title – xxx speaker implementing paediatric procedural sedation in emergency departments: 2013...
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Title – xxx
Speaker
Implementing paediatric procedural sedation in emergency departments: 2013
Ketamine
Dr David Krieser FRACPPaediatric Emergency Physician, Sunshine Hospital – Western Health
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Case
• An 8 year old boy– Monkey bars + Gravity
• FALL– Obvious left upper limb deformity
– Note• Past History• Last intake of solids / liquids• Assessment of injury – neurovascular observations• Pain score and management
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Imaging
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Why parenteral sedation?
• Some procedures too painful for nitrous oxide
• Alternative to GA in theatre
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Why ketamine?
• Predictable response compared with other agents
• IM and IV options
• Maintenance of upper airway tone and reflexes
• Established safety profile
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Ketamine in your ED• Ketamine and/or other parenteral agents will not be
appropriate in all EDs.
• Each health services is responsible to determine what procedures & level of sedation in your ED
• If yes
• Policies and procedures are in place
• Staff trained in paediatric life support
• Staff trained and credentialed in use of Ketamine
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General principles• Appropriate location• Sedation team:
– Proceduralist + sedation doctor + sedation nurse
– Senior doctor support
• Authorisation• Fasting • Consent• IV agents administered by doctor only• Close monitoring
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What is ketamine?
• Dissociative anaesthetic
– Thalamo-cortical input separated from limbic system– Profound amnesia and analgesia – “sensory isolation”– Not a dose dependent effect – a threshold is crossed
• Maintains upper airway tone and protective reflexes
• Cardio respiratory stimulant • There is no reversal agent• Demonstrated as safe in children in EDs
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Indications
• Short very painful ED procedures or if immobilisation needed– Fracture reduction– Laceration repair (esp. facial)– Incision and drainage
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Contraindications• History of airway problems, delayed gastric emptying• Very unwell• URTI, acute respiratory disease
– Laryngospasm
• Children < 1 year – Airway malposition, respiratory depression
• Children >12 years• History of psychosis / ADHD
– Emergence reaction
• Porphyria, thyrotoxicosis– Sympathomimetic effects increased
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Ketamine: Dosing• IV Ketamine
– 1 mg/kg slow IV over 1 minute– Onset 1 minute– Additional doses 0.25-0.5 mg/kg slow IV– Fast push INCREASED RISK of respiratory depression
• IM Ketamine– 4 mg/kg– Onset 3-5 minutes– Additional doses IV 0.25 mg/kg
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Comparing IV and IMRoute of administration
Intravenous (IV)
Intramuscular (IM)
Advantages Ease of repeat dosingFaster recovery
No IV needed
Clinical onset 1 minute 3-5 minutes
Duration of effective sedation (approx.)
15 minutes 15-30 minutes
Recovery (approx.) 60 minutes 90-150 minutes
Initial dose 1 mg/kg 4 mg/kg
Subsequent dose 0.25-0.5 mg/kg Insert IV and give further doses 0.25-0.5 mg/kg
Maximum dose 5 mg/kg 5 mg/kg (combined IM and IV)
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Ketamine: Parent preparation
• Need to warn parents about ketamine effects:– For IV - tell them it usually works VERY fast
• “like a switch”– Eyes open: may appear awake
• “lights are on, nobody is home”– May move and need restraint – May adopt strange limb positions– May drool– May experience unusual sensations on
recovery / agitation / nightmares– Requires observation period before discharge
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Ketamine: Adverse effects• Airway malposition
• Hyper-salivation
• Laryngospasm
• Respiratory depression
• Cardiovascular stimulation
• May elevate intracranial / intraocular pressure
• Ataxia
• Emergence reaction
• Vomiting (recovery)
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Ketamine: Emergence reaction
• Hallucinations, dreaming during recovery– More frequent in adults/adolescents
– Risk factors:• female, rapid IV, excessive noise and stimulation,
prior personality disorder
– Reduce risk:• suggest topics for dreaming – Ask before
sedation what the child likes to do and get them to think about it
• dim and quiet environment
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Let’s use ketamine
Return to the Case
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Case
• An 8 year old boy– Monkey bars + Gravity
• FALL– Obvious left upper limb deformity
– Note• Past History• Last intake of solids / liquids• Assessment of injury – neurovascular
observations• Pain score and management
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Imaging
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StaffKetamine
A doctor, credentialed for the agent used, to administer the sedation and monitor the patient AND a nurse credentialed for paediatric sedation to assist the sedation doctor.
Another doctor to perform the procedure.
Appropriate senior clinician available on site with the ability to immediately respond if required.
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Ketamine: The procedure
• Perform only in designated area with full resuscitation equipment available
• IV administration only by a doctor• Give slowly (over ~ 1 minute) to reduce
adverse effects
• Continuous ECG and O2 sat monitoring
• Record observations (including BP) 5 minutely
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Ketamine: The procedure• 8 year old boy with forearm fracture
– Weight – 25 kg • Remember topical anaesthetic for IV insertion• Guided imagery; music• Must prepare all equipment for reduction and
plaster as per local guidelines– May include: Image Intensifier (+ radiographer), plaster of
Paris, padding, sling etc
• Consent for sedation AND for procedure– Explain risks
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Ketamine: The procedureSuggested prescription
IV administration
1. Calculate the initial dose
2. Draw up into a 1 ml syringe
3. Transfer this (using the drawing up needle) into an appropriate size syringe and dilute with normal saline to a final concentration of 10 mg/ml
4. Administer slowly over 1 minutee.g. 20 kg Child, add 0.2 ml of ketamine to
1.8 ml normal saline = 20 mg/2 ml (10 mg/ml)
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Ketamine: The procedureAtropine
• Have atropine available– Calculate the dose = 0.02 mg/kg (20 mcg/kg)
• Write down this calculated dose in case it is needed
– Do NOT draw up – Use only if symptomatic
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If you don’t label it… you don’t know what it is• Australian Commission on Safety and Quality
in Health Care• National Recommendations for labeling
– All injectable medicines drawn up should be labeled immediately• Includes flushes, normal saline
– Multiple syringes should be prepared and labeled if required
– Care not to cover volume graduations with label
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Other agents
• Include: – propofol– ketamine/propofol (Ketofol) – midazolam (unreliable)– chloral hydrate (non-painful procedures)
• Same principles of safe practice apply
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Summary: Key elements• Procedure can occur in your ED• Child is suitable to have ketamine• Child and parent preparation• Standardised processes including
– Consent– Drug management– Documentation – Monitoring– Discharge
• Credentialing of staff• Recognition and management of adverse events
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Questions