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Ketamine and Propofol (Ketofol) for Pediatric Sedation

Keeping children comfortable benefits everyone! Patients have less pain and psychological trauma. Their families think you are amazing and… your procedure is easier to do when not also performing professional wrestling maneuvers. Honestly, a successful procedural sedation is one of the best things to do in the ED. It satisfies everyone… which makes for some good job satisfaction while you are driving home. On the other hand… a less than successful sedation is… well, not satisfying at all.

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  Intranasal Medications in the Pediatric ER

Delivery of medications intranasally offers an alternative to oral and intravenous drug administration in the emergency department. This method is used to rapidly provide anxiolysis, sedation, amnesia, and/or analgesia in the pediatric population and can play an important role in a safe and successful intervention. Let’s review four common intranasal medications used in the ER: fentanyl, versed, ketamine, and dexmedetomidine.

Articles of Interest

An Evidence-Based Approach To Pediatric Procedural Sedation

Children present a unique challenge when it comes to procedural sedation in the emergency department. For pediatric patients, sedation may be required to facilitate cooperation during a procedure that would not typically require sedation in an adult patient. The amnestic, anxiolytic, and analgesic properties of procedural sedation agents must be weighed against their potential side-effect profiles.

Complications of Procedural Sedation

Clinical Take Home Point: The incidence of serious adverse events during procedural sedation and analgesia in the ED are rare, but shared decision making and informed consent should still be used as this is not a completely benign procedure.

Dexmedetomidine for Sedation in Pediatric ED

It is often used as a simple anxiolytic without extensive monitoring. Dexmedetomidine makes them sleepy, but rousable! Which may be just what you want!

Emergency procedural sedation in children

Consider sedation with a single agent, such as ketamine, over drug combinations. In a prospective cohort of 6295 children, procedural sedations using ketamine alone were associated with fewer adverse events and required less positive pressure ventilation than any other drug combination, which resulted in more completed procedures without unplanned hospital admissions. Laryngospasm occurred in 0.1%–0.3% of sedations. The only absolute contraindications to ketamine use are age younger than 3 months and a known or suspected psychotic disorder.

Episode 76 Pediatric Procedural Sedation

Your initial approach to pain control when the patient hits the ED door will depend on severity of pain. For presentations of severe pain, intranasal fentanyl is a recommended first line agent as it is fast and easy to administer, avoids requiring cooperation with oral medications, and provides reliable analgesia that has been shown to be equivalent to intravenous morphine. For mild to moderate pain, consider oral agents such as ibuprofen, which has been shown to be more effective than acetominophen for pain control in orthopedic injuries in children

Intranasal Analgesia

Fentanyl is a great example of a medication that works well when given via the intranasal route.

Ketamine for Analgesia

The awake patient who needs a brief painful procedure (5-10 min).

Nitrous Oxide for Pediatric Sedation

When nitrous oxide is inhaled at levels below 50%, patients maintain airway protective reflexes and do not require fasting or post-procedure monitoring. This is in contrast to sedatives such as propofol or ketamine, which provide much deeper sedation, and require post-procedural monitoring.

Paediatric Procedural Sedation in the Emergency Department

Ketamine is a phencyclidine (PCP) derivative that acts as a dissociative sedative through binding of the N-methyl-D-aspartate (NMDA) receptor. It has anxiolytic, analgesic, amnesic and dissociative properties with a wide safety margin. Laryngospasm is a rare complication (0.3%) and should be managed by stopping the procedure, repositioning the airway and suctioning any secretions in the first instance. Application of PEEP with a bag-valve mask or Ayre’s T-piece may be required. In the vast majority of cases, the laryngospasm will resolve and the procedure can be completed. If persistent however, a muscle relaxant such as suxamethonium or rocuronium may be required with assisted ventilation until recovery. Preparations for potential intubation should be made and a 2222 call put out for rapid anaesthetic assistance. This can be at the discretion of the senior clinician and will vary on a case by case basis.

Pediatric Procedural Sedation with Ketamine

Ketamine is one of the most under-rated drugs in the ED doc’s arsenal.

Pediatric Procedural Sedation: What are your options?

For young infants, oral sucrose is an effective agent. For patients > 6 months of age, IN or PO midazolam can assist with anxiolysis and amnesia.

Procedural Sedation Delays and NPO Status for Pediatric Patients in the Emergency Department

Not delaying procedural sedation in pediatric emergency department patients based on their NPO status is reasonable.

Safe Pediatric Sedation In The ER: What RTs Need To Know

Procedural sedation is not without risks. Many patient safety concerns apply to the sedation procedure. These include medications delivered, staff competence, adequate monitoring and emergency equipment, presedation patient preparation, post-sedation patient education, and documentation.

Resources

Fentanyl IN

Dose: 1 – 2 mcg/kg, maximum dose of 100 mcg. Expected onset: 10 – 15 minutes. Intranasal fentanyl works! It has been shown to be equally as effective as intravenous morphine...

Ketamine IN

Dose: 1 – 1.5 mg/kg (although wide ranges have been cited), maximum dose of 100 mg – 200 mg. Expected onset: 5 – 10 minutes. Adverse effects: nausea, dizziness, unpleasant taste. Generally, ketamine has been shown to be as effective as fentanyl when administered intranasally, although with greater rates of mild and well-tolerated side effects. Intranasal ketamine may be ideal management of patients who are opioid-tolerant or who are at higher risk of hypotension (e.g trauma patients).

Midazolam IN

Dose for anxiolysis and sedation: 0.2 – 0.3 mg/kg, maximum dose of 10 mg. Expected onset: between 5 – 10 minutes. Adverse effects: mucosal irritation. Although it also has sedative properties, its concentration (5 mg/mL) may limit the ability to achieve the dose needed for sedation in a heavier or older patient. Midazolam may cause nasal burning and mucosal irritation, so also consider pre-treatment with intranasal lidocaine (0.5 mL about 5 minutes before midazolam).

SafeTots.org

The Safetots.org initiative addresses the safe conduct of pediatric anesthesia. We promote the rights of the child for high quality care in the right environment.

Society for Pediatric Sedation

Striving to be the international multidisciplinary leader in the advancement of pediatric sedation by promoting safe, high quality care, innovative research and quality professional education.