Paediatric Procedural Sedation with IV Ketamine SOP – RHCG ED

Ketamine is a dissociative anaesthetic agent. Ketamine acts by binding to N-methyl-D-aspartate (NMDA) receptors and creates dissociation (disconnection) between the cortex and the limbic system and prevents the higher centres from perceiving visual, auditory or painful stimuli.

Ketamine produces a dissociative state characterised by profound analgesia, sedation, amnesia and immobilization. Protective airway reflexes and spontaneous respiration as well as cardiovascular stability are maintained.

Characteristics of ketamine dissociative state:

• Dissociation - the patient passes into a trance like state with the eyes open but not responding
• Catalepsy - normal or slightly increased muscle tone is maintained.
• Analgesia - excellent analgesia is typical
• Amnesia is usually total
• Airway reflexes are maintained.
• Cardiovascular state - blood pressure and heart rate tend to increase slightly.
• Nystagmus is a not uncommon and resolves spontaneously during recovery

• There is no reversal agent for ketamine
• Ketamine should be given as a slow IV push over 1 minute, to avoid transient respiratory depression/apnoea.
• Ketamine should be diluted with 0.9% NaCl to facilitate slower IV bolus (e.g. dilute 1mg/kg ketamine dose into 10mls total volume for injection)
• Initial IV Ketamine dose is 1mg/kg
• Maximum of 2 ‘top-up’ doses in the ED – if further doses required the appropriateness of the procedure should be reviewed and anaesthetic referral for GA should be considered
• Concurrent dose of IV ONDANSETRON should be administered.

Pre-sedation

Complete sedation checklist prior to procedure in all patients – meets criteria as above and possible contraindications assessed.

Analgesia

• Ensure adequate analgesia is given prior to procedure

Minimum staff required - Depending on the procedure taking place additional medical or nursing staff may be required

• Only CLINICIANS COMPETENT IN IV KETAMINE FOR SEDATION may prescribe and administer IV ketamine for emergency procedural sedation.

• Sedating doctor - Prescribe, check and administer IV ketamine sedation; monitor and manage patient during sedation (trained in ketamine sedation and APLS certified).
• Procedure doctor (ED or subspecialty doctor e.g. orthopaedics) – obtain consent and perform the procedure.
• Emergency Department (ED) Nurse – check IV ketamine with Sedating doctor, attach monitoring to patient, complete monitoring observations and chart throughout procedure, recover patient post-procedure. This nurse should be PLS/APLS certified
• Sedating doctor and ED nurse must be available to stay with the patient until patient rousable and fit for transfer out of sedation area (obeying commands/rousable [age appropriate] with normal observations).

Consent

• Informed consent must be obtained from the parent or legal guardian of the child before proceeding with any drug administration. Consent should be obtained by the sedating doctor.
• Consent should include an explanation of sedation, the procedure and any associated risks.

Location

• Emergency procedural sedation should only be carried out in an area where monitoring/emergency equipment as identified below is available and a quiet low light environment can be facilitated. For RHC ED this is either one of the resus bays or one of the procedure rooms.

Equipment

All equipment must be checked and readily available prior to commencing emergency procedural sedation.

• Emergency equipment – bag/valve/mask & t-piece anaesthetic circuit should be ready to use with appropriate size mask for the child, non-rebreathe oxygen mask attached to oxygen source, Yankauer suction catheter should be attached to working suction, emergency airway trolley should be set up with working laryngoscope, appropriate size ETT selected and introducers available.

Monitoring

• All patients should have – ECG, pulse oximetry, blood pressure and non-invasive nasal cannulae capnography monitoring throughout the procedure and during the post-procedure recovery.
• All patients must have a full set of baseline observations documented within the 15 minutes PRIOR to commencing emergency procedural sedation.
• During the procedure, monitoring should be documented on the age appropriate PEWS chart.
• Observations should be recorded at 5 minutely intervals during the procedure and post-procedure until patient has fully recovered.

Documentation – procedure and sedation should be completed in Ketamine sedation proforma.

• The Ketamine sedation proforma including the pre-procedure checklist should be completed for all procedures.
• Any side effects or adverse events should be documented in the Ketamine sedation proforma and TrakCare sedation record should be completed.
• Instructions on completion TrakCare sedation record:
  • Open patient clinical record and open questionnaires tab.
  • Click new and search for ‘sedation’ in questionnaire description box.
  • Open Sedation(EM) form and complete.
  • Staff 1 – Sedating doctor. Staff 2 – Procedural doctor.
  • Under ‘Analgesia’, if patient given intranasal diamorphine then select ‘other’.
  • For ‘Maximum depth of sedation’ please note with a dissociative sedating agent such as Ketamine the procedure should only commence if the patient has achieved one of the following levels of sedation:
    • Response only after painful trapezius squeeze
    • No response after painful trapezius squeeze.
  • ‘Time fit for discharge’ is the time the patient is fit from discharge from the sedation area NOT discharge from ED or discharge home time.
• CLICK ‘UPDATE’ then ‘PRINT’. This printed record should be added to the patient clinical notes.

Post-procedure

• Continuous monitoring with ECG, pulse oximetry, blood pressure and non-invasive nasal cannulae capnography recorded every 5 minutes.
• Observations should be documented every 5 minutes until rousable
• The patient is fit for transfer from sedation area once consistently obeying commands/rousable (age appropriate) with normal observations and the sedation doctor is happy for transfer.
• Ideally patient should be recovered in a quiet low light environment to help reduce the likelihood of emergence phenomena.
• Patient should remain nil by mouth until fully alert.
• Once rousable, continue routine post-operative including any additional observations as appropriate e.g. neurovascular observations, GCS.

Discharge from the Emergency Department

• All patients who undergo emergency procedural sedation in the Emergency Department should be assessed for admission requirement under relevant hospital subspecialty.

• Criteria for transfer to ward – normal observations, alert, no nystagmus. Purposeful movement, can sit without support, can walk if age and clinical condition appropriate (may require assistance). Verbalises appropriately for age. Tolerates oral fluids. No vomiting.
• Criteria for discharge when post-procedure management allows discharge home (either from ED or CDU) - Fully alert, able to walk unassisted (if applicable), tolerating oral fluids, stable observations, adequate analgesia, Parent / carer leaflet given, Parental / carer happy for discharge home.