Ketamine use for procedural sedation

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  • See also

    Nitrous Oxide Guideline
    Analgesia & Sedation Guideline 

    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 - excellent analgesia is typical
    • amnesia is usually total
    • airway reflexes are maintained
    • cardiovascular state - blood pressure and heart rate increase slightly
    • nystagmus and lacrimation is typical

    Indications

    Short painful procedures, particularly if requiring immobilisation.

    For example:

    • 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

    • Children under 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 if any of the following are present:

    • Age 3 – 6 months: only personnel with advanced airway skills
    • Current significant respiratory illness, e.g. asthma, respiratory tract infection
    • Known difficult airway, history of previous airway surgery or congenital anomaly
    • Potential intraoral bleeding such as tongue lacerations
    • Procedures that will stimulate the posterior pharynx
    • Cardiovascular disease where increased HR and workload are contraindicated i.e. IHD, cardiac failure, hypertension, WPW
    • 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 ALS assessment.
    • One senior doctor to administer the sedation and perform the procedure. This doctor must be credentialed in ketamine sedation and ALS certified.
    • Consider having another credentialed staff member present, particularly if the procedure is such that it cannot be immediately ceased to provide airway assistance, or if the child is under 6 months.

    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 e.g. “If you were not here today where would you rather be”. This may help minimise unpleasant emergence phenomena.
    • Apply topical anaesthetic cream early, as it requires approximately 45 minutes to work.
    • Pre-sedation fasting is not required.
    • Pre-oxygenation is not recommended as may mask hypoventilation.

    Adjunctive agents

    Ondansetron may be considered prior to sedation, especially in those over 8-years.

    Administration

    In settings in which IV access can be obtained with minimal upset, the intravenous route is preferable as recovery is faster and there is less emesis.
    Doses may need to be adjusted according to ideal bodyweight.

    Intravenous

    Initial dose: 1.5 mg/kg (maximum of 50 mg)

    Subsequent incremental dose(s) if needed: 0.5 mg/kg (maximum of 25 mg)

    • The Ketamine dose of 1.5 mg/kg is given slowly (over 1-2 min) as more rapid administration is associated with respiratory depression.
    • Especially useful for procedures longer than 15-20 minutes.
    • 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 3-4 mg/kg

    A repeat dose of 2-4 mg/kg may be given after 10 minutes if sedation is inadequate.

    • Ketamine can be safely used without IV access.
    Route of Administration IM IV
    Advantages 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

    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, 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 RSI may be considered
    • Apnoea or respiratory depression: (0.4%) is usually transient
    • Emesis: more common in children over 8yrs; 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

    • Nil orally until fully alert
    • 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 abort 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 pre-treatment functioning. 

    Discharge instructions

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

    Additional notes

    Ketamine use as analgesic

    Intranasal ketamine

    • Consideration for use of intranasal ketamine 1mg/kg for pain management in children aged 3-13 ( <50kg) if opiates inadequate, not preferable, or contraindicated
    • For analgesic dose volumes equal to and less than 0.5 mL, the entire dose is administered in 1 of the nares. Doses greater than 0.5 mL are divided equally between the nares
    • May be associated with mild dizziness, bad taste in mouth, drowsiness, hallucinations (rare)

    IV ketamine

    • IV low dose Ketamine (0.5mg/kg IV) has similar analgesic effects to morphine
    • Repeated doses may be needed after 1-2hrs 

    Ketamine use in the agitated child

    See Acute behavioural disturbance: Acute management

    Ketamine use in premedication (avoid in children under 2 years)

    Route Dose Onset (mins) Duration (hours) Note
    Oral 5 – 10 mg/kg 10 – 20 3 Increased salivation, Nystagmus, Dissociative state  
    Intranasal 3 – 5 mg/kg 10 – 15 1-3
    Buccal / Transmucosal   5 – 6 mg/kg 10  - 15 1-3
    Intramuscular 5 mg/kg 3 – 5 1-3

    Ketamine use in severe asthma

    See Asthma acute

    Information specific to RCH

    When considering using Ketamine for analgesia discuss with Acute Pain Team

    Last updated June, 2019


    • Reference List

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