Pain management and sedation/original research
Nurse-Administered Ketamine Sedation in an Emergency Department in Rural Uganda

Presented as an abstract at the Society of Academic Emergency Medicine, June 2011, Boston, MA.
https://doi.org/10.1016/j.annemergmed.2011.11.004Get rights and content

Study 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%).

Conclusion

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.

Introduction

Throughout many low- and middle-income countries, there is a shortage of medical providers, especially in rural areas.1 Patients may experience delays in care or be unable to receive proper care because of the absence of skilled providers, which results in unnecessary morbidity and mortality, especially in emergency situations. Nurses are generally more plentiful in low- and middle-income countries compared with physicians or midlevel providers.1 Thus, a policy of “task shifting” is being promoted in these settings to help fill the void in services. Task shifting involves delegating tasks that were originally only in the domain of physicians or specialists to nurses who have received appropriate training.

In Uganda, as in most of sub-Saharan Africa, emergency care is not a formally developed medical specialty. Although some referral centers have “casualty wards,” few, if any, hospitals have true emergency departments (EDs) in which patients can be triaged and treated according to severity of illness. In 2008, the first rural ED in Uganda was opened at the Karoli Lwanga Hospital, a nonprofit, nongovernmental hospital located in a rural area of southwestern Uganda. The hospital serves as one of 2 district hospitals for the Rukungiri District. In this district, there is only 1 physician for every 18,500 people. However, there is 1 nurse for every 895 people.2

As in much of sub-Saharan Africa, there are limited physician and anesthetist resources at Karoli Lwanga Hospital, and none of the physicians have specific training in procedural sedation. Out of necessity, many painful urgent and emergent procedures are performed with inadequate pain control, are delayed for unacceptable amounts of time, or are simply not performed.3 This leads to unnecessary pain, complications, and poor outcomes that would be judged unacceptable in a more developed health care system.

In July 2009, with collaboration and input from the Hospital Management Team and district health office, a training program in emergency care was instituted at Karoli Lwanga Hospital by a nongovernmental organization, Global Emergency Care Collaborative, which is composed of emergency physicians from the United States. The goal of the program was to train nurses to independently assess and treat patients with emergent conditions. This training included education on how to carry out procedures necessary for proper emergency care.

Given the large number of painful procedures performed in this setting and the limited anesthetist resources, training in procedural sedation was undertaken. Agents available for procedural sedation at the hospital include diazepam, meperidine, thiopental, and ketamine. Ketamine has been used widely in resource-limited settings and has an excellent safety profile.4 Therefore, it was selected as the agent of choice for ED procedural sedation in patients of all ages.

To our knowledge, this is the first published report of training nonanesthetist nurses in procedural sedation techniques in resource-limited settings. As a result, a quality assurance database was created to ensure that the use of ketamine by these providers was safe and effective. The specific aim of this study was to query the database to determine the safety and effectiveness of ketamine administration by trained nurses in a resource-limited ED in a developing country.

Section snippets

Theoretical Model of the Problem

As part of a comprehensive nurse-training program in emergency care at a Ugandan district hospital, 6 nurse participants were trained in the use of ketamine sedation. Basic nursing education in Uganda involves a 2.5-year training program that includes clinical rotations on various wards, supplemented with basic didactics. The curriculum covers basic anatomy, pharmacology, pathophysiology, and medical ethics. There is no training in basic life support, airway management, anesthetic techniques,

Results

During the study, 192 sedations were eligible for inclusion. Once each nurse had completed the training, all consecutive sedations performed by that nurse were included. Thus, this data set represents all consecutive sedations performed by a nurse certified in our ketamine training program. One sedation was excluded because a visiting emergency physician thought that the patient's injuries were too painful for the patient to be transferred to radiology without being sedated during the transfer.

Limitations

Although this study is a review of a database, it does not have some of the limitations that typically affect such studies. The data were collected prospectively as part of a quality assurance program because there were no models on which to base this sedation training. The database was designed to assess the quality and safety of the nurse-administered sedations after our specific ketamine sedation training program. Although it is possible that some of the outcomes could be interpreted

Discussion

Ketamine is a phencyclidine derivative used for sedation and analgesia. It produces dissociation from the environment (eg, external sight, sound, and pain stimuli) by acting on the limbic system and the cortex. This unique property of ketamine enables it to produce amnesic, analgesic, and sedative effects. Patients have preserved respiratory drive and laryngeal reflexes while in the dissociated state. For these reasons, it has been widely used in resource-limited settings, in which monitoring

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Supervising editor: Knox H. Todd, MD, MPH

Author contributions: MB wrote the article. MB, HH, SWN, and SC were responsible for the sedation curriculum. MB, HH, BD, SWN, and SC were responsible for the overall emergency care training curriculum. MB, KN, HH, SWN, and SC designed the quality assurance database. KN, HH, BB, SWN, SC, FK, AN, AA, and ST edited the article. KN oversaw data collection and deidentified the database. FK participated in the emergency care training program and performed ongoing sedation training. AN assisted with data collection. AA and ST were responsible for data analysis. MB takes responsibility for the paper as a whole.

Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist.

Publication date: Available online December 9, 2011.

Please see page 269 for the Editor's Capsule Summary of this article.

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