RCEM 2022 Safe sedation in the ED and RCEM Ketamine for paediatric procedural sedation guideline. Please read these documents in full or participate in RCEM learning for further information.

Characteristics of ketamine sedation

• Dissociation – trance-like state with eyes open but not responding
• Catalepsy – normal or slightly increased muscle tone maintained
• Analgesia – excellent analgesia is typical
• Amnesia – usually total
• Airway reflexes maintained
• Cardiovascular state – blood pressure and heart rate increase slightly
• Nystagmus is typical – usually horizontal; eyes remain open and glazed

Who can perform it?

• Senior medical staff (ST3+)
• Must have done at least 6 months of anaesthetics/ICU
• Familiar with giving ketamine, particularly in under 5s
• Must have at least 3 staff members – someone to perform sedation, someone to perform procedure, someone to monitor the patient
• Department must be safe – Senior ED Clinician in charge (Consultant of Senior Registrar when Consultant not present in department has final say over if it is appropriate to perform at any given time.

Where should it be performed?

• ED resus
• Full monitoring – 3 lead ECG, sats probe, BP cuff, CO2 monitoring

Indications

• Child >1 years old
• Procedures such as:
  • Reducing fractures
  • Suturing
  • Removal of foreign body
  • Chest drain placement

Contraindications

• Any patient who requires to go to theatre for management of their condition
• Any risk of difficult airway eg. abnormal airway anatomy
• Allergy/serious adverse reaction to ketamine
• Reduced GCS
• Procedure in mouth or throat
• Significant medical problems including:
  • Active respiratory infection/active acute asthma (high risk of laryngospasm)
  • Obstructive sleep apnoea
  • Moderate to severe gastro-oesophageal reflux disease
  • Psychological problems eg. severe behavioural or cognitive impairment or previous psychosis
  • Poorly controlled epilepsy
  • Significant cardiac disease
  • Pulmonary hypertension
  • Chronic Intracranial pathology
  • Intraocular pathology
  • Bowel obstruction
  • Hyperthyroidism
  • Porphyria

Fasting

• For an emergency procedure in a child or young person who has not fasted, balance the risks and benefits of the decision to proceed with sedation before fasting criteria are achieved, on the urgency of the procedure and the target depth of sedation. Consider discussing this child with an anaesthetist.
• Apply the 2-4-6 fasting rule for ketamine sedation in the ED if safe and appropriate for the procedure to wait for this:
  • 2 hours for clear fluids
  • 4 hours for breast milk
  • 6 hours for solids and formula milk

Consent

• Parent and child (if appropriate) should be consented appropriately
• Risks and benefits along with potential side effects should be explained
  • Mild side effects
    • Mild agitation (20%)
    • Hypersalivation and lacrimation (<10%)
    • Involuntary movements / ataxia (5%)
    • Vomiting 5-10% of children will vomit in recovery period
      • Can give ondansetron (0.1mg/kg) in intractable vomiting
    • Transient rash 10%

• • More serious complications
    • Apnoea (0.3%) – Give IV ketamine slowly over 1 minute to avoid this
    • Airway misalignment/noisy breathing (<1%) -Basic airway manoeuvres usually enough to resolve this
    • Laryngospasm (0.3%)
      • Basic airway manoeuvres
      • BVM if needed
      • Ask for help early
      • May require RSI (rarely 0.02%)
    • Emergence Phenomena (1.6% <10 years old, commoner as gets older)
      • • Calm environment before procedure and as awakening
        • In very severe cases can give benzodiazepines (eg. 0.05-0.1mg/kg midazolam)

Ketamine dose

• 1mg/kg – give over 1 minute
• Supplemental dose (eg. in longer procedure if needed) – 0.5mg/kg
• Initial dose and potential supplemental dose should be drawn up into separate syringes to minimise error
• Calculate doses of emergency drugs that may be needed and ensure access to them
• Speed of action of ketamine
  • Clinical onset (approximately) 1 minute
  • Effective sedation 10-20 minutes
  • Time to discharge (average) 90 minutes

Post sedation care

• Observe for 1-2 hours until:

• • Conscious and responding appropriately
  • Nystagmus resolved
  • Able to walk unassisted (older children)
  • Vital signs are within normal limits
  • Respiratory status not compromised
  • Pain and discomfort addressed
• No food or drink for 2 hours after discharge (risk of nausea and vomiting)
• Supervise child closely for 24 hours (risk of ataxia and falls), no driving for older children
• Give advice leaflet to parents/carer
• Ensure that sedation documented on EPR and sign for ketamine in CD book and on EPR