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 CAHS clinical disclaimer.
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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.
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Aim
To guide PCH Emergency Department (ED) staff in the use of ketamine procedural sedation in PCH ED.
*This guideline does not pertain to the use of ketamine for chemical restraint or management of behaviourally disturbed patients.
Key points
- Note: the doses quoted in this guideline are starting doses only and will achieve disassociation safely. More experienced clinicians may alter the dose based on clinical situation and the type of procedure being performed.
- IM administration: the actual overall length of stay in ED when IM ketamine is used is similar to IV administration despite the shorter duration of sedation resulting from the IV route.
- No need for a darkened, quiet room.
Pre-Procedure
- Only credentialled doctors can perform ketamine sedation at PCH ED following the successful completion of the ketamine learning modules, the quiz and observed ketamine sedations.
- Ketamine sedation cannot proceed until it is approved by the ED Consultant and Nurse Coordinator regarding staff availability and acuity of the Emergency Department.
- Recovery will occur in ED Short Stay Unit (ESSU) - request an ESSU bed as early as possible.
General3
Ketamine causes a dissociative anaesthesia to provide anxiolysis, amnesia and analgesia in order to perform procedures. The analgesic properties of ketamine persist well beyond the dissociative properties and protect against the development of neuropathic and/or chronic pain states.
- 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) and 5-minutely blood pressure measurement.
- Requires two doctors: airway / sedation doctor and procedure doctor.
- A patient having undergone sedation with ketamine will be monitored by a nurse at minimum until they have met discharge led criteria or assessed and cleared by a medical practitioner.
Indications
Ketamine is suitable for procedures that may be painful but short (procedure time less than 20 minutes) and require co-operation / stillness of the patient.
Suitable patients
- Patients aged over 12 months.
- Parent / carer informed consent is required.
- Patient is otherwise clinically well.
Examples of suitable procedures
- Closed manipulation of fracture
- Suturing of lacerations
- Removal of foreign body (from ear / nose / soft tissues)
- Aspiration of knee joint
Contraindications1,4
- 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
- Hyperthyroidism or thyroid replacement therapy.
- Porphyria
Precautions
- 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 (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).
- Commence the Procedural Sedation Record (MR301.07).
Staff required
Doctor 1 – credentialled ketamine doctor (airway / sedation doctor)
- Obtain and document informed consent from the legal guardian.
- Prescribe, check and administer sedation.
- Monitor and manage the patient during sedation.
- Complete the procedural sedation chart.
Doctor 2 – ED or subspecialty doctor (procedure doctor)
- To obtain consent and perform procedure.
Nurse (RN)
- Administer (IM only)
- Document medications on the Procedural Sedation Record (MR301.07).
- Monitor patient throughout procedure and recovery and document observations on the Procedural Sedation Record (MR301.07).
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
Intramuscular (IM) Ketamine
- Staff administering dose: nurse (RN)
- Initial dose: ketamine 4 mg/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 2 mg/kg.2
- Onset and duration: approximately 5 minutes until peak effect, dissociative state lasts for 15-30 minutes. Recovery is gradual and varies from patient to patient (note: this is derived from adult pharmacokinetic data)3.
Intravenous (IV) Ketamine
- Initial dose: Ketamine 1-1.5 mg/kg over 60 seconds immediately before the procedure.2
- Use ketamine 200 mg/2 mL ampoule. Add 100 mg (1 mL) of ketamine to 9 mL of sodium chloride 0.9%. This results in a ketamine solution with a concentration of 10 mg/mL.
- Top-up sedation: give further doses of IV ketamine 0.5 mg/kg every 10 minutes2 as required to achieve adequate sedation or prolonged effect.
- Onset and duration: peak effect around 1-2 minutes, dissociative state for around 5-10 minutes. Recovery is gradual and can vary from patient to patient (note: this is derived from adult pharmacokinetic data)3.
Oxygen
- Oxygen should be delivered prior and during the entire procedure.
- PCH ED stocks nasal prong cannulae which concurrently facilitate EtCO2 measurement.
Adjunctive medications
- The routine use of atropine or glycopyrrolate to manage secretions is not supported by robust evidence and not standard of practice in our institution.
- Ondansetron may be considered prophylactically as ketamine can be emetogenic. Consider if there are other post-sedation nausea and vomiting risk factors.
- Female sex
- Post menarchal
- History of post operative nausea and vomiting
- Sub-optimal fasting status
- Rapid sequence intubation medication – emergency plan for management of laryngospasm.
- Consider proximity / availability of induction agent and muscle relaxant.
Post-Procedure
Complications
Doctor 1 – credentialled ketamine doctor (airway / sedation doctor)
Assess for and document any adverse events
4:
- Airway obstruction – laryngospasm
- Vomiting (during or after procedure)
- Emergency dysphoria
- Apnoea
- Nystagmus
- Muscle rigidity
- Random movements (can resemble seizure-like activity)
- Failed procedure (need for a General Anaesthesia)
Aftercare
- Ensure no restriction of chest movement or airway with any restraining devices.
Monitoring
- Baseline: Complete and record a full set of observations on the Observation and Response Tool, record additional information on the Clinical Comments chart.
- Also record a full set of observations on the Procedural Sedation Record (MR 301.07).
- During procedure:
- Maintain continuous pulse oximetry and electrocardiogram (ECG) rhythm.
- EtCO2 should be monitored throughout the period of induction and dissociation.
- PCH ED stock nasal cannulae to provide low flow nasal oxygen during ketamine sedation which concurrently measure EtCO2.
- 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 ESSU 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.
- Note: Criteria Led Discharge paperwork is available in ESSU.
On discharge
- Provide parent with Ketamine sedation - Health Facts Sheet.
- Ensure appropriate follow-up arranged e.g. fracture clinic, letter to general practitioner, discharge summary.
References
- AMH (online). Ketamine. Adelaide: Australian Medicines Handbook Pty Ltd; Accessed March 2024
- AMH Children’s Dosing Companion (online). Ketamine. Adelaide: Australian Medicines Handbook Pty Ltd; Accessed August 2019 from: https://childrens.amh.net.au
- Clinical Pharmacology. Ketamine. Anaesthesia and neuromuscular block. Intravenous anaesthetics.Pharmacokinetics. Nolan, Jerry P.. Published December 31, 2018. © 2019
- MIMS ONLINE. Ketamine. MIMS Australia. Accessed August 2019
- 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
- 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
- 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
- Priestley SJ, Taylor J, McAdam CM et al. Ketamine sedation for children in the emergency department. Paediatric Emergency Medicine.2001; 13: 82‐90.
- American College of Emergency Physicians. Clinical policy for Procedural Sedation and Analgesia in the Emergency Department. Annals of Emergency Medicine. 2014;63:247-258
- Pediatric Committee of the American College of Emergency Physicians. Pediatric analgesia and Sedation. Annals of Emergency Medicine. 1994;23: 237‐50.
- 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.
- Australian College of Emergency Medicine. Use of intravenous sedation for procedures in the emergency department. Emergency Medicine. 1998; 10: 63‐4
| Endorsed by: |
Drug and Therapeutics Committee
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Date: |
Apr 2024 |
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Last reviewed: 21-10-2019
Last updated: 22-04-2024