Ketamine Sedation of Children in Emergency Departments

The guidelines below are reproduced here with the permission of the Royal College of Emergency Medicine (UK).

Summary of recommendations
Scope
Reason for development
Introduction
Indications
Contraindications
Procedure
Potential Complications

Summary of recommendations

1. Before ketamine is used all other options should be fully considered, including analgesia, reassurance, distraction, entonox, intranasal diamorphine, etc.
2. The doses advised for analgesic sedation are designed to leave the patient capable of protecting their airway. There is a significant risk of a failure of sedation if the procedure is prolonged, and the clinician must recognise that the option of general anaesthesia may be preferred in these circumstances.
3. There is no evidence that complications are reduced if the child is fasted, however traditional anaesthetic practice favours a period of fasting prior to any sedative procedure. The fasting state of the child should be considered in relation to the urgency of the procedure, but recent food intake should not be considered as an absolute contraindication to ketamine use.
4. Ketamine should be only used by clinicians experienced in its use and capable of managing any complications, particularly airway obstruction, apnoea and laryngospasm. The doctor managing the ketamine sedation and airway should be suitably trained and experienced in ketamine use, with a full range of advanced airway skills.
5. At least three staff are required: a doctor to manage the sedation and airway, a clinician to perform the procedure and an experienced nurse to monitor and support the patient, family and clinical staff. Observations should be regularly taken and recorded.
6. The child should be managed in high dependency or resuscitation area with immediate access to full resuscitation facilities. Monitoring should include ECG, blood pressure, respiration and pulse oximetry. Supplemental oxygen should be given.
7. After the procedure the child should recover in a quiet, observed and monitored area under the continuous observation of a trained member of staff. Recovery should be complete between 60 and 120 minutes, depending on the dose and route used.
8. There should be a documentation and audit system in place within a system of clinical governance.

Scope

This guideline is to assist experienced emergency physicians using ketamine sedation for children in Emergency Departments. This guideline covers the use of ketamine for analgesic sedation in children via either the intravenous or intramuscular route.

Reason for development

This guideline has been prepared to improve and standardise patient care.

Introduction

Ketamine is a unique dissociative drug introduced into clinical practice in 1970. It has anxiolytic, analgesic, amnesic and dissociative properties with a wide safety margin. It is most commonly used to facilitate short painful procedures, such as suturing under local anaesthetic, removal of a foreign body or brief orthopaedic manipulations.

Before ketamine is used all other options should be fully considered, including analgesia, reassurance, distraction, entonox, intranasal diamorphine, etc.

The doses advised for analgesic sedation are designed to leave the patient capable of protecting their airway. There is a significant risk of a failure of sedation if the procedure is prolonged, and the clinician must recognise that the option of general anaesthesia may be preferred in these circumstances.

Ketamine should be only used by clinicians experienced in its use and capable of managing any complications, particularly airway obstruction, apnoea and laryngospasm.

There should be a documentation and audit system in place within a system of clinical governance.

Indications

(Evidence Levels 2-3)

Ketamine can be used to induce analgesic sedation in children who will need a painful or frightening procedure during the course of their emergency care. It can be used instead of general anaesthesia for minor and moderate procedures in combination with local anaesthetic techniques.

It avoids the need to physically restrain a child.

Trials suggest over 90% efficacy for parenteral Ketamine.

There is no evidence of improved emergence phenomena if midazolam is used as a supplement. (Evidence level 2)

There is no evidence of reduced airway problems if atropine is used as a supplement with low dose ketamine. (Evidence level 3)

Contraindications

(Evidence levels 4 and 5)

• Age less than 12 months due to an increased risk of laryngospasm and airway complications. Children aged between 12 and 24 months should only receive ketamine sedation from expert staff (usually a consultant)
• A high risk of laryngospasm (active respiratory infection, active asthma)
• Unstable or abnormal airway. Tracheal surgery or stenosis.
• Active upper or lower respiratory tract infection
• Proposed procedure within the mouth or pharynx
• Patients with severe psychological problems such as cognitive or motor delay or severe behavioural problems.
• Significant cardiac disease (angina, heart failure, malignant hypertension)
• Recent significant head injury or reduced level of consciousness
• Intracranial hypertension with CSF obstruction.
• Intra-ocular pathology (glaucoma, penetrating injury)
• Previous psychotic illness
• Uncontrolled epilepsy
• Hyperthyroidism or Thyroid medication
• Porphyria
• Prior adverse reaction to Ketamine

Procedure

1. Discuss the proposed procedure and use of ketamine with parent or guardian and obtain written consent. The known risks are: mild agitation (20%), moderate/severe agitation (1·5%), rash (10%), vomiting (7%), transient clonic movements (5%), airway problems (1%). It is important to emphasise to the consenting adult that nystagmus, purposeless movements and some degree of dissociation are normal during ketamine sedation, so that these are expected.
2. The child should be managed in high dependency or resuscitation area with immediate access to full resuscitation facilities. Monitoring should include ECG, blood pressure, respiration and pulse oximetry. Supplemental oxygen should be given.
3. At least three staff are required: a doctor to manage the sedation and airway, a clinician to perform the procedure and an experienced nurse to monitor and support the patient, family and clinical staff. Observations should be regularly taken and recorded.
4. The doctor managing the ketamine sedation and airway should be suitably trained and experienced in ketamine use, with a full range of advanced airway skills.
5. There is no evidence that complications are reduced if the child is fasted, however traditional anaesthetic practice favours a period of fasting prior to any sedative procedure. The fasting state of the child should be considered in relation to the urgency of the procedure, but recent food intake should not be considered as an absolute contraindication to ketamine use.
6. Where time permits, topical anaesthesia (EMLA, Amytop, etc.) should be used to reduce the pain of intravenous canulation or intramuscular injection.
7. The dose of ketamine is 1.0 mg/kg by slow intravenous injection over at least one minute or 2.5mg/kg IM as a single injection in the lateral aspect of the thigh. The dose should be based on the child’s actual weight, not age. Caution and careful checking are required in drawing up the correct dose since there are three different formulations of ketamine available (10mg/l, 50mg/ml and 100mg/ml).
8. Encourage the child to child and parents to talk (dream) about happy topics. This helps minimise unpleasant emergency phenomena
9. Adequate sedation is usually indicated by loss of response to verbal stimuli and nystagmus: heart rate, blood pressure and respiration rate may all increase slightly. Lacrimation or salivation may be observed. The effects of the drug are usually apparent 1-2 minutes after an IV dose, and 5-8 minutes after an IM dose.
10. Supplemental doses of 0.5mg/kg by slow IV injection or 1mg/kg IM may be given if required.
11. Local anaesthetic should be used where indicated.
12. After the procedure the child should recover in a quiet, observed and monitored area under the continuous observation of a trained member of staff. Recovery should be complete between 60 and 120 minutes, depending on the dose and route used.
13. The child can be safely discharged once they are able to ambulate and vocalise/converse at pre-sedation levels. An advice sheet should be given to the parent or guardian advising rest and quiet, supervised activity for the remainder of that day. The child should not eat or drink for two hours after discharge because of the risk of nausea and vomiting.
14. The medical record and local audit documentation should be completed.

Potential Complications

(Evidence level 2, 3, 4)

Airway:

1. Noisy breathing is usually due to airway mal-position and occurs at an incidence of <1%. This can normally be corrected by routine airway position management.
2. In rare cases laryngospasm may occur (0.3%). The reported incidence of intubation for laryngospasm is 0.02%. A recent meta-analysis showed that low IM doses of ketamine (<3.0 mg/kg) exhibited significantly less overall airway and respiratory adverse events. There were no occurrences of either laryngospasm or apnoea in the 682 children receiving lower IM doses. (Green at al, 2008)

Vomiting:

• 5 - 10% incidence. This usually occurs during the recovery phase.

Lacrimation and salivation:

• 10% incidence

Transient rash:

• 10% incidence

Transient clonic movements:

• <5%

References:

Agrawal D, et al. Preprocedural Fasting State and Adverse Events in Children Undergoing Procedural Sedation and Analgesia in a Paediatric Emergency Department. Ann Emerg Med.2003;42:636-646.

American College of Emergency Physicians Clinical Policy for procedural sedation andanalgesia in the emergency department. Ann Emerg Med. 1998; 31:663-677.

Brown L, Christian-Kopp S et al. Adjunctive Atropine Is Unnecessary during KetamineSedation in Children. Acad Emerg Med 2008; 15:314–318.

Green SM, Nakamura R, Johnson N.E, Linda L: Ketamine Sedation for Paediatric Procedures:Part 1, A prospective series. Ann Emerg Med 1990; 19(9): 1024-1032.

Green SM, Johnson NE: Ketamine Sedation for Paediatric Procedures: Part 2, Review andImplications. Ann Emerg Med 1990; 19(9): 1033-1044.

Green SM, Krauss B. The Semantics of ketamine. Ann Emerg Med. November 2000; 36:480-482.

Green SM, Kuppermann N, Rothrock S, Hummel C, Ho M. Predictors of adverse events withintramuscular ketamine sedation in children. Ann Emerg Med 2000; 35; 35-42.

Green S, Roback M, Krauss B, Brown L, McGlone R, et al. Predictors of Airway and Respiratory Adverse Events of Ketamine Sedation in the Emergency Department: An Individual-Patient Data Meta-Analysis of 8,282 Children. Accepted Dec 2008 Ann Emerg Med.

Holloway VJ, Hussain HM, Saetta JP, Gautam V. Accident and Emergency Department led implementation of ketamine sedation in paediatric practice and parental response. Emerg Med J. 2000; 17:25-28.

McGlone RG, Ranasinghe S, Durham S. An alternative to “brutacaine”: a comparison of low dose intramuscular ketamine with intranasal midazolam in children before suturing. Emerg Med J. 1998; 15:231-236.

Roback M, et al. Preprocedural Fasting and Adverse Events in Procedural Sedation and Analgesia in a Pediatric Emergency Department: Are They Related? Ann Emerg Med. 2004;44:454-459.

Sherwin ST, Green SM, Khan A, Chapman S, Dannenberg B. Does adjunctive midazolam reduce recovery agitation after ketamine sedation for paediatric procedures? A randomised, double blind, placebo-controlled trial. Ann Emerg Med 2000; 35:229-238.

Wathen JE, Roback MG, Mackenzie T, Bothner J. Does midazolam alter the effects of intravenous ketamine sedation in children? A double blind, randomised, controlled, emergency department trial. Ann Emerg Med 2000; 36:579-588.

Younge PA, Kendall JM. Sedation for children requiring wound repair: a randomised controlled double blind comparison or oral midazolam and ketamine. Emerg Med J. 2001; 18:30-33.