Implementing paediatric procedural
sedation in emergency departments: 2013
Title – xxx
Ketamine
Dr David Krieser FRACP
Speaker
Paediatric Emergency Physician, Sunshine Hospital – Western Health
Case
• An 8 year old boy
– Monkey bars + Gravity
• FALL
– Obvious left upper limb deformity
– Note
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Past History
Last intake of solids / liquids
Assessment of injury – neurovascular observations
Pain score and management
Imaging
Why parenteral sedation?
• Some procedures too painful for nitrous
oxide
• Alternative to GA in theatre
Why ketamine?
• Predictable response compared with other
agents
• IM and IV options
• Maintenance of upper airway tone and
reflexes
• Established safety profile
Ketamine in your ED
• Ketamine and/or other parenteral agents will not be
appropriate in all EDs.
• Each health services is responsible to determine what
procedures & level of sedation in your ED
• If yes
• Policies and procedures are in place
• Staff trained in paediatric life support
• Staff trained and credentialed in use of Ketamine
General principles
• Appropriate location
• Sedation team:
– Proceduralist + sedation doctor + sedation nurse
– Senior doctor support
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Authorisation
Fasting
Consent
IV agents administered by doctor only
Close monitoring
What is ketamine?
• Dissociative anaesthetic
– Thalamo-cortical input separated from limbic system
– Profound amnesia and analgesia – “sensory isolation”
– Not a dose dependent effect – a threshold is crossed
• Maintains upper airway tone and protective
reflexes
• Cardio respiratory stimulant
• There is no reversal agent
• Demonstrated as safe in children in EDs
Indications
• Short very painful ED procedures or if
immobilisation needed
– Fracture reduction
– Laceration repair (esp. facial)
– Incision and drainage
Contraindications
• History of airway problems, delayed gastric emptying
• Very unwell
• URTI, acute respiratory disease
– Laryngospasm
• Children < 1 year
– Airway malposition, respiratory depression
• Children >12 years
• History of psychosis / ADHD
– Emergence reaction
• Porphyria, thyrotoxicosis
– Sympathomimetic effects increased
Ketamine: Dosing
• IV Ketamine
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1 mg/kg slow IV over 1 minute
Onset 1 minute
Additional doses 0.25-0.5 mg/kg slow IV
Fast push INCREASED RISK of respiratory depression
• IM Ketamine
– 4 mg/kg
– Onset 3-5 minutes
– Additional doses IV 0.25 mg/kg
Comparing IV and IM
Route of
administration
Intravenous
(IV)
Intramuscular
(IM)
Advantages
Ease of repeat dosing
Faster recovery
No IV needed
Clinical onset
1 minute
3-5 minutes
Duration of effective
sedation (approx.)
15 minutes
15-30 minutes
Recovery (approx.)
60 minutes
90-150 minutes
Initial dose
1 mg/kg
4 mg/kg
Subsequent dose
0.25-0.5 mg/kg
Insert IV and give
further doses
0.25-0.5 mg/kg
Maximum dose
5 mg/kg
5 mg/kg (combined IM
and IV)
Ketamine: Parent preparation
• Need to warn parents about ketamine effects:
– For IV - tell them it usually works VERY fast
• “like a switch”
– Eyes open: may appear awake
• “lights are on, nobody is home”
– May move and need restraint
– May adopt strange limb positions
– May drool
– May experience unusual sensations on
recovery / agitation / nightmares
– Requires observation period before discharge
Ketamine: Adverse effects
• Airway malposition
• May elevate intracranial /
intraocular pressure
• Hyper-salivation
• Ataxia
• Laryngospasm
• Emergence reaction
• Respiratory depression
• Vomiting (recovery)
• Cardiovascular
stimulation
Ketamine: Emergence reaction
• Hallucinations, dreaming during recovery
– More frequent in adults/adolescents
– Risk factors:
• female, rapid IV, excessive noise and stimulation,
prior personality disorder
– Reduce risk:
• suggest topics for dreaming – Ask before
sedation what the child likes to do and get them
to think about it
• dim and quiet environment
Let’s use ketamine
Return to the Case
Case
• An 8 year old boy
– Monkey bars + Gravity
• FALL
– Obvious left upper limb deformity
– Note
• Past History
• Last intake of solids / liquids
• Assessment of injury – neurovascular
observations
• Pain score and management
Imaging
Staff
Ketamine
A doctor, credentialed for the agent
used, to administer the sedation
and monitor the patient AND a
nurse credentialed for paediatric
sedation to assist the sedation
doctor.
Another doctor to perform the
procedure.
Appropriate senior clinician
available on site with the ability to
immediately respond if required.
Ketamine: The procedure
• Perform only in designated area with full
resuscitation equipment available
• IV administration only by a doctor
• Give slowly (over ~ 1 minute) to reduce
adverse effects
• Continuous ECG and O2 sat monitoring
• Record observations (including BP)
5 minutely
Ketamine: The procedure
• 8 year old boy with forearm fracture
– Weight – 25 kg
• Remember topical anaesthetic for IV insertion
• Guided imagery; music
• Must prepare all equipment for reduction and
plaster as per local guidelines
– May include: Image Intensifier (+ radiographer), plaster of
Paris, padding, sling etc
• Consent for sedation AND for procedure
– Explain risks
Ketamine: The procedure
Suggested prescription
IV administration
1. Calculate the initial dose
2. Draw up into a 1 ml syringe
3. Transfer this (using the drawing up needle) into
an appropriate size syringe and dilute with
normal saline to a final concentration of 10 mg/ml
4. Administer slowly over 1 minute
e.g. 20 kg Child, add 0.2 ml of ketamine to
1.8 ml normal saline = 20 mg/2 ml (10 mg/ml)
Ketamine: The procedure
Atropine
• Have atropine available
– Calculate the dose = 0.02 mg/kg (20 mcg/kg)
• Write down this calculated dose in case it is
needed
– Do NOT draw up
– Use only if symptomatic
If you don’t label it…
you don’t know what it is
• Australian Commission on Safety and Quality
in Health Care
• National Recommendations for labeling
– All injectable medicines drawn up should be
labeled immediately
• Includes flushes, normal saline
– Multiple syringes should be prepared and
labeled if required
– Care not to cover volume graduations with
label
Other agents
• Include:
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propofol
ketamine/propofol (Ketofol)
midazolam (unreliable)
chloral hydrate (non-painful procedures)
• Same principles of safe practice apply
Summary: Key elements
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Procedure can occur in your ED
Child is suitable to have ketamine
Child and parent preparation
Standardised processes including
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Consent
Drug management
Documentation
Monitoring
Discharge
• Credentialing of staff
• Recognition and management of adverse events
Questions