Intravenous Ketamine Sedation of Pediatric Patients in the Emergency Department,☆☆,

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Abstract

Study objective: To determine efficacy, safety, recovery times, and parental satisfaction with IV ketamine sedation in pediatric patients requiring brief, painful procedures in the emergency department. Methods: Pediatric ED patients whom we found to require brief (<10 minutes), painful procedures were considered candidates for ketamine sedation. Each subject received 1.0 to 2.0 mg/kg IV ketamine, after which the necessary procedure was performed. Results: Thirty patients, ranging in age from 18 months to 8 years, were enrolled in the study. With the exception of one patient in whom ketamine was inadvertently given subcutaneously, all subjects given IV ketamine exhibited sedation adequate for the planned painful procedure within 2 minutes of ketamine administration. An initial bolus of 1.0 mg/kg required supplemental administration of ketamine in 50% of the patients (6 of 12), whereas an initial bolus of 1.5 mg/kg reliably produced adequate sedation in 94% (17 of 18). The median time elapsed before the criteria for discharge after injection were fulfilled was 25 minutes. No deleterious cardiopulmonary effects were noted. Vomiting and mild agitation after the procedure were observed in two and four cases, respectively. At follow-up all parents reported satisfaction with ketamine sedation. Conclusion: IV ketamine is a consistently effective method of producing a rapid, brief period of profound sedation and analgesia in children in the ED. Although no serious complications were noted in our series, larger studies are needed to establish this drug's safety profile in the ED. Vomiting, ataxia, and agitation were noted in a few cases. [Dachs RJ, Innes GM: Intravenous ketamine sedation of pediatric patients in the emergency department. Ann Emerg Med January 1997;29:146-150.]

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INTRODUCTION

The appropriate relief of pain and anxiety is essential in the management of pediatric patients undergoing painful procedures in the emergency department. To accomplish this goal, a pharmacologic agent or combination of agents should provide ease of administration, rapid onset, effective and predictable analgesia; avoid airway and cardiopulmonary compromise; and result in rapid and smooth recovery.1, 2

Ketamine hydrochloride is a unique pharmacologic agent that produces a trancelike catatonic

MATERIALS AND METHODS

This study was approved by the Institutional Review Board of Albany Memorial Hospital. Patients aged 3 months through 8 years whom we deemed to require immobilization for painful or emotionally disturbing procedures that were expected to be completed in 10 minutes or less were considered candidates for ketamine sedation. We excluded patients with acute or chronic pulmonary infection or cardiovascular disease, including hypertension; head injury associated with loss of consciousness, altered

RESULTS

Thirty children were enrolled in the study (age range, 18 months to 8 years; median, 38 months). Twenty-one were boys. Laceration repair was the most common procedure (27 of 30 [90%]). The remaining cases included removal of foreign bodies from feet and ears and lumbar puncture.

Veins in the hands and antecubital regions were most often used for IV access (17 and 13 cases, respectively). In one case, IV access was believed to be present when the characteristic “flash” of blood appeared in the

DISCUSSION

IV ketamine administration has many attractive pharmacokinetic properties that recommend it for sedation of children in the ED. A dose of 1 mg/kg has been reported to have resulted in a peak concentration and clinical effects within 1 minute.6 In our study, a dose of 1.5 mg/kg reliably produced dissociative sedation within 2 minutes.

After IV administration, ketamine is rapidly distributed into peripheral tissues, resulting in return of coherence within 15 minutes.7 We found that this property

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From the Department of Emergency Medicine, Albany Memorial Hospital, Albany, New York.

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Address for reprints: Robert J Dachs, MD, Department of Emergency Medicine, Albany Memorial Hospital, 600 Northern Boulevard, Albany, New York 12204

Reprint no. 47/1/78154

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