Ketamine for conscious sedation in peds in the ED

TazziRN, RN · Aug 9, 2006

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

Oh my, I wish I could help. I've used it for kids at the last ER I worked at, but anesthesiology was the one who directed the conscious sedations when ketamine was used. I saw wonderful results with it, no negative ones.

Pediatric Critical Care Columnist · Aug 9, 2006

we use a lot of ketamine in our picu. at times it seems like the flavour of the month.

will this work? from davis drugs

ketamine

trade name(s)

* ketalar

pregnancy category

category unknown

ther. class.

general anesthetics

indications

* anesthesia for short-term diagnostic and surgical procedures

* as induction before the use of other anesthetics

* as a supplement to other anesthetics

unlabelled use(s):

provides sedation and analgesia

action

* blocks afferent impulses of pain perception

* suppresses spinal cord activity

* affects cns transmitter systems

therapeutic effect(s):

anesthesia with profound analgesia, minimal respiratory depression, and minimal skeletal muscle relaxation

pharmacokinetics

absorption: rapidly absorbed after im administration

distribution: rapidly distributed. enters the cns; crosses the placenta

metabolism and excretion: mostly metabolized by the liver. some conversion to another active compound

half-life: 2.5 hr

time/action profile (anesthesia)

routeonsetpeakduration

iv30 secunknown5-10 min

im3-4 minunknown12-25 min

contraindicated in:

* hypersensitivity

* psychiatric disturbances

* hypertension

* elevated intracranial pressure

* pregnancy or lactation

use cautiously in:

* cardiovascular disease

* procedures involving larynx, pharynx, or bronchial tree (muscle relaxants required)

* gastroesophageal reflux

* hepatic dysfunction

* history of alcohol abuse

* cerebral trauma

* intracerebral mass or hemorrhage

* hyperthyroidism

* history of psychiatric problems

* increased cerebrospinal fluid (csf) pressure

* increased intraocular pressure

* severe eye trauma

adverse reactions/side effects

cns: emergence reactions, elevated intracranial pressure.

eent: diplopia, increased intraocular pressure, nystagmus.

resp: laryngospasm, respiratory depression and apnea (rapid iv administration of large doses).

cv: hypertension, tachycardia, arrhythmias, bradycardia, hypotension.

gi: excessive salivation, nausea, vomiting.

derm: erythema, rash.

local: pain at injection site.

ms: increased skeletal muscle tone.

*capitals indicates life-threatening.

*italic indicates most frequent.

interactions

drug-drug

* use with barbiturates, hydroxyzine and opioid analgesics may result in prolonged recovery time

* use with halothane may result in decreased blood pressure, cardiac output, and heart rate

* use with tubocurarine or nondepolarizing neuromuscular blocking agents may result in prolonged respiratory depression

* concurrent use with thyroid hormone increases the risk of tachycardia and hypertension

* concurrent administration with diazepam may decrease the incidence of emergence reaction

* concurrent administration with atropine may increase the incidence of unpleasant dreams

route/dosage

general anesthesia

* iv (adults):

induction--1-2 mg/kg (range 1-4.5 mg/kg)-2 mg produces 5-10 min of surgical anesthesia or 1-2 mg/kg as a single injection or infused at 0.5 mg/min. may be used with concurrent diazepam.

maintenance--increments of ½ to the full induction dose may be repeated as needed. if given with concurrent diazepam, an infusion of 0.1-0.5 mg/min may be used, augmented by 2-5 mg doses of diazepam.

* iv (children): 0.5-2 mg/kg, use smaller doses (0.5-1 mg/kg)for minor procedures.

* im (adults): 3-8 mg/kg (10 mg/kg produces 12-25 min of surgical anesthesia).

* im (children): 3-7 mg/kg.

* po (children): 6-10 mg/kg for 1 dose (mix in cola or other beverage) 30 min prior to procedure.

sedation/analgesia (unlabeled)

* iv (adults): 200-750 mcg (0.2-0.75 mg)/kg over 2-3 min initially, followed by 5-20 mcg (0.005-0.02 mg)/kg/min as an infusion.

* iv (children): 5-20 mcg/kg/min.

* im (adults): 2-4 mg/kg initially, then 5-20 mcg (0.005-0.02 mg)/kg/min as an iv infusion.

availability

* injection: 10 mg/ml, 50 mg/ml, 100 mg/ml

assessment

* assess level of consciousness frequently throughout therapy. ketamine produces a dissociative state. the patient does not appear to be asleep and experiences a feeling of dissociation from the environment

* monitor blood pressure, ecg, and respiratory status frequently throughout therapy. may cause hypertension and tachycardia. may cause increased csf pressure and increased intraocular pressure

toxicity and overdose

* respiratory depression or apnea may be treated with mechanical ventilation or analeptics

potential nursing diagnoses

* risk for injury (side effects)

* disturbed sensory perception (adverse reaction)

* deficient knowledge, related to medication regimen (patient/family teaching)

implementation

* administer on an empty stomach to prevent vomiting and aspiration

» may be administered concurrently with a drying agent (atropine, scopolamine); ketamine increases salivary and tracheobronchial mucous gland secretions. atropine may also increase the incidence of unpleasant dreams

» patients may experience a state of confusion (emergence delirium) during recovery from ketamine. administering a benzodiazepine and minimizing verbal, tactile, and visual stimulation may prevent emergence delirium. severe emergence delirium may be treated with short- or ultra-short-acting barbiturates

* po: use 100 mg/ml iv solution and mix appropriate dose in 0.2-0.3 ml/kg of cola or other beverage

* direct iv: dilute 100 mg/ml concentration with equal parts of sterile water for injection, 0.9% nacl, or d5w

* rate: administer over 60 sec unless a rapid-sequence induction technique is indicated. more rapid administration may cause respiratory depression, apnea, and hypertension. do not exceed 0.5 mg/kg/min. maximum concentration for slow iv push 50 mg/ml

* continuous infusion: dilute 10 ml of 50 mg/ml concentration or 5 ml of 100 mg/ml concentration with 500 ml of 0.9% nacl or d5w and mix well, for a concentration of 1 mg/ml. dilution with 250 ml may be used if fluid restriction is needed, for a maximum concentration of 2 mg/ml

* rate: administer at a rate of 0.5 mg/kg/min for induction. maintenance infusion may be administered at a rate of 1-2 mg/min or 0.1-0.5 mg/min given concurrently with diazepam. dosage must be titrated according to individual patient requirements. tonic-clonic movements during anesthesia do not indicate the need for more ketamine

* syringe compatibility:

» benzquinamide

* syringe incompatibility:

» barbiturates

» diazepam

» doxapram

patient/family teaching

* psychomotor impairment may last for 24 hr after anesthesia. caution patient to avoid driving or other activities requiring alertness until response to medication is known

* advise patient to avoid alcohol or other cns depressants for 24 hr after anesthesia

evaluation/desired outcomes

sense of dissociation and general anesthesia without muscle relaxation

Home Health Columnist / Guide · Aug 9, 2006

good info on: emedicine - pediatrics, sedation : article by jeffrey hom, md, mph ...

nanb · Aug 10, 2006

Thanks all. Exactly what I needed!!

Pedi-ER-RN, RN · Aug 10, 2006

We use it alot in the ER for ortho reductions, large lac repairs, etc... Only an MD can push it. I hate using it on adolescents, they seem to get mean or crazy when they come out of it. They usually start telling their parents who they have had sex with or they start hallucinating and seeing dead relatives (both of which send the parents into histerics!) All in all, it is a very good drug. With conscious sedation, we have TONS of paperwork, consents, etc.. to do and we have a protocol.

RunnerRN, BSN, RN · Aug 11, 2006

We use it a lot, mainly on peds reductions with morphine. The one practical tip I can pass on - keep the room dark and quiet as the kiddo comes out of the med. There is some emergence difficulty sometimes (as the above poster pointed out) with hallucinations and bad dreams. We've had to redose kids when they've come out badly. Usually though, you get the kids that sing oldies, or ask daddy "why's my bed flying." We've just found that keeping stimuli down (includes keeping extra family out - for some reason, ortho like to leave the room, go to the WR and tell the family "we're done" then everyone tries to rush in) keeps the kid coming out well.

Great drug, good luck with the technical stuff!

Pedi-ER-RN, RN · Aug 11, 2006

We don't re-dose, but there have been many times that I have wanted to. Usually versed works well for emergence. I did 2 conscious sedations during my last shift and both of them went great, both kids were 2-3 and did good, no complications.

passgasser · Aug 11, 2006

Well, I typed all this once, and got dumped. Try try again.

At the risk of being severely beaten by all the ER nurses out there who "have been giving ketamine safely for ages," as a CRNA I would advise you not to do it. You are asking your nurses to do something that is outside of their scope of practice, i.e. administer general anesthesia.

See the post of janfrn, under "Therapeutic class." Ketamine is classed as a general anesthetic agent. (As is, by the way, the other perennial (corrected to get rid of a bad joke) anesthetic favorite of ER docs, Propofol.) Do a Yahoo search for "ketamine package insert" and read what the Bedford labs insert says about administration of the drug:

"Ketamine should be used by or under the direction of physicians experienced in administering general anesthetics and in maintenance of an airway and in the control of respiration."

Pretty specific about who should or should not be giving the drug. While some of your ER physicians may be pretty good at intubation, that in no way qualifies them to administer general anesthetics, nor does it qualify them to supervise your nurses to do so.

Simply put, let me ask you a question. Would you expect your nurses to be able to administer general anesthesia in the OR? If not, why do you expect them to be able to do so (on pediatrics, no less) in the less controlled environs of the ER?

tridil2000, MSN, RN · Aug 11, 2006

we use ketamine in our ed as well. we also give atropine. 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.

CritterLover, BSN, RN · Aug 11, 2006

well, i typed all this once, and got dumped. try try again.
at the risk of being severely beaten by all the er nurses out there who "have been giving ketamine safely for ages," as a crna i would advise you not to do it. you are asking your nurses to do something that is outside of their scope of practice, i.e. administer general anesthesia.
see the post of janfrn, under "therapeutic class." ketamine is classed as a general anesthetic agent. (as is, by the way, the other perennial (corrected to get rid of a bad joke) anesthetic favorite of er docs, propofol.) do a yahoo search for "ketamine package insert" and read what the bedford labs insert says about administration of the drug:
"ketamine should be used by or under the direction of physicians experienced in administering general anesthetics and in maintenance of an airway and in the control of respiration."
pretty specific about who should or should not be giving the drug. while some of your er physicians may be pretty good at intubation, that in no way qualifies them to administer general anesthetics, nor does it qualify them to supervise your nurses to do so.
simply put, let me ask you a question. would you expect your nurses to be able to administer general anesthesia in the or? if not, why do you expect them to be able to do so (on pediatrics, no less) in the less controlled environs of the er?

have to agree with above, and i do work in an er. in fact, one of our er docs is upset because none of us will push the ketamine -- it is outside of the scope of our practice in the state we are in. i'm not sure about other states, but i'd be willing to bet it isn't allowed in most.

i'm actually pretty comfortalbe administering it -- to animals. give it to them fairly often for anesthesia. sometimes intubated, sometimes not, but we can always intubate them if we need to. however, i don't do this independently; there is always a vet present, who will be able to intubate the animal if it is needed and i'm unsuccessful. and, giving anesthesia to animals doesn't require a license. giving anesthesia to people does. so i won't give it, no matter how mad it makes the docs. (won't give diprivan, either, unless the patient is intubated and on a vent).

AM-RN · Aug 11, 2006

Check out the ENA's Journal of Emergency Nursing -- (April 2006, Volume 32, Number 32) -- article "Ketamine: The Sedative of Choice in a Busy Pediatric Emergency Department" by Haley-Andrews, S. --- good info on dosing IV vs IM, etc...

Good luck.