title: Nurse-administered ketamine sedation in an emergency department in rural Uganda.
abstract: OBJECTIVE
  We determine whether, after a brief training program in procedural sedation, nurses can safely independently administer ketamine sedation in a resource-limited environment.
  
  
  METHODS
  This is an observational case series of consecutive sedations performed in an emergency department in rural Uganda at approximately 5,000 feet above sea level. The data were collected prospectively in a quality assurance database. As part of a larger training program in emergency care at Karoli Lwanga Hospital in rural Uganda, nurses with no sedation experience were trained in procedural sedation with ketamine. All sedations were monitored by a nonphysician research assistant, who recorded ketamine dosing, duration of each procedure, adverse events, and nurse interventions for each adverse event. In accordance with standard definitions in the emergency medicine sedation literature, adverse events were defined a priori and classified as major (death, need for bag-valve-mask ventilation, or unanticipated admission to the hospital) or minor (hypoxia, vomiting, emergence reactions, hypersalivation). The primary statistical analysis was descriptive, with reporting of adverse event rates with 95% confidence intervals (CIs), using the nurse as the unit of analysis.
  
  
  RESULTS
  There were a total of 191 administrations by 6 nurses during the study period (December 2009 through March 2010). Overall, there was an 18% adverse event rate (95% CI 7% to 30%), which is similar to the rate reported in resource-rich countries. These events included hypoxia (22 cases; 12%), vomiting (9 cases; 5%), and emergence reaction (7 cases; 4%). All adverse events met our a priori defined criteria for minor events, with a 0% incidence of major events (1-sided 97.5% CI with the nurse as unit of analysis 0% to 46%). The procedural success rate was 99%. Sedation was practitioner rated as "excellent" in 91% of cases (95% CI 86% to 94%) and "good" in 9% (95% CI 6% to 14%). Patients reported they would want ketamine for a future procedure in 98% of cases (95% CI 95% to 100%).
  
  
  CONCLUSIONS
  In resource-limited settings, nurse-administered ketamine sedation appears to be safe and effective. A brief procedural sedation training program, coupled with a comprehensive training program in emergency care, can increase access to appropriate and safe sedation for patients in resource-limited settings.
authors.affiliation: Department of Emergency Medicine, University of Massachusetts Memorial Medical Center, Worcester, MA, USA. mark.bisanzo@umassmemorial.org.
authors.forename: Mark
authors.initials: M
authors.lastname: Bisanzo
authors.forename: Kelly
authors.initials: K
authors.lastname: Nichols
authors.forename: Heather
authors.initials: H
authors.lastname: Hammerstedt
authors.forename: Bradley
authors.initials: B
authors.lastname: Dreifuss
authors.forename: Sara W
authors.initials: SW
authors.lastname: Nelson
authors.forename: Stacey
authors.initials: S
authors.lastname: Chamberlain
authors.forename: Felista
authors.initials: F
authors.lastname: Kyomugisha
authors.forename: Amelia
authors.initials: A
authors.lastname: Noble
authors.forename: Annette
authors.initials: A
authors.lastname: Arthur
authors.forename: Stephen
authors.initials: S
authors.lastname: Thomas
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000778:Anesthetics, Dissociative / Q000008:administration & dosage*; D002648:Child; D002675:Child, Preschool; D016292:Procedural Sedation / Q000379:methods / Q000451:nursing*; D016529:Emergency Nursing / Q000193:education; D004636:Emergency Service, Hospital; D006780:Hospitals, Rural; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007273:Injections, Intramuscular / Q000451:nursing; D007275:Injections, Intravenous / Q000451:nursing; D007649:Ketamine / Q000008:administration & dosage*; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D011446:Prospective Studies; D014454:Uganda; D055815:Young Adult
chemical_list: D000778:Anesthetics, Dissociative; D007649:Ketamine