Safety and Efficacy of Ketamine Sedation for Infant Flexible Fiberoptic Bronchoscopy* John W. Berkenbosch, MD; Gavin R. Graff, MD; and James M. Stark, MD, PhD Objective: To describe our experience with ketamine sedation during infant flexible fiberoptic bronchoscopy. Design: Retrospective chart review. Infants were sedated with midazolam and ketamine with or without fentanyl. The sedation regimen, final procedure performed, procedure duration, and complications were recorded. Complication rates between infants < 6 months or > 6 months of age and between infants with upper vs lower airway symptoms were compared by  2 test with a contingency table. Results: Fifty-nine procedures were performed in 55 patients aged 6.1  3.1 months (mean  SD). Sedation was achieved with ketamine and midazolam (n  30) or ketamine, midazolam, and fentanyl (n  29). Bronchoscopy with BAL was performed in 44 patients and bronchoscopy alone in 3 patients. In 11 patients, severe upper airway obstruction and/or anomalies prevented subglottic passage of the bronchoscope. One patient could not be ade- quately sedated. There were no major complications. Minor complications occurred in 14 patients (23.7%), most commonly mild hypoxemia (n  9). Brief central apnea developed in three patients. Complication rates were unaffected by age or indication for bronchoscopy. Conclusions: Infant flexible fiberoptic bronchoscopy can be safely and effectively performed using ketamine sedation. Complications, especially mild hypoxemia, appear more common in infants, likely due to smaller airway diameter. Regardless of the sedative(s) used, additional vigilance is required when performing bronchoscopy in this population. (CHEST 2004; 125:1132–1137) Key words: complication; fentanyl; hypoxemia; midazolam; pediatric; procedural sedation F lexible fiberoptic bronchoscopy has been recog- nized as an important tool in the evaluation and management of infant and pediatric respiratory dis- ease for  20 years. 1,2 Subsequent to these initial reports, larger series 3,4 have confirmed the safety and value of this procedure. While authors 1–5 recog- nize the need for appropriate sedation during this procedure, few data exist regarding the safety and efficacy of specific sedation regimens. While the most commonly reported regimens include an opi- oid/benzodiazepine combination, 3,4 other authors 5–7 have suggested that ketamine, with or without a benzodiazepine, may be both safe and effective. Ketamine is a dissociative anesthetic, chemically related to phencyclidine. 8 Initially utilized predomi- nantly in the operating room, increasing experience with this agent outside of the operating room has demonstrated its safety and efficacy, and has enabled it to become a popular choice for pediatric proce- dural sedation in both the emergency depart- ment 9 –11 and procedure suite. 7,12,13 In these settings, ketamine is reported to provide excellent sedation, analgesia, and amnesia with minimal adverse respi- *From the Department of Child Health (Drs. Berkenbosch and Stark), The University of Missouri-Columbia, Columbia, MO; and the Department of Pediatrics (Dr. Graff), Penn State University, Hershey, PA. Manuscript received February 21, 2003; revision accepted Au- gust 4, 2003. Reproduction of this article is prohibited without written permis- sion from the American College of Chest Physicians (e-mail: permissions@chestnet.org). Correspondence to: John W. Berkenbosch, MD, Assistant Profes- sor, Child Health, Pediatric Critical Care, The University of Missouri Department of Child Health, One Hospital Drive, Columbia, MO 65212; e-mail: berkenboschj@health.missouri.edu bronchoscopy 1132 Bronchoscopy Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/20385/ on 06/26/2017