Ketamine for conscious sedation in peds in the ED

[nanb]

Our physicians in my ED want to use Ketamine for conscious sedation in children for short procedures. All of the nursing drug references I've looked at have no pedi references for use: dosages, route of administration, side-effercts etc. I've also looked at sources that say it's an anesthetic agent and not approved by the FDA for use in children. So, who out there uses it and where can I find some user friendly guidelines to educate my staff? I need a written reference to give them, not just an MD's order and our MD's telling me how safe and effective it is.:typing

[passgasser]

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.

Versed is a great drug for kids, given orally at 0.5 mg/kg. It's amnestic properties are very helpful with children. I've also heard of some docs who like chloralhydrate po for sedation. Remember, your goal is to sedate the patient, but be able to rouse the patient to voice or touch. If you sedate the patient to a state where they are not rousable, you have passed the level of "conscious" or moderate sedation and taken the patient to deep sedation, or even what we jokingly refer to as a "room air general."

[NotReady4PrimeTime, RN]

Several years ago my cognitively handicapped son had several fillings done in the dentist's office using oral midazolam. It was very effective; he was "out" for all intents and purposes but did move a bit when the drill started and when things hurt a bit. I'd had no experience with oral midaz to that point and was amazed at how it worked. He had it mixed in apple juice (his choice) and slurped it right down with a straw. One second he was sitting up playing with my purse and the next he was slumped over sideways in his wheelchair, limp as wet Kleenex!

Another choice for short-term sedation in the ER might be fentanyl lollipops. No chance of overdosing... they fall asleep and the sucker falls on the floor.

[CEN35]

I can tell you from working in pacu, with adults it is horrendous to keep the patients tame afterwards.

However, our peds ER uses it also. They come as suckers that the patient can suck on. They love using it, it works great for kids.

Rick

[BrandNewNurse]

We use ketamine in our pediatric ER. The MD always pushes the first dose, then the RN pushes any additional doses needed. Talked to the MD a few nights ago about using ketamine....she prefers to use it on kids only under 12. Like many of you, she commented on the crazy reactions of the kids when coming out of it...hallucinations and violent behavior. I've seen it used a few times. Just depends on the MD...some prefer other meds.

[rn29306]

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.

You beat me to it. Very nice illustration of ICP and why ketamine was probably the WORST agent to use in this case.

[JessicRN]

I agree with passgasser in my state and hospital ,ketamine falls under the same category as Propofol. It is a general anesthetic and only an anethetist or md can give it. Any nurse pushing it is risking her licence if something were to happen to the pt. Just because it is widely used does not make it righ and the courts won't care that it was widely used if the scope of practice says by MD only. WHY RISK IT. Recommend all you nurses giving it check with your BON before you push the next dose.

[mamanaynay]

we use ketamine in our ed as well. we also give atropine to prevent bradycardia. i agree with the general notion that the ed doc should push it. also, the pt needs to be monitored and o2 on. plus have the intubation box at the bedside.

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.

We use atropine with Ketamine but our indication is to decrease the excesssive salvation associated with ketamine. Ketamine can raise ICP so our docs don't use it with possible head injury patients. We usually don't give Ketamine to patients over 10 years old due to the vivid hallucinations it causes unless other forms of cons Sedation are not indicated.

[nuangel1, BSN, RN]

we don't use ketamine or propofol for cs we use fentanyl and versed.

[passgasser]

We usually don't give Ketamine to patients over 10 years old due to the vivid hallucinations it causes unless other forms of cons Sedation are not indicated.

I think this is interesting. Another way to say the same thing: "We know about the intense hallucinations the drug causes, so we only give it to that segment of our patient population that is least able to distinguish between reality and dreaming."

Not to say it is a bad drug for kids, but as I have already pointed out, it is a drug that should only be given by those who are well educated in its use.

[ERNP]

passgasser... I would be interested in your thoughts.

Have been using Ketamine for a few years now. Haven't had a bad outcome but that doesn't mean one isn't around the corner. I have known that ketamine is classified as an anesthetic, a dissociative anesthetic if I am not mistaken. All that said, since ketamine has become so mainstreamed for use in peds patients in ER, I had sort of quit thinking of it as anesthetic. I will think some more about my position on use of ketamine for peds sedation. I have truly appreciated your input.

I haven't ever had much success with oral versed but in the past I have had good results with PR valium for sedation of peds patients. What are your thoughts on this?

One of the reasons ketamine is so popular where I am is that is can be given IM. We don't start start IVs on kids sedated with ketamine. Would you consider PR valium or some other agent to be a safe and viable alternative for sedating kids?

[passgasser]

ERNP

The first thing I would tell you is that I don't use valium with any of my patients, and never have. The reason for that is because I consider versed to be a far better drug. It is generally shorter acting (particularly when given IV) and I think it has better amnestic properties.

So, I am reluctant to comment on the use of valium in peds patients. I have gone out on the net this morning and looked at some monographs on the drug, and from that perspective alone it would appear to me to be safe for use in the way you mention.

Generally, when I hear complaints that Versed does not work, the reasons for the complaints fall into one of two categories. The first is dosage. In giving oral versed to peds, I give 1/2 milligram per kilogram. I don't give more than 20 milligrams to pediatric patients orally, and have generally found that dosage to be sufficient to provide sedation and amnesia for most procedures.

The second complaint comes from the fact that some folks are looking for the drug to do something it is not intended to do, which is render the child unconscious, or nearly so. Frankly, I believe that if you need to sedate anyone, particularly a child, that deeply, you are entering the realm of anesthesia. What versed will do for you is to provide some sedation, and a lot of amnesia, for whatever needs doing. My own daughter is a great example:

She had cut her finger deeply enough to need stitches, and at three years old, was not about to sit still even for localization of the finger. I took her to the ER, where they initially wanted to give her chloral hydrate for sedation, but knowing I was a CRNA, asked my opinion. I told them I hadn't given that drug, and if they found it effective, go ahead, but I also told them of my preference for versed. The doc there hadn't used it in peds before, but was willing to try it. Long story short, she got lethargic, and he put the digital block in to stitch up her finger. Since versed has no analgesic properties, she wasn't real happy with that, but her level of sedation was such that she didn't really fight it either. Once that was in, I was able to keep her distracted from being sutured by quietly playing with her. She actually looked at what the physician was doing a few times, but since she was not in pain, she didn't care. We actually most of the time he was suturing her finger laughing and singing. His reaction to the sedation was generally favorable.

The next morning, she woke up bright eyed and bushy tailed. I am quite sure that she remembered little if any of the procedure, because she was a bit surprised to find that she had stitches in her finger.

[ERNP]

I thank you passgasser. You have given me much to consider. I guess part of why I have become comfortable with IM Ketamine is that I have never seen a child so out of it that they stopped responding or didn't require local anesthesia for wound repair. The children I have used ketamine for don't appear more sedated than the ones that receive another agent. Maybe it is dose or route (IM vs IV) related. I am not comfortable with IV ketamine and it seems unnecessary since the IM route works so quickly.

All that being said, I would like to share a story. Recently we used ketamine for wound repair on a child that had autism. He had been in early intervention and had limited language skills. While I worked, his mother sat at the head of the stretcher talking to him. This mother had been working with this child for many years with very little in return. That day he counted in English and Spanish. He recited his ABC's and sang all the songs she had been singing since he was a small child. He told her he loved her that day for what I guess was the first time.

I don't know if another agent would have produced the same effect. But I do know the mother was grateful for the peek inside her child's mostly locked mind. I was grateful to be present for such a special moment between mother and child.