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agitated multi-trauma patients were given ketamine +/– mid- 8. Costi D, Cyna AM, Ahmed S, et al. Effects of sevoflurane versus
66
azolam at the providers’ discretion. In all 11 cases, ketamine other general anaesthesia on emergence agitation in children. Co-
alone was successful, with all patients avoiding intubation or chrane Dator both? A challenge for clinicians. Pediatr Anesthesia.
2015;25:524–529.
the use of restraints. As such, their current protocol calls for 9. Green SM, Krauss B. The taming of ketamine–40 years later. Ann
ketamine first and midazolam only if judged to be necessary. Emerg Med. 2011;57(2):115–116.
Likewise, the Australians are employing a similar approach 10. Strayer RJ, Nelson LS. Adverse events associated with ketamine
based on data from a randomized controlled trial in 2012. 67 for procedural sedation in adults. Am J Emerg Med. 2008;26(9):
985–1028.
11. Guldner GT, Clemens P, Foster S, Antoine S. Ketamine for proce-
Summary dural sedation and analgesia by nonanesthesiologists in the field:
a review for military health care providers. Mil Med. 2006;171
Ketamine is a safe and effective drug for use in the prehospi- (6):484–490.
tal, combat, and prolonged field care stages of care. Ketamine 12. Green S, Roback MG, Kennedy RM, Krauss B. Clinical practice
possesses a wide margin of safety with both the cardiovascular guideline for the emergency department ketamine dissociative seda-
tion: 2011 update. Ann Emerg Med. 2011;57(5):449–461.
and respiratory systems. Midazolam is an effective drug for 13. Ahern TL, Herring AA, Anderson ES, et al. The first 500: ini-
treating agitation associated with incomplete dissociation and tial experience with widespread use of low-dose ketamine for
emergence. However, midazolam should only be administered acute pain management in the ED. Am J Emerg Med. 2015;
after the treating medical provider has performed a careful 33(2):197–201.
risk/benefit analysis of both the medical and tactical situation. 14. Prolonged Field Care. Analgesia and Sedation. 2014. https://
Strict protocols requiring midazolam administration to pre- prolongedfieldcare.org/2014/12/18/analgesia-and-sedation/. Ac-
cessed 24 July 2021.
vent agitation are not recommended. 15. Hadi SM, Saleh AJ, Tang YZ, et al. The effect of KETODEX on
the incidence and severity of emergence agitation in children under-
Disclaimer going adenotonsillectomy using sevoflurane-based anesthesia. Int J
The views expressed in this article are those of the author(s) Pediatr Otorhinolaryngol. 2015;79(5):671–676.
and do not necessarily reflect the official policy or position of 16. Dahmani S, Delivet H, Hilly J. Emergence delirium in children: an
update. Curr Opin Anaesthesiol. 2014;27(3):309–315.
the Department of the Navy, Department of the Army, Depart- 17. Eghbal MH, Taregh S, Amin A, Sahmeddini MA. Ketamine
ment of Defense or the United States Government. improves postoperative pain and emergence agitation follow-
ing adenotonsillectomy in children. A randomized clinical trial.
HH, BD, AF, MC, and JS are military Servicemembers. This Middle East J Anaesthesiol. 2013;22(2):155–160.
work was prepared as part of their official duties. Title 17 18. Chen JY, Jia JE, Liu TJ, et al. Comparison of the effects of dex-
U.S.C. 105 provides that “Copyright protection under this medetomidine, ketamine, and placebo on emergence agitation
after strabismus surgery in children. Can J Anaesth. 2013;60(4):
title is not available for any work of the United States Gov- 385–392.
ernment.” Title 17 U.S.C. 101 defines a United States Govern- 19. Abdelhalim AA, Alarfaj AM. The effect of ketamine versus fen-
ment work as a work prepared by a military Servicemember tanyl on the incidence of emergence agitation after sevoflurane
or employee of the United States Government as part of that anesthesia in pediatric patients undergoing tonsillectomy with or
person’s official duties. without adenoidectomy. Saudi J Anaesth. 2013;7(4):392–398.
20. Jeong WJ, Kim WY, Moon MG, et al. The effect of ketamine
on the separation anxiety and emergence agitation in children
Disclosures undergoing brief ophthalmic surgery under desflurane general
HH, BD, AF, MC, and JS have no financial disclosures to anesthesia. Korean J Anesthesiol. 2012;63(3):203–208.
report. 21. Lee YS, Kim WY, Choi JH, et al. The effect of ketamine on the
incidence of emergence agitation in children undergoing tonsil-
lectomy and adenoidectomy under sevoflurane general anesthe-
Author Contributions sia. Korean J Anesthesiol. 2010;58(5):440–445.
BD, JS, MC, conceived the study concept. HH, BD, AF compiled 22. Khattab AM, El-Seify ZA, Shaaban A, et al. Sevoflurane-emergence
the evidence and literature review. HH and BD wrote the man- agitation: effect of supplementary low-dose oral ketamine premed-
uscript. BD, JS, MC, and HH approved the final manuscript. ication in preschool children undergoing dental surgery. Eur J
Anaesthesiol. 2010;27(4):353–358.
23. Jung HJ, Kim JB, Im KS, et al. Effect of ketamine versus thiopen-
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