DSI, Ketamine, and Apnea

• In recent years, delayed sequence intubation (DSI) with ketamine has been used in select patients to maximize preoxygenation and dinitrogenation. 
• Importantly, DSI is not well studied. In the only prospective trial of DSI, patients received approximately 1.4 mg/kg of ketamine.
• Driver, et al. report the abrupt onset of apnea in a patient who received a much lower dose of ketamine (25 mg) for DSI.
• Take Home Point: If DSI is a part of your preoxygenation armamentarium, apnea can occur even at low doses of ketamine.  Stand at the patient's bedside and be ready to immediately intubate the patient.

References

Driver BE, Reardon RF. Apnea after low-dose ketamine sedation during attempted delayed sequence intubation. Ann Emerg Med 2017; 69:34-35.