Ketamine sedation

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

Read the full PCH Emergency Department disclaimer.


High Risk Drug

Ketamine is a High Risk Medication. Please refer to the CAHS High Risk Policy (internal WA Health only) and the PCH Ketamine Monograph (internal WA Health only) for detailed medicine information.


Aim

To guide PCH ED staff in the use of ketamine sedation in PCH ED.

Note: the doses quoted in this guideline are starting doses only and will safely achieve disassociation. More experienced clinicians may alter the dose based on clinical situation and the type of procedure being performed.

Pre-Procedure

  • Only accredited doctors can perform ketamine sedation in PCH ED.
  • Ketamine sedation cannot proceed until confirmed with ED Consultant and Nurse Coordinator regarding staff availability and acuity of the Department.
  • If confirmed, commence and proceed through the Ketamine Clinical Pathway.
  • Request an ED Short Stay Unit bed as early as possible.

General1

Ketamine causes a dissociative anaesthesia to provide anxiolysis, amnesia and analgesia in order to perform procedures.
  • Procedures with ketamine should only be performed in the procedure room or resuscitation areas.
  • Procedures under ketamine sedation require close monitoring (continuous oxygen saturation measured by pulse oximetry [SpO2] monitoring until alert).
  • Requires two doctors: airway / ketamine doctor and procedure doctor.

Indications

Ketamine is suitable for procedures that may be painful but are short (procedure time less than 20 mins) and require co-operation / stillness of the patient.

Suitable patients

  • Patients aged over 12 months
  • Parent / carer consent
  • Otherwise clinically well.

Procedures that may be suitable are:

  • Closed manipulation of fracture
  • Suturing of lacerations
  • Removal of foreign body (from ear / nose / soft tissues)
  • Aspiration of knee joint.

Contraindications

  • Previous adverse reaction to ketamine or any components of the formulation
  • Altered conscious state
  • Unstable patient: seizures, vomiting, hypotension
  • Cardiovascular disease including heart failure, uncontrolled hypertension, congenital heart disease
  • Procedures involving stimulation of posterior pharynx, known airway instability, tracheal abnormality
  • Psychosis
  • Thyroid disorder or medication
  • Porphyria.

Relative contraindications

  • Risk of raised intraocular or intracranial pressure.
  • Active pulmonary infection or disease (including acute asthma and upper respiratory tract infection).
  • Full meal within 3 hours (relative contraindication only, balance risk against urgency of procedure).
  • Consider effects of recent sedating drugs and analgesics (morphine / fentanyl).
  • Acute intoxication e.g. alcohol, illicit or prescription drugs.

Preparation

Staff

  • Consider the need for specialist staff when timing the procedure (Surgical or Orthopaedic Registrar).

Staff required

Doctor 1 (accredited ketamine doctor) to: 

  • order, check and administer sedation 
  • monitor and manage patient during sedation
  • complete the procedural sedation chart
Doctor 2 (ED or subspecialty doctor) to obtain consent and perform procedure.

Nurse (RN) to: 
  • administer (IM only) and 
  • document medications
  • monitor patient throughout procedure and recovery and document observations

Equipment

  • All necessary equipment must be available (including equipment for the procedure itself and airway equipment) – consider this when a Surgical or subspecialty Registrar is undertaking the procedure.
  • Airway equipment: ensure suction, oxygen, bag and mask ventilation and full airway resuscitation trolley are available and all equipment is working.

Procedure

Medications

  • Ketamine can be given via the intramuscular (IM) route in children with difficult intravenous (IV) access.
  • When given via the IM route, IV access is not required.
  • IV Ketamine has a more predictable pharmacokinetic profile.
  • Consider dosing according to ideal body weight for overweight and obese children 2 to 18 years of age. Refer to Guidelines for Drug Dosing in Overweight and Obese Children 2 to 18 Years of Age (internal WA Health only).

Intramuscular (IM) Ketamine

  • Initial dose: ketamine 4mg/kg, five minutes before the procedure.2
  • Top-up sedation: if adequate sedation not achieved by 15 mins after initial dose, give a further dose of IM Ketamine 2mg/kg.2
  • Onset and duration: approximately 5 mins until peak effect, dissociative state lasts for 15-30 mins, and return of coherence and purposeful movement around 30-120 mins.

Intravenous (IV) Ketamine

  • Initial dose: Ketamine 1mg/kg over 60 seconds immediately before the procedure.2
  • Use ketamine 200mg/2mL ampoule. Add 100mg (1mL) of ketamine to 9mL of sodium chloride 0.9%. This results in a ketamine solution with a concentration of 10mg/mL.
  • Top-up sedation: give further doses of IV ketamine 0.5mg/kg every 10 minutes2 as required to achieve adequate sedation or prolonged effect.
  • Onset and duration: peak effect around 1-2 mins, dissociative state for around 10-15 mins and return of coherence and purposeful movement around 30 mins.

Post-Procedure

Complications

Doctor 1 (sedation): Assess for and document any adverse events4:
  • Airway obstruction
  • Nystagmus
  • Muscle rigidity
  • Random movements (can resemble seizure like activity)
  • Vomiting (during or after procedure)
  • Emergence phenomena
  • Apnoea
  • Failed procedure (need for a General Anaesthesia)

Aftercare

  • Ensure no restriction of chest movement or airway with any restraining devices.

Monitoring

  • Baseline: heart rate (HR), blood pressure (BP), respiratory rate (RR), oxygen saturations, sedation score documented on procedural sedation chart 
  • During procedure:  
    • Maintain continuous pulse oximetry and electrocardiogram (ECG) rhythm
    • Document pulse, respirations, blood pressure, oxygen saturation and sedation score: 
      • Initially 2 minutes post administration of ketamine
      • Then every 5 minutes until rousable - beware of possible decreased conscious state with cessation of noxious stimuli.
    • At the end of the procedure place the patient in the recovery position and move them to the ED Short Stay Unit if clinically appropriate. Discuss with ED Nurse Coordinator.
    • Once rousable, routine post-operative observations, as per local policy. 
Note: also include other observations as clinically indicated e.g. neurovascular observations for limb injury.

Discharge criteria

  • Normal vital signs, alert, no nystagmus.
  • Purposeful movement, can sit without support, can walk if age appropriate, with assistance if necessary (complete resolution of ataxia is not necessary).
  • Verbalises appropriately for age.
  • Tolerates oral fluids (no ongoing vomiting).
  • Accompanied by appropriate carer.

On discharge

Evidence points

  • IM administration: the actual overall length of stay in the ED is similar (despite shorter duration of sedation for the IV route).
  • No need for a darkened, quiet room.

References

  1. Green SM, Johnson NE. Ketamine sedation for Paediatric Procedures: Part 2, Review and Implications. Annals of Emergency Medicine. 1990; 19: 1033‐46.
  2. AMH Children’s Dosing Companion (online). Ketamine. Adelaide: Australian Medicines Handbook Pty Ltd; Accessed August 2019 from: https://childrens.amh.net.au
  3. AMH Children’s Dosing Companion (online). Atropine. Adelaide: Australian Medicines Handbook Pty Ltd; Accessed August 2019 from: https://childrens.amh.net.au
  4. MIMS ONLINE. Ketamine. MIMS Australia. Accessed August 2019

Bibliography

  1. Ramaswamy P, Babl FE, Deasy C, Sharwood LN. Pediatric procedural sedation with ketamine: time to discharge after intramuscular versus intravenous administration. Acad Emerg Med. 2009 Feb;16(2):101-7. PubMed PMID: 19076105
  2. Brown L, Christian-Kopp S, Sherwin TS, Khan A, Barcega B, Denmark TK, Moynihan JA, Kim GJ, Stewart G, Green SM. Adjunctive atropine is unnecessary during ketamine sedation in children. Acad Emerg Med. 2008 Apr;15(4):314-8. PubMed PMID: 18370983
  3. Heinz P, Geelhoed GC, Wee C, Pascoe EM. Is atropine needed with ketaminesedation? A prospective, randomised, double blind study. Emerg Med J. 2006 Mar;23(3):206-9. PubMed PMID: 16498158; PubMed Central PMCID: PMC2464444
  4. Priestley SJ, Taylor J, McAdam CM et al. Ketamine sedation for children in the emergency department. Paediatric Emergency Medicine.2001; 13: 82‐90.
  5. American College of Emergency Physicians. Clinical policy for Procedural Sedation and Analgesia in the Emergency Department. Annals of Emergency Medicine. 2014;63:247-258
  6. Pediatric Committee of the American College of Emergency Physicians. Pediatric analgesia and Sedation. Annals of Emergency Medicine. 1994;23: 237‐50.
  7. American Academy of Paediatrics, Committee on drugs. Guidelines for Monitoring and management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures. Pedaitrics;1992;89: 1110‐5.
  8. Australian College of Emergency Medicine. Use of intravenous sedation for procedures in the emergency department. Emergency Medicine. 1998; 10: 63‐4.

Reviewer/Team: ED Consultants, ED Clinical Nurse Specialist, Deputy Chief Pharmacist, Medication Safety Pharmacist, Senior Pharmacist
Last reviewed: Aug 2022


Review date: Sept 2019
Endorsed by:

Drug and Therapeutics Committee Date:  Sept 2019


This document can be made available in alternative formats on request for a person with a disability.


Last reviewed: 21-10-2019
Last updated: 15-11-2019

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