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Procedural Skills (SLO6)
Question 34 of 127
You have been asked to assist in performing a ketamine sedation for a child who requires suturing to a large laceration on her right thigh. Which of the following is a contraindication to paediatric ketamine sedation?
Answer:
Ketamine should not be used for sedation in the Emergency Department for children under the age of 1 year (increased risk of airway complications). Ketamine should be only be used by clinicians with significant relevant experience in the use of ketamine when performing procedural sedation in children aged between 2-5 years.Paediatric Ketamine Sedation
Pain & Sedation / Procedural Skills (SLO6)
Last Updated: 6th June 2023
Pharmacology
Ketamine is a phencyclidine (PCP) derivative that acts as a dissociative sedative through antagonism of the N-methyl-D-aspartate (NMDA) receptor. It has anxiolytic, analgesic, amnesic and dissociative properties with a wide safety margin.
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 relatively stable - BP and HR increase slightly
- Nystagmus is typical, usually horizontal
Timings of ketamine sedation:
- Clinical onset: 1 minute
- Effective sedation: 10 - 20 minutes
- Time to discharge: 90 minutes
Indications
Ketamine can be used for procedural sedation in children over 12 months of age 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. It can be used in combination with local anaesthetic techniques. Before ketamine procedural sedation is used all other options should be fully considered, including analgesia, reassurance, distraction, nitrous oxide/ Entonox®, intranasal diamorphine, and play therapy.
Ketamine should not be used for sedation in the Emergency Department for children under the age of 1 year (increased risk of airway complications). Ketamine should only be used by clinicians with significant relevant experience in the use of ketamine when performing procedural sedation in children aged between 2-5 years.
Examples of potential procedures where ketamine may be used:
- Wound exploration/irrigation
- Foreign body removal
- Suturing
- Fracture or joint reduction/manipulation
- Burn management
- Incision and drainage of abscess
- Tube thoracostomy placement
Contraindications
- Age < 12 months
- Pulmonary hypertension
- High risk of laryngospasm
- Unstable or abnormal airway (tracheal stenosis or surgery)
- Active upper or lower respiratory tract infection
- Proposed procedure within the mouth or pharynx
- 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
- Intraocular pathology (glaucoma, penetrating injury)
- Previous psychotic illness
- Uncontrolled epilepsy
- Hyperthyroidism or thyroid medication
- Porphyria
- Prior adverse reaction to ketamine
- Altered conscious level due to acute illness or injury
- Drug/alcohol intoxication
Side effects
- Mild agitation (20%)
- Moderate/severe agitation (1.5%)
- Hypersalivation and lacrimation (<10%)
- Involuntary movements/ataxia (5%)
- Vomiting (5-10%)
- Transient rash (10%)
- Airway problems (<1%)
Most of the above self-resolve and require observation only.
Complications
- Apnoea (0.3%)
- This can occur after rapid IV bolusing of ketamine but is rare (0.3%). Airway repositioning or brief bag-valve-mask ventilation has been occasionally required. IV administration over 60 seconds eliminates this problem.
- Airway misalignment/noisy breathing (<1%)
- Basic airway repositioning is usually sufficient to resolve this uncommon event. So called ‘ketamine breathing’, deep sighing respirations, can be misinterpreted as stridor, and again is minimised with correct head positioning.
- Laryngospasm (0.3%)
- The reported incidence of intubation of laryngospasm is 0.02%. The risk appears higher in children who undergo stimulation of the posterior pharynx, or who have active respiratory disease (e.g. URTI); which are therefore contraindications to ketamine procedural sedation in the ED. Again, airway and patient positioning and occasional bag-valve-mask ventilation will usually suffice.
- Management of laryngospasm
- If the child develops stridor attempt airway repositioning, gently try suctioning and secretions and apply a high flow oxygen mask with reservoir bag.
- If the child is saturating appropriately continue the procedure.
- If the stridor gets worse or the child starts desaturating let the child breathe oxygen via a bag-valve-mask. Stop the procedure. Ask for Help.
- If de-saturation reaches below 92% start gentle bag-valve-mask ventilation.
- Apply PEEP, if necessary. Prepare for RSI.
- If the stridor worsens further, seek help and prepare relevant anaesthetic
agent (e.g. suxamethonium) and proceed to RSI.
- Emergence phenomena
- Ketamine is known to induce agitation and hallucinations in both adults and children as the dissociative effects wear off. In children under 10 years, it is still uncommon (1.6%), but is more common beyond mid adolescence (can affect up to 1 in 3 adults). This can be reduced by positive psychology prior to drug administration (‘have a happy dream’) and can be mitigated with benzodiazepines on occurrence in the recovery period, however prophylactic administration is NOT necessary. If the patient is suffering severe emergency reactions and is significantly distressed then small increments of midazolam may be given in doses of 0.05-0.1mg/kg.
- Intractable vomiting
- If intractable vomiting occurs post procedure, consider use of IV ondansetron in a dose of 0.1mg/kg (maximum of 4mg) by slow intravenous injection.
Procedure
- Pre-sedation assessment should include comorbidities, regular and acute medications, allergies, details of previous sedation and anaesthesia (including any associated problems) as well as ASA
grade. This assessment should be formally documented. - The fasting state of the child should be considered in relation to the urgency of the procedure and the child’s comorbidity but recent food intake should not be considered as a contraindication to ketamine use.
- At least three dedicated staff are required for the duration of the procedure:
- a doctor to manage the sedation and airway,
- a clinician to perform the procedure
- an experienced nurse to monitor and support the patient, family and clinical staff.
- Ketamine procedural sedation should be only used by clinicians experienced in its use and capable of managing any complications, particularly airway obstruction, apnoea and laryngospasm.
- The child should be managed in high dependency or resuscitation area with immediate access to full resuscitation facilities. Monitoring should include sedation level, pain, ECG, blood pressure, respiration and pulse oximetry and capnography. Observations should be regularly taken and recorded (every 5 minutes).
- Supplemental oxygen should be given prior to and during the procedure (recognising that on occasion the procedure (facial suturing) may prevent the use of an oxygen mask during the procedure. However, it should be recognised that there is clear evidence for the safety of using ‘room air’ only during ketamine in procedural sedation.
- Where time permits, topical anaesthesia (EMLA®, Ametop®, etc.) should be used to reduce the pain of intravenous cannulation.
- Draw up ketamine dose. Calculate key resuscitation drugs and ensure they are readily available. Encourage the child and parents to talk (dream) about happy topics. This helps minimise unpleasant emergence phenomena. Parents should be encouraged to stay with the child until sedation is achieved and whilst the child is recovering.
- The literature recommends a dose of ketamine of 1.0 mg/kg by slow intravenous injection over at least one minute (more rapid administration is associated with respiratory depression). Successful sedation for short procedures can be achieved with lower doses such as 0.6-0.8 mg/kg. Supplemental doses of 0.5mg/kg by slow IV injection, may be required after 5-10 minutes to achieve the required dissociative state.
- The effects of ketamine are usually evident 1-2 minutes after administration. Painful procedures should not be initiated until 2 minutes after ketamine has been administered. 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.
- After the procedure the child should recover in a quiet, observed and monitored area under the continuous observation of a trained member of staff. Monitoring may be removed once the sedating doctor is satisfied that vital signs are within normal limits for that child.
- Recovery should be complete between 60 and 120 minutes, depending on the dose used. The child can be safely discharged once they are at pre-sedation levels:
- 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
- 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. The risk of ataxia may persist and lead to an increased risk of falls (in older children they should not drive for at least 24 hours).
- The medical record and local audit documentation should be completed. All adverse events should be documented and reviewed and if appropriate reported as a clinical incident.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
