The article, "Safe and efficacious use of procedural sedation and analgesia (PSA) by non-anesthesiologists in a pediatric hematology-oncology unit" in the April 2006 issue was indeed very interesting. Regarding the use of ketamine for PSA in children outside the operation theater, certain important points need to be emphasized.

Firstly, though midazolam and ketamine is probably the best combination available for PSA, the incidence of oxygen desaturation is much higher with this as compared to use of a single drug alone. This combination is also reported to produce prolonged sedation and psychedelic effects in children which may adversely alter the child’s comfort and parental satisfaction(1).

Secondly, as mentioned in the article, vigilant monitoring for occurrence of known complications like apnea, hypoxia, laryngospasm, seizures, arrhythmias, vomiting, etc; is essential. As far as possible, adequate preventive measures such as addition of an antiemetic and anticholinergic is recommended. Another exceptional feature of ketamine is that as opposed to other sedative drugs with cardio-depressant properties, it causes a rise in heart rate as well as both systolic and diastolic blood pressure(6).

Besides ketamine, PSA has been administered successfully using alternate drugs like propofol, etomidate and methohexital. In comparison to ketamine, propofol has shown more rapid recovery, smoother emergence, and shorter stay in the pediatric critical care department(3).

Sona Chaturvedi,
Department of Anesthesiology,
Mahatma Gandhi Institute of Medical Sciences,
Sewagram 442 102,
Maharashtra, India.