Detection of hypoventilation by capnography and its association with hypoxia in children undergoing sedation with ketamine

Objectives: Hypopneic hypoventilation, a decrease in tidal volume without a change in respiratory rate, is not easily detected by standard monitoring practices during sedation but can be detected by capnography. Our goal was to determine the frequency of hypopneic hypoventilation and its association with hypoxia in children undergoing sedation with ketamine. Methods: Children who received intravenous ketamine with or without midazolam for sedation in a pediatric emergency department were prospectively enrolled. Heart rate, respiratory rate, pulse oximetry, and end-tidal carbon dioxide (ETCO ₂) levels were recorded every 30 seconds. Results: Fifty-eight subjects were included in this study. Fifty percent of subjects had recorded ETCO2 values less than 30 mm Hg without a rise in respiratory rate. Twenty-eight percent of subjects experienced a decrease in pulse oximetry less than 95%. Patients who experienced a persistent decrease in ETCO₂ at least 30 seconds in length were much more likely to have a persistent decrease in pulse oximetry than those with normal or transient decreases in ETCO2 (relative risk, 6.6; 95% confidence interval, 1.4-30.5). Decreases in ETcO₂ occurred on an average of 3.7 minutes before decreases in pulse oximetry. Conclusions: Hypopneic hypoventilation as detected by capnography is common in children undergoing sedation with ketamine with or without midazolam. Hypoxia is frequently preceded by low ETCO₂ levels. Further studies are needed to determine if the addition of routine monitoring with capnography can reduce the frequency of hypoxia in children undergoing sedation.