The Procedure

Stop! Reconsider:

• Is ketamine sedation the right answer for the child’s complaint?
• Is the child adequately analgesed?
• Can the operator complete the procedure within 20 minutes?

Weight of child

Weigh the child when possible. If not, calculate the weight as per the standard formula: weight (kg) = (age + 4) x 2. Be prepared to adjust when common sense suggests.

IM or IV administration

The major change in the Best Practice Guideline February 2020 [3] is the move away from IM ketamine to IV ketamine for procedural sedation in children. It has been recognised that whilst IV access has always been seen as a minimum standard for adults, this has not been the case for children. Whilst the use of IM ketamine is still recognised as a pragmatic option when used by a senior decision maker, clinicians should be mindful of the perceived safety benefits of having intravenous access from the start of the procedure to mitigate a rare adverse event. IM ketamine has a higher risk of emesis and a longer recovery time. IV access also facilitates repeat dosing for longer procedures.

We opt for cannulation in the child friendly cubical/room to which they’ve become accustomed – using distraction techniques previously described. We then move parent and child to the ‘special’ room the paediatric resuscitation bay equipped with a ceiling mounted DVD. We encourage younger children to sit on mum or dad’s lap. That way, there is hopefully a distinction from the child’s perspective, of the room of pain – or at least where things haven’t been particularly great – and the DVD room where there is no more pain. Get it?

The room

A dedicated, isolated room with full paediatric resuscitation facilities is the ideal. Ensure that you are familiar with the environment and have checked that the child specific equipment is available and functions beforehand. This includes rescue airway equipment. Establish the child specific dose of atropine and suxamethonium too and ensure these are trolleyside. ECG/NIBP/RR/sats monitoring and supplemental oxygen are all advised. You will need a team of three – the sedator, the operator and a registered nurse.

Dosage

The IV dose is 1 mg/kg slowly – no less than a minute, so as to avoid apnoea. If the child isn’t engaged in the DVD/ipad/phone, do encourage some happy chitchat between parent and child. A book or toy may substitute for a DVD/ipad/phone.

Within 60 seconds you should sense that the child becomes vacant, demonstrating occasional nystagmus. You may wish to invite mum or dad to leave at this stage. Your operating colleague may now proceed. Infiltrative local is still advised where indicated, despite the apparent sedation.

Supplemental (slow) IV doses of 0.5 mg/kg may be required should you deem the level of sedation inadequate, or if the procedure is prolonged.

Your nursing colleague should record observations regularly – every five minutes until the procedure is complete in the my department.

Red flag

Note that three different vials of ketamine are available: 10, 50 and 100 mg/ml solutions. You will need the 100 mg/ml vial in order to minimise the IM volume; the 10 mg/ml preparation is better suited for accurate IV dosing. We see no reason to stock a 50 mg/ml preparation.

Check the drug preparation carefully to avoid a drug error. My own department keeps the IM and IV vials separately with brightly coloured laminates attached to the inside of the locked cupboard.

Learning bites

• Slow IV ketamine administration, no less than 60 seconds.
• ECG, NIBP, RR, sats monitoring and supplemental oxygen are all advised.