Apnea After Low-Dose Ketamine Sedation During Attempted Delayed Sequence Intubation

Area of Science:

• Anesthesiology
• Critical Care Medicine
• Emergency Medicine

Background:

• Agitated patients often struggle with conventional preoxygenation methods like face masks or noninvasive ventilation.
• Delayed sequence intubation (DSI) uses ketamine sedation to facilitate preoxygenation in challenging patient populations.

Observation:

• A 60-year-old woman with acute hypoxic respiratory failure could not tolerate noninvasive ventilation.
• Despite high-flow oxygen, her saturation remained suboptimal at 93%.

Findings:

• Intravenous ketamine (25 mg) was administered to enable noninvasive ventilation, leading to apnea within one minute.
• The patient was successfully bag-valve-mask ventilated and intubated without complication after receiving succinylcholine and etomidate.

Implications:

• Apnea is a potential complication of ketamine-facilitated preoxygenation in critically ill patients.
• Clinicians must be prepared for immediate airway intervention when using DSI for agitated patients.
• Sedation remains a valuable tool for optimizing preoxygenation, but requires careful consideration and readiness for airway management.