Paediatric Procedural Sedation with IV Ketamine SOP – RHCG ED

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Audience

***ONLY FOR USE BY CLINICIANS COMPETENT IN IV KETAMINE SEDATION***

The use of IV Ketamine for Paediatric Procedural Sedation within RHC ED is at the discretion of the ED consultant and ED nurse co-ordinator.  Appropriate case selection and clinical demands of the rest of the department may influence the availability of this service.

 

This SOP for IV Ketamine use in Procedural sedation can be adapted for use out with the Emergency Department however Minimum staffing , monitoring & equipment instructions should be replicated in the location the procedural sedation is being performed.

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

During the COVID period the use of PPE for procedural sedation should follow the most up to date guidance released by Health Protection Scotland (HPS) with specific attention made to management for suspected/proven COVID positive versus non-COVID patients.

Warning – interventions required to manage adverse reactions may result in aerosol generation procedures (ie – suctioning or positive pressure ventilation).  PPE appropriate for these interventions should be used.

 

Indications for use

  • The decision to use IV ketamine sedation is that of the emergency department consultant and nurse in charge.
  • Children aged 12 months and over
  • Short painful procedure (ideally less than 20 minutes duration) e.g. fracture reduction / wound repair.

STRICT contraindications

  • Procedures that will stimulate the posterior pharynx / intraoral procedures.
  • Glaucoma or acute globe injury

Use Ketamine sedation with added caution in these situations:

  • Children aged 12-24 months
  • Airway assessment concerns identified (see airway assessment section below for details).
  • Food within 2 hours
  • Cardiovascular disease
  • Poorly controlled seizure disorder
  • Psychosis, porphyria
  • Thyroid disease
  • CNS or neuromuscular disorders
  • Head injury with LOC, altered consciousness or vomiting
  • Respiratory tract infection or lung disease
  • Children with complex medical conditions
  • History of previous airway surgery or congenital abnormality

Airway Assessment

Modified ‘LEMON’ assessment:  any issues that may contribute to a difficult intubation?

L: Look for facial abnormalities / dysmorphism.

E: Evaluation of mouth opening, tongue size, oral cavity, tonsil size, jaw position (retrognathia)

M: Mallampati score if applicable (see below – if Class 3 or 4 then inform ED Consultant in charge)

O: Obstruction - any signs of upper airway obstruction, stridor, drooling, difficulty with secretions.

N: Neck - assess neck mobility (check for limited extension / disproportionally short neck).

Mallampati score:

If there are any concerns identified on initial airway assessment above then these MUST be discussed with ED consultant in charge as part of the sedation approval process.

KETAMINE

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
IV Ketamine administration
  • 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.

KETAMINE

Route of administration

Intravenous (IV)

Clinical onset

1 minute

Duration of effective sedation

15 minutes

Recovery

60 minutes

Initial dose

1mg/kg

Subsequent dose

0.25-0.5mg/kg

Maximum dose

2mg/kg

 

Ondansetron - to be given prior to initial ketamine dose.

Route of administration

Intravenous (IV)

Dose

0.1mg/kg (max 4mg dose) – given over 30 seconds.

Potential side-effects & management pathways for management

Potential side effect

Management

Airway malposition (<1%)

1.    Airway repositioning manoeuvres +/- airway adjuncts as required.

2.    If not resolved with above stop procedure and contact 84342 (anaesthetic on call) for assistance and prepare for rapid sequence intubation (RSI) with IV suxamethonium (2mg/kg) for paralysis. Continue airway and ventilation support efforts.

Laryngospasm (0.3% )
(Intubation for laryngospasm very rare – 0.02%) 

1.    Stop procedure.

2.    Airway repositioning manoeuvres +/- adjuncts as required.

3.    Direct suction of secretions using Yankauer suction catheter.

4.    Provide PEEP with 100% oxygen delivered via T-Piece anaesthetic circuit.

5.    If not resolved with above contact 84342 (anaesthetic on call) for assistance and prepare for rapid sequence intubation (RSI) with IV suxamethonium (2mg/kg) for paralysis. Continue airway and ventilation support efforts.

Hyper-salivation
(4.2% incidence requiring intervention)

1.    Direct suction of secretions using Yankauer suction catheter

2.    If persisting, stop procedure and administer IV atropine.

Respiratory depression, apnoea

1.    Stop procedure

2.    Provide ventilation via oxygen driven BVM / T-Piece anaesthetic circuit to prevent hypoxia.

Cardiovascular depression
(bradycardia – 0.5%, hypotension >0.01%)

 

1.    Stop procedure

3.    Direct suction of secretions if present using Yankauer suction catheter

4.    Administer IV atropine

5.    If persisting then administer 10ml/kg fluid bolus of 0.9%NaCl.

Emergence phenomena – transient psychotic effects, hallucinations, nightmares (more common beyond mid-adolescence)

1.    Reassurance for patient

2.    Administer IV midazolam (50 micrograms/kg IV increments) for severe episodes.

Nausea, vomiting
(may occur late in the recovery phase when the patient is already alert.)

1.    Optimise patient position to avoid any aspiration risk.

 

Seizures – extremely rare

1.    Stop procedure and follow APLS guidance for seizures

Allergy
(true allergy extremely rare, transient blanching flushed erythematous rash on torso is common and self resolving.)

2.    Stop procedure and follow APLS guidance for allergy/anaphylaxis.

Diplopia, nystagmus, random purposeless movements, muscle twitching and rash are common

No intervention required.

Adjunctive agents to consider in event of side effects / adverse events

Midazolam - for treatment of ‘emergence phenomena/agitation’

Route of administration

Intravenous (IV)

Dose

50 micrograms/kg (0.05mg/kg) – given over 2-3minutes. (Max 6mg dose)

 

Atropine – for treatment of hyper-salivation or bradycardia

Route of administration

Intravenous (IV)

Initial dose

 

20 micrograms/kg (0.02mg/kg) – given over 2-3minutes. (Max 3mg dose)

Drug action

Anti-muscarinic agent that:

  • Relaxes smooth muscles
  • Inhibits salivary and bronchial secretions
  • Increases heart rate and dilates pupils

 

SUXAMETHONIUM for paralysis in severe laryngospasm / airway compromise

Route of administration

Intravenous (IV)

Dose

2mg/kg

Drug action

Short acting neuromuscular blockade.

Paediatric Procedural Sedation process

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.
References

Green SM, Roback MG, Krauss B, Brown L, McGlone RG, Agrawal D, et al. Predictors of Airway and Respiratory Adverse Events With Ketamine Sedation in the Emergency Department: An Individual-Patient Data Meta-analysis of 8,282 Children. Ann Emerg Med. 2009;54(2)

Bhatt M, Johnson DW, Chan J, et al. Risk Factors for Adverse Events in Emergency Department Procedural Sedation for Children. JAMA Pediatr. 2017;171(10):957–964. 

Bhatt M, Johnson DW, Taljaard M, et al. Association of Preprocedural Fasting With Outcomes of Emergency Department Sedation in Children. JAMA Pediatr. 2018;172(7):678–685. 

Bellolio MF, Puls HA,Anderson JL, et al. Incidence of adverse events in paediatric procedural sedation in the emergency department: a systematic review and meta-analysis. BMJ Open 2016;6:e011384.

Langston WT, Wathen JE, Roback MG and Bajaj L.  Effect of Ondansetron on the Incidence of Vomiting Associated With Ketamine Sedation in Children: A Double-Blind, Randomized, Placebo-Controlled Trial. Annals of Emergency Medicine 2008 Jul; 52(1):30-34. 

Editorial Information

Last reviewed: 01 June 2021

Next review: 30 June 2024

Author(s): Dr Steve Foster (Consultant in Paediatric Emergency Medicine, RHC Glasgow) & Dr Michael McCarron (Paediatric Trainee, RHC Glasgow)

Co-Author(s): Stakeholders: Dr Tony Moores (Consultant Paediatric anaesthetist, RHC Glasgow); Mr Stephen Bowhay (Lead Clinical Pharmacist, RHC Glasgow).

Approved By: RHC ED Clinical governance subgroup