Ketamine use for procedural sedation

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  • 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


    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


    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


    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


    • 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


    • 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    


    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


    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

    Route of Administration




    No IV necessary

    Ease of repeat dosing, slightly faster recovery

    Clinical onset

    3–4 minutes

    1 minute

    Effective sedation

    15–30 minutes

    10–20 minutes

    Time to discharge (average)

    100–140 minutes

    90–120 minutes


    • 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

      • Reference List

        1. Australia and New Zealand College of Anaesthetists. Guideline on sedation and/or analgesia for diagnostic and interventional medical, dental or surgical procedures, 2014 (accessed November 2021)
        2. Bellolio, M et al. Incidence of adverse events in paediatric procedural sedation in the emergency department: a systematic review and meta-analysis. BMJ Open. 2016. 6 (6), e011384
        3. Bhatt, M et al.  Association of Preprocedural Fasting With Outcomes of Emergency Department Sedation in Children. JAMA Pediatrics. 2018. 172(7), 678-685.
        4. Bhatt,  M et al. Risk Factors for Adverse Events in Emergency Department Procedural Sedation for Children. JAMA Pediatrics. 2017. 171(10), 957-964.
        5. Coralic, Z et al. Ketamine procedural sedation in the emergency department of an urban tertiary hospital in Dar es Salaam, Tanzania. Emergency Medicine  Journal. 2018. 35(4), 214-219.
        6. Graudins, A et al. The PICHFORK (Pain in Children Fentanyl or Ketamine) trial: a randomized controlled trial comparing intranasal ketamine and fentanyl for the relief of moderate to severe pain in children with limb injuries. Annals of Emergency Medicine. 2015. 65(3), 248-254.
        7. Green, S et al. Clinical Practice Guideline for Emergency Department Ketamine Dissociative Sedation: 2011 Update. Annals of Emergency Medicine. 2011. 57(5), 449-61
        8. Grindlay,  J et al. Sedation Manual 5th Edition Emergency Department Royal Children’s Hospital Melbourne. RCH intranet only
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