concious sedation

Jolie, BSN · May 22, 2005

Does anyone out there have experience in concious sedation for pediatric patients WITHOUT using IV access? We have a several docs who insist that starting an IV before sedation is counterproductive and they want to go with IM meds.
Specifically I have refused to give ketamine IM in a 3 year old without IV access, but they are referring to more than that specific med. I am used to EKG, sat and BP moniter, O2 and crash cart available and IV access BEFORE starting the procedure.

Wow! I have no experience in this, but it seems to defy logic! I can't imagine taking this risk with someone's child unless there were absolutely no alternative, such as multiple unsuccessful IV attempts. Isn't EMLA cream used prior to an IV start? If so, is it really all that traumatic? What procedures are to be done in these patients?

Trauma Columnist · May 22, 2005

Yes, we do conscious sedation in our facility (ER) without IV access. We utilize rectal meds, IM meds (only as last resort) and inhalation meds. Myself, I always look to see what they have venous-wise, but I don't sweat it. We don't use a lot of Ketamine either - mostly just rectal versed which works like a charm. We are a level one trauma center with appropriate resuscitation bedside (oxygen, BVM, intubation equipment, etc). We are also well-trained.

ERNURSE4MS · May 22, 2005

Moderate sedation(what Joint commision is calling concious sedation) at my facility requires 1: a doctor to fully assess the pt for entubation risks and prepare for an entubation( even though 99% are not entubated) 2: the nurse MUST either have an IV access or have the supplies present for an IV access- ( our ped are sometimes given an oral sedative prior to start of procedure) 3 : continuous BP, EKG, and O2 sat monitoring, and4: a nurse for and 1-2 hours post procedure to continually monitor sedation level. We don't give the heavy stuff IM or PO. Usually we do it all IV. Only the anethesia personel- CRNA or anesthesiologist- do anything different and they have protecols to cover it. Joint commision really honed in on moderate sedation last year and I got grilled by 1 of them and the Director of Emergency Services to see if the facility could improve our sedation practices. Hope this helps you.

mommatrauma, RN · May 22, 2005

We do it all the time..We use IM ketamine and both IM and rectal Brevital...We use them specifically so we don't have to put an IV in...We monitor them the same way we do any other conscious sedation...We've not had any problems with the exception of a transient pulse ox drop with the Brevital for which we increase O2 support and in my 5 years as an ER nurse I've never had an incident where I had to put an IV in while doing it because of any complications...Where I used to work, we always did IM ketamine. Where I work now we mostly use the Brevital simply because of the immersion nightmares in kids with the ketamine..and because of how fast onset and short acting it is...Good stuff!

mommatrauma, RN · May 22, 2005

Wow! I have no experience in this, but it seems to defy logic! I can't imagine taking this risk with someone's child unless there were absolutely no alternative, such as multiple unsuccessful IV attempts. Isn't EMLA cream used prior to an IV start? If so, is it really all that traumatic? What procedures are to be done in these patients?

EMLA is nice..when you have the 20 minutes to let it sit for proper effectiveness...and what happens if you miss the vein you emla? You have to start all over again...In the ER its not always an option to do that...If we are putting an IV in a child, its most likely because they really need it pretty quickly...I can probably count on one hand the times I have actually used it for an IV start...we do use it all the time however for stitches...

rjflyn, ASN, RN · May 22, 2005

To answer the OP yes I have worked where we have given IM Ketamine without IV access. But always with all the precautions one would use for IV sedaiton, ie monitor, pulse ox, O2, a qualified MD at the bedside-one skilled in peds intubation. Also IV supplies at the ready. The rational given is that the med is rapid acting, short duration and has a wide dose range 3-7mg/kg IM ie for a 20 kg pt the dose is 60-140mg. The typical patient we used it for is fracture reductions/splinting, removal of FB's from the nose/ear, fishhook removal, LP's . Didnt use it too ofter for suturing because of the need to redose.

Rj:rolleyes:

**canoehead, BSN, RN** · May 22, 2005

So, here's the thing- we are a small hospital licensed for 20 beds. I don't know how our ER docs are at intubations, and I'd be willing to bet they might do one every 5 years. I KNOW that I can do peds IV's, but not in an emergent situation, not with parents and doc hovering, and certainly not if the child's BP had just dropped to nothing. We also don't have ready access to anesthesia 24h/day and NO pediatricians. Usually anesthesia is in the OR or they are on call, and in both of those situations would not be able to respond emergently.

Given the staff and our experience, the more I think about it the less OK I am with doing without the line...but am I overreacting? I've had 6 years of pediatrics and am generally OK with kids- but this is giving me the heebie-jeebies. Then again, a doc that I would trust otherwise is saying it's perfectly safe.

lifesaverwv · May 22, 2005

Hi, we give our kids versed mixed in cherry syrup. How do you give it rectally & how long before it works? Thanks for the info

kat911 · May 23, 2005

Hi, we give our kids versed mixed in cherry syrup. How do you give it rectally & how long before it works? Thanks for the info

Versed can be given rectally or intranasal. We tried it but it is not very efective, takes to long to act and usually inadequate sedation. We use IM ketamine and it works great. Love watching the little buggers wake up from it, weaving and unsteady, don't let go of them, they can fall easily, sitting or standing.

Giving rectal meds, cut off the needle on a butterfly and insert the tubing into the rectum. You still have the hub to inject the med and no worry about perf'ing the rectum.

mommatrauma, RN · May 23, 2005

Hi, we give our kids versed mixed in cherry syrup. How do you give it rectally & how long before it works? Thanks for the info

We take an 18G angiocath (minus the needle of course) 1 1/2 inch and hook the syringe end. and inject it rectally that way...however Versed does not do well in the rectal form...its bioavailability is about 50% vs 80% when given IM...it has about the same half life though...and since children usually require hire doses than adults...if given rectally it would have to be an even higher dose due to the absorption difference...so its usually not worth it...

BittyBabyGrower, MSN, RN · May 23, 2005

Our hospital policy for all peds con.sedation is for them to have an IV.

Canoe...you may need to do IV's just for the comfort level of your staff...do you have any peds in house on off shifts?