the prediction of 4 clinically relevant traumatic brain injury outcomes. Despite the widespread use of the GCS for the initial evaluation of traumatic brain injury, this score may be unnecessarily complex for this indication.

The Bispectral Index Monitor (BIS) is validated as a measure of sedation depth during general anesthesia, but its value otherwise remains unclear. We hypothesized that BIS scores would correlate with standard subjective measures of assessing sedation in intubated adult ED patients and that BIS would predict inadequate sedation. Sedation was assessed by recording clinical features and by having treating physicians complete a visual analog scale (VAS; rated "not sedated" to "completely sedated") at 10, 30, and 60 minutes after intubation. Measurements of BIS were later paired with sedation assessments. Despite being statistically significant ( p = .002), the correlation between BIS and VAS in our 147 paired readings was fair (Pearson's rho=−0.37) and displayed wide variability. Receiver operating characteristic curve analysis of BIS demonstrated no discriminatory power in predicting sedation adequacy (area under curve 0.53). BIS is not associated with and did not predict standard measures of sedation adequacy in intubated adults.

Objectives: A daily part of emergency medicine practice includes assessing patients with altered levels of consciousness (ALOC). The authors hypothesized that a bispectral index monitor (BIS), a processed electroencephalographic monitor traditionally used to monitor patients under anesthesia, would represent an objective quantification of impairment of consciousness. They compared the BIS score with the Glasgow Coma Scale score (GCS) in emergency department (ED) patients with ALOC. Methods: The authors performed a convenience sampling of ED adults presenting with ALOC (GCS ≤ 14). Patients with abnormal baseline mental status were excluded, as were those who were unable to tolerate the forehead BIS leads. The blinded BIS value was recorded after the treating physician assigned a GCS to the patient. The BIS and GCS measurements were then correlated. Results: Data were obtained for 38 patients (20 male, 18 female). The median age was 42 years (range 14 to 93 years). Despite being statistically significant (p = 0.0165), the correlation between the GCS and the BIS score was only moderate (Spearman's rho = 0.387) and displayed wide variability. For example, when the GCS was between 3 and 5, the corresponding BIS scores ranged from 47 to 98. When the GCS was between 12 and 14, the corresponding BIS scores ranged from 56 to 98. Receiver operating characteristic curves for BIS at each GCS threshold demonstrated low discriminatory power (areas under the curve range 0.61 to 0.73). Conclusions: BIS monitoring does not reliably correlate with GCS in ED patients with ALOC, and does not appear to have potential to accurately quantify impairment of consciousness in this setting.

The Bispectral Index Monitor has been validated as an objective measure of sedation depth in the operating room; however, its value for states other than general anesthesia remains unclear. We hypothesized that bispectral index monitoring would reliably correlate with traditional definitions of sedation depth in emergency department patients undergoing procedural sedation and analgesia.In this prospective observational study we measured the Bispectral Index score and a modified Ramsay Sedation Scale score every 5 minutes in a convenience sample of adult ED patients undergoing procedural sedation and analgesia. Investigators and treating physicians were blinded to Bispectral Index scores, which were later correlated with modified Ramsay Sedation Scale scores. We constructed receiver operating characteristic curves to determine the most discriminatory Bispectral Index score thresholds for sedation depth.Two hundred seventy paired readings were obtained from 37 patients. Despite being statistically significant (P.0005), the correlation between the Bispectral Index Monitor and modified Ramsay Sedation Scale scores was only moderate (Spearman rho=-0.690) and displayed wide variability. A modified Ramsay Sedation Scale score consistent with mild-to-moderate sedation corresponded to Bispectral Index scores of 34 (general anesthesia) to 98 (fully awake), whereas a modified Ramsay Sedation Scale score consistent with deep sedation corresponded to Bispectral Index scores of 40 to 98. Areas under receiver operating characteristic curves demonstrated moderate (0.83 to 0.86) discriminatory power at all modified Ramsay Sedation Scale thresholds, with the exception of a modified Ramsay Sedation Scale score of 7 or less, which demonstrated high discriminatory power (0.95). A Bispectral Index score of greater than 83 reliably excluded general anesthesia, and a Bispectral Index score of 70 or less reliably identified general anesthesia.Bispectral index monitoring reliably predicted patients undergoing procedural sedation and analgesia who were sedated to the point of general anesthesia from those with lesser degrees of sedation but did not discriminate mild-to-moderate sedation or moderate-to-deep sedation, as measured by the Ramsay Sedation Scale score for the patients undergoing procedural sedation and analgesia in our ED.

[Green SM, Krauss B. Procedural sedation terminology: moving beyond "conscious sedation." Ann Emerg Med. April 2002;39:433-435.]

A 7-month-old child suffered a cardiopulmonary arrest. After eight minutes of basic CPR by the parents, paramedics arrived and found the child in asystole. Endotracheal intubation and peripheral venous access were unsuccessful, and intraosseous equipment was unavailable in the field. The patient then received 1.5 mg epinephrine and 0.15 mg atropine injected sublingually with prompt return of a sinus rhythm and a palpable pulse. One hour after arrival in the emergency department, the patient again arrested, this time fatally. This case may represent the first report of successful resuscitation from cardiac arrest using sublingually injected medications.

The pediatric sedative combination of meperidine, promethazine, and chlorpromazine (MPC) has been widely used for more than 40 years. Despite its relatively poor efficacy and questionable safety profile, many emergency departments (EDs) continue to stock specially formulated mixtures of these three agents. We report a case of iatrogenic cardiac arrest in a 2-month-old infant in whom a consulting resident administered too much MPC (10 times the expected dose) by the wrong route (intravenous instead of intramuscular). The child was successfully resuscitated with no apparent neurologic deficit. Subsequently, we have removed MPC entirely from our ED and instituted a policy restricting ED procedural sedation privileges to emergency physicians. We urge other EDs to do likewise.

To describe our experience using ketamine sedation to facilitate pediatric critical care procedures, and to document the safety profile of ketamine in this setting.Retrospective consecutive case series.Pediatric intensive care unit of a tertiary children's hospital.Children receiving ketamine for procedural sedation over a 5-year period.We reviewed patient records to determine indication, dosing, adverse events, inadequate sedation, and recovery time for each sedation.Descriptive features of sedation including adverse events.During the study period, children in our pediatric intensive care unit received ketamine at total of 442 times to facilitate a wide variety of critical care procedures, most commonly central line placement, esophagogastroduodenoscopy, and wound debridement. Most study children had substantial underlying illness (ASAor = 3 in 88%; ASAor = 4 in 39%). Inadequate sedation was noted in only nine (2%) procedures. Adverse effects included transient laryngospasm (n = 9), transient partial airway obstruction (n = 5), apnea with bradycardia (n = 1), emesis during the procedure (n = 2), emesis during recovery (n = 9), mild recovery agitation (n = 10), moderate-to-severe recovery agitation (n = 1), and excessive salivation (n = 4). There were no adverse outcomes attributable to ketamine.Pediatric intensivists skilled in ketamine administration can safely and effectively administer this drug to facilitate critical care procedures. Despite the ill nature of our patient sample, adverse effects were uncommon.

Background Although the dissociative sedative ketamine is used commonly for pediatric procedural sedation in other settings, the safety of this agent in pediatric gastroenterology is not well-studied. A 5-year experience with 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 procedures during a 5-year period. Patient's records were reviewed to determine indication, dosage, adverse effects, drugs, inadequate sedation, and recovery time for each sedation. A multiple logistic regression analysis was performed 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 intravenous 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%) procedures. Adverse effects included transient laryngospasm (8.2%), emesis (4.1%), recovery agitation (2.4%), partial airway obstruction (1.3%), apnea and respiratory depression (0.5%), and excessive salivation (0.3%). There were no adverse outcomes attributable to ketamine. Nearly half (46%) the subjects had severe underlying illness (American Society of Anesthesiologists [ASA] class ≥3). All instances of laryngospasm occurred during EGD (9.5% incidence), and the only independent predictor of laryngospasm in this sample was decreasing age. The incidence of laryngospasm was 13.9% in preschool-aged (≤6 years) children and was 3.6% in school-aged (>6 years) children (difference 10.3%, 95% confidence intervals 5.5–14.9%). No dose relationship was noted with laryngospasm, and the risk did not increase with underlying illness. Conclusion Pediatric gastroenterologists skilled in ketamine administration and basic airway management can effectively administer this drug to facilitate gastrointestinal procedures. Transient laryngospasm occurred in 9.5% of children receiving ketamine for EGD, and its incidence was greater in preschool than in school-aged children.

Study objective: Despite widespread use of adjunctive benzodiazepines during ketamine sedation, their efficacy in reducing recovery agitation in children has never been studied. We wished to characterize the nature and severity of recovery agitation after ketamine sedation in children treated in the emergency department and to determine whether the addition of adjunctive midazolam reduces the magnitude of such recovery agitation. Methods: The study was a randomized, double-blind, clinical trial of adjunctive midazolam versus placebo during ketamine sedation. We enrolled 104 children aged 12 months to 15 years (median age, 6 years) at a combined university medical center and children's hospital. Subjects received either intravenous midazolam (0.05 mg/kg up to 2 mg) or placebo after intravenous administration of a ketamine loading dose (1.5 mg/kg). Treating physicians and nurses independently noted the presence of crying, hallucinations, and nightmares during recovery and graded recovery agitation by using a 100-mm visual analog scale. Preprocedure agitation and external stimulation during recovery were also graded. The time from ketamine injection until each subject met the recovery criteria was recorded. Results: Fifty-three subjects received midazolam, and 51 received placebo. Potentially confounding variables were similar between the groups. Sedation efficacy, adverse effects, and recovery time were also similar between groups. Interobserver agreement between physician and nurse assessments was substantial. Median physician assessment of recovery agitation was 4 mm (interquartile range, 2 to 19) in the midazolam group and 5 mm (interquartile range, 3 to 14) in the placebo group (difference –1; 95% confidence interval –3 to 2; P =.705). Recovery agitation was moderately correlated with preprocedure agitation (ρ=0.486) but not with external stimulation during recovery (ρ=0.147). Conclusion: Recovery agitation is common but generally of very low magnitude after ketamine sedation in children in the ED. We observed a median physician rating of 5 mm on a 100-mm visual analog scale, a score that we believe to be clinically insignificant. The degree of recovery agitation after ketamine sedation is significantly related to the degree of preprocedure agitation. In this study, concurrent midazolam did not diminish such agitation and had no measurably beneficial effect. Use of adjunctive benzodiazepines in pediatric ketamine sedation appears unnecessary. [Sherwin TS, Green SM, Khan A, Chapman DS, Dannenberg B. Does adjunctive midazolam reduce recovery agitation after ketamine sedation for pediatric procedures? A randomized, double-blind, placebo-controlled trial. Ann Emerg Med .March 2000;35:229-238.]

Objective: The optimal dose of IM ketamine for ED procedural sedation in children is not known. The authors wished to quantify the dose-response of ketamine with respect to sedation adequacy, time to discharge, and adverse effects in order to identify an optimal dose. Methods: The study was a consecutive case series of 1,022 children ≤15 years of age given IM ketamine in the EDs of a university medical center and an affiliated county hospital over a nine-year period. Adequacy of sedation, time to discharge, and adverse effects were compared with dose administered. Results: Doses in the sample averaged 3.96 ± 0.69 mg/kg, with a range of 0.48 to 9.09 mg/kg. Children judged to be adequately sedated received higher doses compared with those inadequately sedated (3.94 ± 0.44 mg/kg vs 3.77 ± 0.49 mg/kg, p = 0.041), and a nonsignificant trend was noted toward uniformly adequate sedation with increasing dose (≤91% at

OBJECTIVES To determine the safety of i.v. ketamine when administered by emergency physicians (EPs) for pediatric procedures, and to contrast the sedation characteristics of the i.v. and i.m. routes. METHODS The study was a retrospective consecutive case series of children aged < or =15 years given i.v. ketamine in the EDs of a university medical center and an affiliated county hospital over a 9-year period. A protocol for ketamine was used by treating physicians. Records were reviewed for adverse effects, indication, dosing, adjunctive drugs, inadequate sedation, and time to release. Results were contrasted with previously reported data for the i.m. route. RESULTS During the study period i.v. ketamine was administered 156 times, primarily for laceration repair and fracture reduction. Transient apnea and respiratory depression occurred in one patient each; both were quickly identified and were without sequelae. Laryngospasm or aspiration was not noted in any children. There were 6 children with emesis and 2 with mild agitation during recovery. The median time from initial dose to ED release was 103 minutes (25th to 75th percentiles 76 to 146 minutes). The i.v. and i.m. routes were comparable in terms of adverse effects, inadequate sedation, and time to release. CONCLUSION I.v. ketamine can be administered safely by EPs to facilitate pediatric procedures when used in a defined protocol. The sedation characteristics of the i.v. and i.m. routes appear comparable.

Study objective: Although adjunctive intravenous bicarbonate therapy is commonly recommended for children with severe diabetic ketoacidosis (DKA), no studies assessing clinical outcome with this therapy have ever been performed. Our objective was to determine whether bicarbonate therapy influenced outcome for pediatric DKA. Methods: The study was a retrospective consecutive case series of 147 admissions for severe DKA (initial pH ≤7.15 and glucose concentration ≥300 mg/dL [16.7 mmol/L]) in 106 children during a 16-year period at a tertiary university medical center. Descriptive statistics were applied to the 147 admissions. The first patient admitted with DKA was then selected for each of the 106 children, and clinical and laboratory data were compared between subjects who did and did not receive bicarbonate. Multivariate and matched pair analyses were performed to control potentially confounding variables. Results: Fifty-seven of the 147 patients admitted with DKA (39%) were successfully treated without bicarbonate, including 9 with a pH of 7.00 or less and one with a pH of 6.73. The frequency of complications was comparable between bicarbonate and nonbicarbonate groups (4% versus 2%, P =1.00). The mean duration of hospitalization for children receiving bicarbonate was 23% (16 hours) longer than children who did not receive bicarbonate in the multivariate analysis ( P =.07) and 37% (22 hours) longer in the matched pair analysis ( P =.01). The mean rate of metabolic recovery by three distinct measures was similar between groups, and the sample had 80% power to detect differences of 14% to 29% in these measures. Conclusion: We found no evidence that adjunctive bicarbonate improved clinical outcome in children with severe DKA. The rate of metabolic recovery and complications were similar in patients treated with and without bicarbonate, and prolonged hospitalizations were noted in the bicarbonate group. We conclude that adjunctive bicarbonate is unnecessary and potentially disadvantageous in severe pediatric DKA. [Green SM, Rothrock SG, Ho JD, Gallant RD, Borger R, Thomas TL, Zimmerman GJ: Failure of adjunctive bicarbonate to improve outcome in severe pediatric diabetic ketoacidosis. Ann Emerg Med January 1998;31:41-48.]