• Lance Brown, Sarah Christian-Kopp, Thomas S Sherwin, Aqeel Khan, Besh Barcega, T Kent Denmark, James A Moynihan, Grace J Kim, Gail Stewart, and Steven M Green.
• Division of Pediatric Emergency Medicine, Loma Linda University Medical Center & Children's Hospital, Loma Linda, CA, USA.
• Acad Emerg Med. 2008 Apr 1;15(4):314-8.

BackgroundThe prophylactic coadministration of atropine or other anticholinergics during dissociative sedation has historically been considered mandatory to mitigate ketamine-associated hypersalivation. Emergency physicians (EPs) are known to omit this adjunct, so a prospective study to describe the safety profile of this practice was initiated.ObjectivesTo quantify the magnitude of excessive salivation, describe interventions for hypersalivation, and describe any associated airway complications.MethodsIn this prospective observational study of emergency department (ED) pediatric patients receiving dissociative sedation, treating physicians rated excessive salivation on a 100-mm visual analog scale and recorded the frequency and nature of airway complications and interventions for hypersalivation.ResultsOf 1,090 ketamine sedations during the 3-year study period, 947 (86.9%) were performed without adjunctive atropine. Treating physicians assigned the majority (92%) of these subjects salivation visual analog scale ratings of 0 mm, i.e., "none," and only 1.3% of ratings were >or= 50 mm. Transient airway complications occurred in 3.2%, with just one (brief desaturation) felt related to hypersalivation (incidence 0.11%, 95% confidence interval = 0.003% to 0.59%). Interventions for hypersalivation (most commonly suctioning) occurred in 4.2%, with no occurrences of assisted ventilation or intubation.ConclusionsWhen adjunctive atropine is omitted during ketamine sedation in children, excessive salivation is uncommon, and associated airway complications are rare. Anticholinergic prophylaxis is not routinely necessary in this setting.

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