DISCUSSION

Ketamine has been used as an oral sedative in the management of uncooperative patients. Common side effects of ketamine are nausea and vomiting, which have been reported in 0-43% of patients. In this study, the addition of promethazine, a potent antiemetic drug, reduced the vomiting incidence from 27% (control group) to 0% (experimental group).

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The age range of the subjects was 21-43 months, with a mean age of 33V2 months. There were no significant differences in age (for controls, range, 21-43 months; mean, 33 months; for experimental patients, range, 25-43 months; mean, 34 months) (Table 3). Under the conditions of this study, the average time in the operatory, from placement onto the Papoose Board until treatment completion, was not significantly different between the 2 groups using the Student’s t test at P = .05 (Table 3). In the control group (ketamine only), 3 (27%) of 11 patients vomited. The first patient had one episode of vomiting during the treatment procedure and once when she left the office. The second patient vomited once when he left the office. The third patient vomited once approximately 15 minutes after receiving the ketamine. These patients vomited varying small amounts of clear liquids. In the experimental group (ketamine and promethazine), none of the subjects experienced vomiting (0%). A 2 X 2 chi-square contingency table showed that there was a statistically significant difference in the vomiting frequencies between the 2 drug regimens at P <. 05.

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Pediatric dental patients from the Houston Medical Center Pediatric Dental Clinic, Houston, Tex, were chosen for the study, which was approved by the Committee for the Protection of Human Subjects. The selection cri­teria included healthy patients between IV2 and 3Vi years of age with no previous dental experience and those who demonstrated such poor behavior at the initial dental examination that they were deemed to need oral sedation for subsequent restorative visits. Poor behavior included crying, apprehension, uncooperation for the examination and cleaning, poor response to behavioral management techniques and verbal commands, and physical resistance. Risks and benefits of the sedation followed by the presedation instructions were explained to the parent at the initial examination appointment. The patients had taken nothing by mouth for at least 8 hours before the procedure. A written consent form was obtained for each parent or guardian at the initial appointment.

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Ketamine is a dissociative anesthetic agent that has been shown to be useful as a safe and effective oral sedative. The drug was first derived in 1961, and reports on human trials were begun in 1965. It is a chemical derivative of phencyclidine and cyclohexami-ne. Ketamine is unique in being effective for induction of anesthesia by either the intravenous or the intramuscular route; however, only recently has the drug been studied in subanesthetic sedative doses per oral administration. Patients who are given anesthetic doses of ketamine may appear to be awake with open eyes, yet are unaware of the environment and do not experience pain. This response is termed dissociative anesthesia, during which patients independently and continuously maintain their protective reflexes and may or may not respond appropriately to verbal or painful stimulation, depending on the level of dissociation. Patients often exhibit nonpurposeful movement independent of the stimulation. In the central nervous system, dissociative anesthesia is characterized by electroencephalographic evidence of dissociation between the limbic system and the thalamus. Ketamine also produces intense analgesia, which can be explained in part by specific suppression of the spinal cord activity necessary for transmission of pain to the higher brain centers. Anterograde amnesia is intense, which may be a beneficial effect in the consciously sedated patient. Nystagmus associated with ketamine often heralds the onset of dissociative sedation. Although nystagmus may preclude the use of the drug for operations or examinations of the eyes, this side effect is of little importance in the dental patient. Emergence delirium, including dreams and hallucinations, ranges from 5-30%, with an increased incidence reported in patients older than 16 years, female patients, patients taking high intravenous doses (>2 mgAg), and patients with a history of personality problems or frequent dreaming. Emergence delirium can also be attenuated with concomitant use of a benzodiazepine agent. Other central nervous system effects include an increase in cerebral blood flow and subsequent increase in intracranial pressure. This ketamine-induced activity is unlikely to precipitate convulsions in patients with seizure disorders and does not alter the seizure threshold in epileptic patients.

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