Patients:
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Children requiring short, painful interventions. For example, suturing complex lacerations, incision and drainage of abscesses, minor orthopaedic manipulations, repair of finger tip injuries, etc. |
Contraindications:
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• Active lung disease or infection including URTI. (Asthma not contraindicated.) |
• Cardiovascular disease, for example, congenital, cardiomyopathy, hypertension. |
• Head injury if associated with history of loss of consciousness, vomiting, altered mental state, or any sign of raised intracerebral pressure. |
• Central nervous system disease, for example, hydrocephalus, intracranial mass, epilepsy. |
• Others: porphyria, thyroid disease, glaucoma, psychosis. |
Preparation:
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• Ensure child is starved for minimum of three hours. |
• Record weight in kilograms. |
• Obtain written consent from guardian after explaining potential risks/side effects of procedure. |
• Apply EMLA cream 60 minutes before procedure over the area for injection. |
• Encourage parent to stay with child during procedure and recovery. |
Requirements:
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• Presence of two doctors, at least one trained in paediatric resuscitation. |
• Presence of qualified nurse ideally with paediatric experience to monitor the child until fully recovered. |
• Record baseline vital signs before drug administration. |
• Equipment needed: oxygen, suction, vital sign monitors including pulse oxymeter and a full paediatric resuscitation trolley. (Intravenous access not essential.) |
• A designated area where noise and disturbance are minimal. |
Dose:
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Ketamine 5 mg/kg as initial dose 2 mg/kg if repeat dose required at 10 minute intervals. Atropine (100–200 μg/kg) may be added to minimise ketamine associated hypersecretion. |
Procedure:
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• Ketamine (and atropine if required) are administered intramuscularly into the pre-anaesthetised skin over buttock or thigh. Child to be held in parent's arms if possible. |
• Once sedated the child is placed on their side on a tilting trolley with continuous pulse and oxygen saturation monitoring. |
• Optimise airway position, occasional gentle suction of oropharynx may be required to clear secretions. |
• Monitor continuously until fully recovered. |
• Recovery area should be quiet if possible, with minimal tactile stimulation. Mean recovery time is 60–140 minutes. |
Side effects:
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Observe for: airway compromise—that is, laryngospasm, apnoea, hypersalivation. |
Also, vomiting, agitation, hallucinations, nightmares, ataxia. |
Discharge:
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• When child has returned to pre-treatment level of awareness, recognition, speech, and purposeful activity. |
• Instruct parents to give nothing by mouth until fully orientated and closely observe ambulation for next 24 hours. |