I witnessed the third patient to have apnea as a side effect of ketamine administration. As in the other two cases ketamine was infused as a push, rather than the slow administration. This was not the resident, but typically and to be by the book, MDs should be the ones pushing ketamine. SLOWLY.

In this case our resident did well managing the sedation. Hypoventilation was diagnosed well before desaturation. Painful stimuli did not induce respirations as the ketamine is too good of an analgesic. We began to BVM ventilate, placed nasal trumpet, sat was never lower than 85%. Took about 8 minutes to get spontaneous respirations. We gave narcan as the patient had fentanyl prior to ketamine. As in one other case of ketamine apnea the narcan did not help, but should be attempted.

So learning point. NEVER SLAM ketamine into the patient. Dilute the 1cc (50mg-100mg) of ketamine in 10cc of saline if it will help the temptation to push it.

Also follow the algorithm below for PSA intervention. We will have the sedation review sheet and reference card finished soon.