HWN Suggests

Special K is not just for breakfast

The initial IV dose is 1 to 1.5 mg/kg with repeat doses of 0.5 to 1 mg/kg given q5-10 minutes as needed. If you are also giving Propofol, you can give 0.5 mg/kg. The IM dose is 4 to 5 mg/kg with a repeated IM dose of 2 to 4 mg/kg after 10 minutes if needed. IM dosing takes longer and has a higher risk of side effects, so I prefer IV.

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Articles of Interest

Don't Forget the Bubbles

Ketamine has been described as the “ideal” agent for paediatric sedation. It has rapidly become the drug of choice for short, painful procedures in the ED due to its rapid onset of action and anxiolytic, analgesic and amnesic properties. Ketamine dissociation results in a lack of response to painful or noxious stimuli whilst preserving respiratory and cardiovascular stability. Absolute contraindication to ketamine - Infants less than six months (due to increased risk of airway compromise and recent animal studies which have found that ketamine is involved in neuronal degeneration within the developing brain)

A dissociative state of mind: Talking to parents about ketamine

So you’ve got another procedural sedation to do in the pediatric emergency department. If your ED is anything like ours, your options for sedation include ketamine, ketamine, and, well, more ketamine. The pharmacology of ketamine is totally different from any other sedative. It works by dissociating the CNS from outside stimuli causing a cataleptic trancelike state. This amazing medication does not blunt the respiratory drive nor cause hypotension, and at the same time allows for effective sedation, amnesia, and analgesia. It is almost too good to be true!

Absolute and relative contraindications for ketamine use in the Pediatric Emergency Department

When is ketamine ABSOLUTELY contraindicated? Age younger than 3 months (primarily for risk of airway complications). Schizophrenia (studies show this condition may be exacerbated with ketamine administration)

Clinical Practice Guideline for Emergency Department Ketamine Dissociative Sedation: 2011 Update

We update an evidence-based clinical practice guideline for the administration of the dissociative agent ketamine for emergency department procedural sedation and analgesia. Substantial new research warrants revision of the widely disseminated 2004 guideline, particularly with respect to contraindications, age recommendations, potential neurotoxicity, and the role of coadministered anticholinergics and benzodiazepines.

Current Concepts in Ketamine Therapy in the Emergency Department

Ketamine has long-established uses in the emergency department, including analgesia, procedural sedation, and rapid sequence intubation; however, its atypical dose-response action must be taken into account for maximum effectiveness and to avoid distressing emergence reactions. As more ED uses for ketamine emerge, an understanding of the current state of evidence is crucial.

Intranasal Ketamine for Procedural Sedation and Analgesia in Children: A Systematic Review

Ketamine is the most commonly used agent for procedural sedation in children in the emergency department. Evidence suggests ketamine can be administered intranasally, obviating the need for intravenous access. However, studies are conflicting with regards to dosing and indications, limiting the ability of clinicians to extrapolate findings to practice.

Intravenous ketamine for adult procedural sedation in the emergency department: a prospective cohort study

Ketamine is an effective agent for procedural sedation in the emergency department. There were no serious adverse events associated with its use, but there is a significant incidence of recovery agitation which may require treatment with a benzodiazepine.

IV Ketamine Is Effective for Procedural Sedation in Adults

Ketamine is an attractive agent for procedural sedation because it maintains airway protective reflexes while providing both analgesic and sedative effects. However, emergence reactions and increases in BP and heart rate raise concerns about its use in adults. Emergence reactions necessitated the use of midazolam in 7% of study patients. In addition, patients in whom BP and heart rate increases could cause potential harm were excluded, so no conclusions can be drawn about ketamine’s safety in such patients.

Medication choices

I typically choose between ketamine and propofol on a spectrum. Factors on the propofol side: young, healthy, BP/respiratory reserve, shorter procedure, ortho procedure (propofol is much better at loosening up patients, plus these often end quickly). Factors on the ketamine side: older, more comorbidities, less respiratory reserve, longer procedures, non-reduction procedures, more protractedly-painful procedures (e.g. I&D).

Pediatric Procedural Sedation with Ketamine

Ketamine is one of the most under-rated drugs in the ED doc’s arsenal. This post is a Q-and-A review of an article from @EBMedicine which is all about using ketamine for procedural sedation in children:

Should we premedicate for ketamine sedation?

One question that often arises is whether to give patients pre-treatment with midazolam in order to smooth emergence and decrease side effects. In children, and via the BestBets methodology we developed here our view is that it probably does not work, but what about adults? I will admit that I did go through a phase of using small doses of midazolam (1-2mg) before the procedure, in particular when the patient appeared anxious. However, in recent years I’ve used it less and less. I’ve also had the experience of dealing with some really disturbing emergence phenomena. I remember deciding to use ketamine for the sedation of an elderly patient with a significant limb injury. All went well, but on recovery she became psychotic, believing that she was dead and that we were all dying. It was rather chaotic and distressing for all involved, so if there is something we might do to avoid this then all the better.

The adverse effects of Ketamine on Procedural Sedation and Analgesia (PSA) in the Emergency Department

Ketamine is a drug with good analgesic, sedative properties and has been shown to have a good safety profile with minimal adverse events for use as PSA in ED. Side effects were most common in the younger adult age group and hypertension was the most common side effect.

When can we use oral ketamine for procedural sedation?

This week, we’re gonna talk about ketamine. Love it or hate it, it does have its own unique set of properties, and if used correctly in the right patient and at the right dose, it can be very useful. In this episode, we’ll discuss how to give ketamine orally prior to minor procedures in patients who won’t take IM or IV medications. Specifically, this often refers to patients who have underlying mental or neurological disorders, like autism or Down syndrome.