See also

Nitrous oxide – oxygen mix

Procedural sedation
Emergency Airway Management
Acute Pain Management
Communicating procedures to children

Key points

1. Ketamine is a safe and effective procedural sedation option for children in the emergency department setting
2. Ketamine is a potent sedative, amnestic, analgesic and anaesthetic agent
3. This guideline relates to the use of ketamine for procedural sedation. Detailed description of other uses (analgesia, agitation, pre-sedation, rapid sequence induction) are beyond the scope of this guideline

Background

Characteristics of ketamine dissociative state:

• Dissociation: the child passes into a trance like state, eyes may be open
• Catalepsy: normal or slightly increased muscle tone is maintained
• Analgesia: effective analgesia
• Amnesia is usually total
• Airway reflexes are maintained
• Cardiovascular state: blood pressure and heart rate increase slightly
• Nystagmus and lacrimation are typical

Indications

Ketamine is useful for short, painful procedures, particularly if requiring immobilisation, eg:

• Lacerations (especially of the face)
• Fracture reduction
• Abscess incision & drainage
• Removal of foreign bodies from eye, ear, nose, skin where nitrous oxide has been or is likely to be inadequate

Absolute Contraindications

• Infants <3 months
• Although true allergy is rare, it has been documented and should be treated in accordance with usual allergy/anaphylaxis management

Relative Contraindications

Discuss with senior staff with experience in procedural sedation if any of the following are present:

• Infants <12 months (absolute contraindication in some jurisdictions, including NSW)
• Current significant respiratory illness, eg asthma, respiratory tract infection
• Known difficult airway, history of previous airway surgery or congenital anomaly
• Intraoral Procedures or potential intraoral bleeding such as tongue lacerations and dental procedures
• Procedures that will stimulate the posterior pharynx
• Cardiovascular disease where increased HR and workload are contraindicated, eg ischaemic heart disease, cardiac failure, hypertension, Wolff-Parkinson-White syndrome
• Glaucoma or acute globe injury
• Porphyria
• Thyroid disease
• Bowel obstruction
• Psychosis

Procedure

Staff required

• Senior staff present in the department must be aware of the sedation, and able to provide immediate assistance if required
• One registered nurse capable of airway management and advanced monitoring of child. This nurse must be assessed as competent in ketamine sedation and have completed annual Advanced Life Support (ALS) assessment
• One senior doctor to administer the sedation. This doctor must be credentialed in ketamine sedation and ALS certified
• One doctor to perform the procedure. Some departments may choose to combine the sedation and procedure roles, for certain procedures. In some health care settings, including NSW health, the presence of a third credentialled clinician is mandatory.

Resuscitation equipment must be readily available

Pre-sedation

• The procedure should be explained to the caregivers and child including an explanation of the effects of ketamine
• Informed consent must be obtained
• Baseline observations should include BP, HR, RR and O₂ saturation
• Facilitate/encourage non-procedural conversation prior and during administration of ketamine eg “If you were not here today where would you rather be”. This may help minimise unpleasant emergence phenomena
• Consider distraction techniques eg music
• Apply topical anaesthetic cream early, as it requires approximately 45 minutes to work
• Fasting (see local fasting guidelines)
• Pre-oxygenation is not recommended as may mask hypoventilation

Administration

• Doses may need to be adjusted according to ideal bodyweight
• In settings in which IV access can be obtained with minimal upset, the intravenous route is preferable as:
• The dose can be titrated to effect
• Shorter recovery time
• Reduced risk of emesis    

Intravenous

Initial dose:  1–1.5 mg/kg over 1–2 minutes immediately before the procedure

Subsequent incremental dose(s) if needed: 0.25-0.5 mg/kg every 10 minutes until procedure is complete

Maximum dose 4.5 mg/kg (though this would be rarely required)

• IV doses of >2.5 mg/kg are associated with increased risk of adverse events
• If doses higher than 2.5 mg/kg are required, consider aborting procedure / explore alternative sedation options

Intramuscular

Initial dose of 4 mg/kg (maximum of 6 mg/kg)
A repeat dose of 2 mg/kg may be given after 10 minutes if sedation is inadequate
Ketamine can be safely used without IV access

Monitoring

• Each child should have pulse oximetry and cardiac monitoring, and a clinician in attendance until recovery is well established
• Close observation of the airway and chest movements is necessary

Potential side effects and management

Inform families of these effects as part of consent

• Random purposeless movements or stiffness, muscle twitching, rash, and vocalisations: common and of no clinical significance
• Tachycardia and/or hypertension: transient
• Hypersalivation: suctioning of hypersalivation may rarely be necessary
• Transient laryngospasm: (0.3%) Positive pressure ventilation may be required, or intubation by Rapid Sequence Induction (RSI) may be considered
• Apnoea or respiratory depression: (0.4%) is usually transient
• Emesis: more common in children over 8 years therefore suctioning may be necessary
• Unpleasant emergence phenomena: more common beyond mid adolescence and will resolve in time, a quiet and low stimulation environment may assist
• Recovery agitation: (1.4%) uncommon and transient 

Post procedure recovery

• The child should not be discharged home until they have returned to their premorbid neurological baseline
• Nurse in a quiet area with minimal noise and physical contact, allow dim lighting if possible, and do not stimulate prematurely

If ketamine sedation is unsuccessful:

Consider discussion with senior staff or anaesthetics, may need to abandon sedation and procedure

Consider transfer when

Child requiring care above the level of comfort of the local centre

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services 

Consider discharge when

Child is able to ambulate and verbalise at a level consistent with their premorbid neurological baseline

Discharge instructions

Careful family observation and supervision if mobilising for at least two hours

Additional notes

IN ketamine is not currently recommended for procedural sedation due to limited evidence supporting efficacy as a sedation given via IN

Ketamine use in severe asthma

See Asthma acute

Last updated December 2021