Intramuscular Ketamine for Pediatric Sedation in the Emergency Department: Safety Profile in 1,022 Cases,☆☆,

Presented at the Society for Academic Emergency Medicine Annual Meeting, Washington DC, May 1997.
https://doi.org/10.1016/S0196-0644(98)70226-4Get rights and content

Abstract

Study objective: To determine the safety of intramuscular ketamine when administered by emergency physicians for pediatric procedures in accordance with a defined protocol. Methods: We assembled a consecutive case series of children aged 15 years or younger who were given ketamine in the emergency departments of a university medical center and an affiliated county hospital over a 9-year period. A protocol for ketamine use (4 mg/kg, intramuscularly) was followed. Treating physicians were instructed to complete data forms recording complications and adequacy of sedation concurrent with patient care. Subsequent chart review was used to determine indications, adjunctive drugs, time to discharge, and adverse reactions for all patients. Results: Intramuscular ketamine was administered 1,022 times, mainly for laceration repair and fracture reduction. Physicians completed data forms for 431 of treated children (42%). Transient airway complications occurred in 1.4%: airway malalignment (n=7), laryngospasm (n=4), apnea (n=2), and respiratory depression (n=1). All were quickly identified and treated without intubation or sequelae. Emesis occurred in 6.7%, without evidence of aspiration. Mild recovery agitation occurred in 17.6%, moderate to severe agitation in 1.6%. No child required hospitalization for complications caused by ketamine. Ketamine produced acceptable sedation in 98% of patients. The median time from injection to emergency department discharge was 110 minutes for children given a single dose of ketamine. Conclusion: Intramuscular ketamine may be administered safely by emergency physicians to facilitate pediatric procedures in accordance with a defined protocol and with appropriate monitoring. Ketamine is highly effective, has a wide margin of safety, does not require intravenous access, and uniquely preserves protective airway reflexes. [Green SM, Rothrock SG, Lynch EL, Ho M, Harris T, Hestdalen R, Hopkins GA, Garrett W, Westcott K: Intramuscular ketamine for pediatric sedation in the emergency department: Safety profile in 1,022 cases. Ann Emerg Med June 1998;31:688-697.]

Introduction

The use of ketamine for pediatric sedation in the ED1, 2, 3, 4, 5, 6, 7, 8 and other non–operating-room settings9, 10, 11, 12, 13 has become increasingly popular. Ketamine may be administered intramuscularly or intravenously, does not require endotracheal intubation, and reliably produces potent analgesia, sedation, and amnesia.1, 2, 14, 15, 16, 17

In 1990 our center published a pilot series of 108 children given intramuscular ketamine 4 mg/kg for ED procedural sedation.2 In that study, ketamine was noted to have a rapid onset, a high rate of acceptable sedation, and a mean duration of effect of 82 minutes from administration until discharge criteria were met. The only complication requiring intervention was transient laryngospasm, in one child. This report and other small series have substantiated the efficacy of ketamine for pediatric procedural sedation3, 4, 5, 6, 7; however, no reports have contained enough subjects to reliably determine the safety profile of this agent in the ED setting.

Subsequent to completion of the pilot series, we continued data collection under the same protocol. To profile the safety of intramuscular ketamine when administered by emergency physicians, we report our 9 years of experience with this agent.

Section snippets

Materials And Methods

The study was performed in the EDs of a university medical center and an affiliated county hospital. These EDs have annual censuses of 39,000 and 50,000, respectively. The study included all patients aged 15 years or younger who were given intramuscular ketamine between October 1, 1987, and September 30, 1996.

The study was approved by the institutional review board of each institution.

At the start of the study, a detailed protocol based on a literature review14 was prepared, and emergency

Results

Ketamine was administered in the ED 1,235 times during the 9-year period. Thirty cases were excluded because their records could not be located. One hundred eighty-three cases were excluded because ketamine was administered intravenously (n=156) or patients were older than 15 years (n=27). Thus the dataset comprised 1,022 consecutive evaluable administrations of intramuscular ketamine in children in the ED. Treating physicians had completed concurrent data forms in 431 of the 1,022 cases (42%).

Discussion

This report constitutes the third-largest ketamine series ever reported,20, 21 and the largest focusing on administration by nonanesthesiologists. Our data validate the conclusions of smaller studies2, 3, 4, 5, 6, 7 that ketamine may be safely administered by emergency physicians. No adverse effects with sequelae were noted in 1,022 consecutive cases. On the basis of this sample size, the probability of such a complication is extremely low—95% CI, 0 to .3%. Although potentially serious airway

Acknowledgements

We thank our ED nurses for invaluable assistance in patient monitoring and parental education and Christopher Hummel, MD; Carl Schultz, MD; Arthur Glickman, RN; N Eric Johnson, MD; Stephen W Corbett, MD, PhD; and Emory Petrack, MD for their review of the manuscript and many helpful comments.

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    From the Departments of Emergency Medicine, Loma Linda University School of Medicine, Loma Linda, CA*; Riverside General Hospital, Riverside, CA*; and Orlando Regional Medical Center, Orlando, FL.

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