The edition · Emergency & Critical Care
Sentinel events in children's ED ketamine sedation: about one in 24,000 across nearly 59,000 sedations
A systematic review found no deaths or permanent harm. Also: starting vasopressin within three hours of escalating noradrenaline, AI-assisted triage, a new PE shock score, and peripheral noradrenaline.
The edition in brief
A systematic review of 20 large studies (58,752 children) of intravenous ketamine sedation in the emergency department found no deaths or permanent harm; sentinel events such as intubation or aspiration occurred about once per 24,390 sedations, and serious adverse events in 0.33%, modestly more likely with age 10 or over, an upper respiratory infection or co-administered opioids. A target trial emulation in 3,810 adults with septic shock found starting vasopressin within three hours of noradrenaline reaching 0.25 µg/kg/min was associated with lower 28-day mortality (48.1% vs 53.0%) and less renal replacement therapy than starting at three to six hours. A systematic review of AI-assisted triage found good discrimination for adult critical illness (pooled AUC 0.87) but poor calibration reporting, little external validation and no evidence yet of better patient outcomes. The pearl covers short-term peripheral noradrenaline.
Earlier vasopressin after noradrenaline escalation in septic shock
In septic shock, consider adding vasopressin within about three hours of noradrenaline reaching 0.25 µg/kg/min rather than waiting.
AI-assisted triage discriminates well, but is not ready for the front door
AI-assisted triage shows promising discrimination but no proven patient benefit; validate locally before relying on it.
A new PE shock score did no better than sPESI or ESC for deterioration
Continue to stratify PE with sPESI and ESC classes; CPES adds little except in predicting who will need advanced intervention.
Peripheral noradrenaline while central access is arranged
Do not delay vasopressors for central access; start noradrenaline peripherally in a large vein and watch the site.
IV ketamine sedation in children: sentinel events are vanishingly rare
IV ketamine is a very safe choice for paediatric procedural sedation in the ED, with airway readiness and extra care in older children, respiratory infection and opioid co-use.
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