Ketamine Sedation in Children

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This page is our version of the BAEM Clinical Effectiveness Committee Guidelines on Ketamine Sedation in Children

Introduction

Ketamine is a powerful anaesthetic agent with anxiolytic and analgesic and amnesic properties with a wide safety margin. This guideline covers its use in analgesic sedation, primarily for children. The doses advised for analgesic sedation are designed to leave the patient capable of protecting their airway. Consequently there is a significant risk of failure of sedation and the clinician must recognise that the option of general anaesthesia must be discussed with the patient and parents. Ketamine should be only used by clinicians experienced in its use and capable of managing any complications.There should be an audit method in place to allow for adequate clinical governance.Print Cork Emergency Departments Sedation Record.

Indications

Ketamine has a role in inducing mild protective sedation in children who will need a painful or frightening procedure performing in the course of their emergency care. It can be used instead of formal anaesthesia for minor and moderate procedures in combination with local anaesthetic techniques. It potentially replaces physical restraint of the child. Trials suggest 90% efficacy for parenteral Ketamine.Print Cork Emergency Departments Sedation Record

Algorithm

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Contraindications

• A full meal within 3 hours
• A high risk of laryngospasm (active respiratory infection, active asthma, age less than 3 months)
• Patients with severe psychological problems such as cognitive or motor delay or severe behavioural problems
• Significant cardiac disease (angina, heart failure, malignant hypertension)
• Intracranial hypertension with CSF obstruction
• Intra-ocular pathology (glaucoma, penetrating injury)
• Previous psychotic illness
• Hyperthyroidism or Thyroid medication
• Porphyria
• Prior adverse reaction to Ketamine

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Procedure

Procedure Induction

• Have and use monitoring. The minimum required is pulse oximetry
• Have a procedure sheet capable of recording; Staff involved, pre-sedation assessment, drug dosage and timing, sequential heart rate and saturation as well as a measure of sedation e.g. GCS
• Obtain written consent from parents
• In children, the intra-muscular route is preferred
• If time is available, prepare the injection site with 45 mins pre-treatment with local anaesthetic cream (emla, ametop)
• Use an initial dose of 2mg per Kg body weight
  Level 3
• A supplementary dose of 1mg per Kg may be given
• Atropine 0.01mg/kg (dose range 0.1 to 0.5mg) reduces the salivation reaction to ketamine
Level 3
• It is suggested that a Weight - Dose chart be pre-calculated and used.
• There is no evidence of improved emergence phenomena if midazolam is used as a supplement
Level 2

Procedure Management

• After 5 minutes, the patient will be sedated which will be diagnosed by glazed eyes and nystagmus
• This condition will last for approximately 30 mins
• Apply local anaesthetic to the area to be treated
  Level 4
• Continue recording observations during the procedure

Procedure Recovery

 

• 30 minutes after induction the patient should be taken to a dedicated quiet monitoring area where minimal stimulation (including from monitoring) should be allowed so as to prevent emergence phenomena. Consequently monitoring should use pulse oximetry but not blood pressure monitoring unless indicated.
• The child should be monitored by staff trained in the management of sedated children.
• Observations should be continued and recorded until recovery is deemed complete.
• Recovery should be complete within 90 minutes.
  Level 4
• Allow home with carer when able to walk
• Written discharge information should be issued including possible problems to be expected and their management.

 

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Potential complications

• Airway
  • 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
  • In rare cases mild laryngospasm may occur (0.3%). The reported incidence of intubation for laryngospasm is 0.02%
• Vomiting: up to 10% incidence
  • <10% and can be reduced with atropine premedication
• Lacrimation and salivation
• Transient rash 10%
• Transient clonic movements <5%
• Emergence Phenomena <20%

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Links

• SIGN April 2004 Guidelines on safe sedation
• British Association for Emergency Medicine
• Local version BAEM  Guideline Children
• Print version Cork Emergency Departments Sedation Record

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Content by Dr Íomhar O' Sullivan 01/11/2004.   Reviewed by Dr ÍOS 25/05/2006. Next review 25/05/2007.