Ketamine for conscious sedation in peds in the ED

Pedi-ER-RN, RN · Aug 11, 2006

I didn't say that I loved the administration of ketamine, but it is usually the MD's drug of choice. I personally like versed and fentanyl. We as nurses DO NOT administer ketamine by any route. We are there to monitor the patient during the procedure.

nanb · Aug 11, 2006

Thank you all for your reply's. Boy, Ketamine is really a hot topic!!!!:angryfire

passgasser · Aug 11, 2006

Sorry, it isn't my intent to turn your question into a "hot topic." But what I am telling you isn't just my opinion. It is also the official position of the American Association of Nurse Anesthetists, as well as the American Society of Anesthesiologists, and not because we want "the money." We take this position strictly from the position of what is best and safest for the patient. Personally, though I am frequently troubled by what folks don't know about these drugs, I am far more troubled, even frightened, by the fact that folks don't even know what they don't know, and don't want to be educated by the folks who do know.

I am not picking on anyone, but allow me to use a few posters remarks to show you what I mean. Both Pedi-ER-RN and NurseErica alluded to some bad reactions kids could have, particularly when "coming out" from under ketamine. Well, there's a pretty good reason for this. Ketamine is a chemical relative of PCP, and as such it can be a powerful hallucinogenic agent (think short acting LSD). It can cause some benign hallucinations, but it also has the ability to cause some that are pretty terrifying (think bad LSD trip). That's why both of these nurses see these kinds of "fighting" reactions to the drug. So, if a child is having a "bad trip," perhaps it might not be the best drug to "re-dose" to counteract this reaction. You could easily only prolong and perhaps intensify what is already a terrifying experience. (By the way, what NurseErica tells you about keeping stimuli down to reduce the hallucinations is true. It's also used as one line of treatment for a person on a bad LSD trip. Maybe you don't want to do this to a three year old.)

Tridil2000 related the following experience: "once, we had a mentally challenged adult who fell and hit his head. we could not get a line in him and we needed to ct his head. he was wild! we used ketamine im on him and got out ct."

Were I called as an anesthesia provider to do deep sedation for such a patient, ketamine is the last drug I would choose. I wouldn't even bring it with me. First of all, imagine this same, combative patient, having frightening hallucinations. A bad situation just got worse. But there is an even better reason not to use this drug in this case. Go back to the post of janfrn, and look at Adverse Reactions/Side Effects, particularly the CNS section. Ketamine elevates intracranial pressure. Whatever you might be looking for on a head CT, I can't think of any cranial pathology that cannot be worsened by elevating the ICP. Every anesthesia provider knows this, and knows that for any suspected head pathology, ketamine is contraindicated.

Also consider this. Most procedures for which this drug is used in the ER are for the correction of traumatic injuries. Having worked as an ER staff nurse, I feel confident saying that nobody comes to the ER adequately meeting the 8 hour NPO criteria for general anesthesia. Hence, as an anesthesia provider, if I had to pass the point of conscious sedation for a procedure, my next option would be a rapid sequence induction of general anesthesia with an intubation (and I just might go straight to that). Why? The patient must be presumed to have a full stomach (unlikely that the patient was completely NPO for 8 hours before the injury, and has been in a state of slowed or halted gastric motility since the injury.) Again, I refer you to the post of janfrn. Look at the GI side effects, and see that the drug can cause nausea and vomiting. Also look at the respiratory effect. What it does effectively do is blunt the protective airway reflexes. So, you have a patient with a full (or partially full) stomach, and your doc wants to give them a drug that blunts the airway reflexes and can cause vomiting. Now, suppose a 14 year old patient came in with a dislocated shoulder. Painful, and in need of treatment, but not life threatening. You, at your doc's orders, give the patient an appropriate dose of ketamine to reduce the shoulder dislocation. During the reduction, the patient vomits and aspirates. If you are lucky, you just gave that kid a trip to the ICU to be ventilated while his/her lungs heal. If you are unlucky, you are sending that kid to the morgue. All because your doc "likes" this drug. Is it really worth it?

If you are determined to pursue this course, I would first check with your state board of nursing to see if nurses in your state are permitted to administer anesthetic agents. If so, next I suggest you run the package insert from the ketamine (pharmacy will be happy to give it to you) by your risk management. Point out what it has to say about who should be administering the drug, and ask them if they are ok with it being ordered by an ER physician and administered by an ER staff RN. Make sure the hospital attorney is present for this meeting.

Really, I am not trying to make this into a "hot issue." I'm not belittling the abilities of ER RN's in the least. I was one, for goodness sakes. What I am trying to do is to make clear why both the AANA and the ASA believe that only trained and educated anesthesia providers should be giving these drugs. We not only know what the drug is supposed to do, we know what it can do, and why it can do it. When we give these drugs, we have, within arms reach, the tools, equipment, and medications to deal with the potential reactions. Not out in the hall, not down in the Pyxis machine, not in the room next door. In the room and within our reach.

EDValerieRN, ASN, RN · Aug 12, 2006

Sorry, it isn't my intent to turn your question into a "hot topic." But what I am telling you isn't just my opinion. It is also the official position of the American Association of Nurse Anesthetists, as well as the American Society of Anesthesiologists, and not because we want "the money." We take this position strictly from the position of what is best and safest for the patient. Personally, though I am frequently troubled by what folks don't know about these drugs, I am far more troubled, even frightened, by the fact that folks don't even know what they don't know, and don't want to be educated by the folks who do know.

I am not picking on anyone, but allow me to use a few posters remarks to show you what I mean. Both Pedi-ER-RN and NurseErica alluded to some bad reactions kids could have, particularly when "coming out" from under ketamine. Well, there's a pretty good reason for this. Ketamine is a chemical relative of PCP, and as such it can be a powerful hallucinogenic agent (think short acting LSD). It can cause some benign hallucinations, but it also has the ability to cause some that are pretty terrifying (think bad LSD trip). That's why both of these nurses see these kinds of "fighting" reactions to the drug. So, if a child is having a "bad trip," perhaps it might not be the best drug to "re-dose" to counteract this reaction. You could easily only prolong and perhaps intensify what is already a terrifying experience. (By the way, what NurseErica tells you about keeping stimuli down to reduce the hallucinations is true. It's also used as one line of treatment for a person on a bad LSD trip. Maybe you don't want to do this to a three year old.)

Tridil2000 related the following experience: "once, we had a mentally challenged adult who fell and hit his head. we could not get a line in him and we needed to ct his head. he was wild! we used ketamine im on him and got out ct."

Were I called as an anesthesia provider to do deep sedation for such a patient, ketamine is the last drug I would choose. I wouldn't even bring it with me. First of all, imagine this same, combative patient, having frightening hallucinations. A bad situation just got worse. But there is an even better reason not to use this drug in this case. Go back to the post of janfrn, and look at Adverse Reactions/Side Effects, particularly the CNS section. Ketamine elevates intracranial pressure. Whatever you might be looking for on a head CT, I can't think of any cranial pathology that cannot be worsened by elevating the ICP. Every anesthesia provider knows this, and knows that for any suspected head pathology, ketamine is contraindicated.

Also consider this. Most procedures for which this drug is used in the ER are for the correction of traumatic injuries. Having worked as an ER staff nurse, I feel confident saying that nobody comes to the ER adequately meeting the 8 hour NPO criteria for general anesthesia. Hence, as an anesthesia provider, if I had to pass the point of conscious sedation for a procedure, my next option would be a rapid sequence induction of general anesthesia with an intubation (and I just might go straight to that). Why? The patient must be presumed to have a full stomach (unlikely that the patient was completely NPO for 8 hours before the injury, and has been in a state of slowed or halted gastric motility since the injury.) Again, I refer you to the post of janfrn. Look at the GI side effects, and see that the drug can cause nausea and vomiting. Also look at the respiratory effect. What it does effectively do is blunt the protective airway reflexes. So, you have a patient with a full (or partially full) stomach, and your doc wants to give them a drug that blunts the airway reflexes and can cause vomiting. Now, suppose a 14 year old patient came in with a dislocated shoulder. Painful, and in need of treatment, but not life threatening. You, at your doc's orders, give the patient an appropriate dose of ketamine to reduce the shoulder dislocation. During the reduction, the patient vomits and aspirates. If you are lucky, you just gave that kid a trip to the ICU to be ventilated while his/her lungs heal. If you are unlucky, you are sending that kid to the morgue. All because your doc "likes" this drug. Is it really worth it?

If you are determined to pursue this course, I would first check with your state board of nursing to see if nurses in your state are permitted to administer anesthetic agents. If so, next I suggest you run the package insert from the ketamine (pharmacy will be happy to give it to you) by your risk management. Point out what it has to say about who should be administering the drug, and ask them if they are ok with it being ordered by an ER physician and administered by an ER staff RN. Make sure the hospital attorney is present for this meeting.

Really, I am not trying to make this into a "hot issue." I'm not belittling the abilities of ER RN's in the least. I was one, for goodness sakes. What I am trying to do is to make clear why both the AANA and the ASA believe that only trained and educated anesthesia providers should be giving these drugs. We not only know what the drug is supposed to do, we know what it can do, and why it can do it. When we give these drugs, we have, within arms reach, the tools, equipment, and medications to deal with the potential reactions. Not out in the hall, not down in the Pyxis machine, not in the room next door. In the room and within our reach.

Good info here. Thanks for the explanation.

Pediatric Critical Care Columnist · Aug 12, 2006

passgasser makes a lot of very good points. We use ketamine in our PICU for a number of things, most often for burn dressing changes. We seem to have runs on it, as in "the flavour of the month". The RN may give it (certification required), but there must be a physician present. All of our patients have airway maintenance equipment at the bedside: oral airways, suction, bag-valve-mask ventilation with the oxygen on and flowing, and there is always a physician or an RT with intubation skills available.

Personally :twocents: , I think there are perhaps better choices for procedural sedation than ketamine. Midazolam and fentanyl are a good combo, although with fentanyl there is a risk of chest wall rigidity and apnea which requires careful observation during and after infusion. I had an adolescent burn patient refuse ketamine; he said he'd rather endure the pain than the horrible "dreams". The conventional wisdom that children don't experience emergence reactions to the same degree as adults isn't much comfort when your patient is one ofthe exceptions! And with kids too, benzos don't offer protection from emergence reactions as they do for big people. Not my favourite drug.

Pediatric Critical Care Columnist · Aug 12, 2006

There was a story in the paper today about a study that used ketamine for treatment of severe depression. It was a small study, only 18 patients, and the finding was that a single dose of ketamine produced striking improvements in mood for most of the participants. Some of them responded immediately, and many had a long interval of improvement. Here's the NIH's press release:

http://www.nih.gov/news/pr/aug2006/nimh-07b.htm

fgoff · Aug 13, 2006

Nanb, has this been discussed with the pharacist in your hospital, they can be an excellent source of training material.

errn1968 · Aug 13, 2006

We use Ketamine for our ortho reductions, complicated lacs as well, but our docs who have to be certified in Ketamine administration only give it. We always give it with a combination of Robinal (to decrease oral secretions and dry them up) and Versed (to decrease emergence problems) and then give the ketamine. The RN gives the first two, But the MDs have to push the Ketamine and stay for the entire procedure. Ketamine admin is outside the scope of practice for an RN. Also, we wait a 6 hr npo period before they will give this mixture and absolutely... airway, suction, full monitor on and at the bedside. The ER MD will sometimes redose the Ketamine during the procedure if the patient is complaining of pain up to 3 doses. But the Robinal and Versed are the one time initial dose.

JazzyRN · Aug 13, 2006

I use and give Ketamine in the PICU. I personally have never seen a bad outcome from giving the drug to any peds patient. The only side effect Ive seen is hallucinations or I notice these kids and babies like to hold their hands in front of their face and move them back and forth, it amuses them for quite some time. We always give Ketamine with Robinul as well and versed. Ive had the drug used for sedation in I&Ds, dressing changes, burn care. Also with those difficult to sedate peds pts, that arent responding to their morphine/fentanyl/versed gtts, we will sometimes(but rarely) start a ketamine gtt. Now the new thing is that neurosurg wants all their post op spinal fusion pts on morphine PCA and Ketamine gtt postop day1. Which is not in practice yet but in hot debate there now and I dont know that I necessarily agree with. With using it in the PICU, I dont see a problem with it. I would consider its use under the direct supervision of a physician, physicians and nurses that are both used to managing airways, and therefore within my scope of practice.

nanb · Aug 14, 2006

Again, to all of you, a hugh thank you. Passgasser, you are not stirring up the pot, you're giving me crucial information I need to know and I'm so appreciative. My MD has given me numerous articles on the effectiveness of the drug in Ped's, but it's been administered by the physician. We are getting our hospital attorney involved and I and my manager don't want ANY of our nurses administering drugs out of our scope of practice. I'll keep you informed as to what the atty says. By the way, I'm in the state of CT. Where are all of you from?

passgasser · Aug 15, 2006

I'm glad I haven't offended. I've been berated for my position on this topic (administration of anesthetic agents by non-anesthesia qualified nurses) many times.

Just to be clear, I've talked with attorneys familiar with health care civil law before. They all seem to be in agreement. If there is a bad outcome, a minimially competent plaintiff's attorney will introduce the package insert as evidence in any lawsuit. With a package insert that plainly states that the drug must be given by a competent anesthesia provider, it probably won't matter what hospital policy, or really even the state board has to say on the topic. The people who make the drug are saying it can only be safely administered by those who make a living doing anesthesia. You (or the hospital) would lose such a case.

Added: The manufacturer puts that statement in the package insert for their own protection from liability. If there is a bad outcome, and the mfg is sued as well, all they have to do is say "look, these people didn't even follow our recommendations for how this drug should be administered." At that point, they are off the hook, and your hospital, and possibly the nurse who administered the drug, might as well sign blank checks and hand them over to the plaintiff.

**canoehead, BSN, RN** · Aug 15, 2006

So in the case of a child needing moderate sedation what are your best choices in the ER. Assume you have an RN administering the med with MD doing the procedure.