Procedural Sedation - Ketamine (> 3 months)



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Procedural Sedation - Ketamine (> 3 months)

Meets discharge criteria?

Consider equipment failure, possible need for increased ketamine dose

Apply monitoring equipment

  • Pulse oximetry
  • Capnography
  • Cardiorespiratory monitor
  • Blood pressure

Ondansetron (PF) (Zofran) Injection 4 mg
Ondansetron (Zofran) 0.1 mg/kg IV - weight based

Place IV (if possible)

Morphine

  • Morphine > 30 min prior to ketamine sedation was not linked to increased adverse effects

Admit To Inpatient

Obtain informed consent

Features of a difficult airway

Lemon © mneumonic

  • Look externally
  • Evaluate 3-3-2
  • Mallampati
  • Obstruction/Obesity
  • Neck mobility

Contraindications to ondansteron?

Patient adequately sedated?

Preform procedure

Discharge

Inclusion Criteria
  • Clinical need for procedural sedation
Exclusion Criteria
  • Hypertension or heart failure
  • Porphyria, thyroid disease, Schizophrenia, glaucoma, open globe injury
  • High risk anatomical features
  • High risk medical/surgical history
  • Allergy or hypersensitivity to ketamine
  • History of complications with sedation
  • < 3 months old

Meets NPO criteria?

ASA classification appropriate for sedation?

Risk of difficult airway appropriate for sedation?

IM route required?

Wait for appropriate times if possible

Emergent need for sedation?

NPO Diet

Apply as many non-emergent sedation practices as possible, consider NG/OG tube to evacuate stomach contents, consult advanced airway practitioner if possible

Sedation goals:

  • Guard the patient’s safety and welfare
  • Minimize physical discomfort and pain
  • Control anxiety, minimize psychological trauma, and maximize the potential for amnesia
  • Control behavior and/or movement to allow the safe completion of the procedure
  • Return the patient to a state in which safe discharge from medical supervision, as determined by recognized criteria, is possible

Contraindications to ondansetron

  • Allergy or hypersensitivity
  • Long QT disorders

1.5 mg/kg IV

Ketamine (ketalar) Injection - Weight Based
4 mg/kg IM

Ketamine (ketalar) Injection - Weight Based

Pre-procedure checklist

  • Procedure timeout
  • Personal present
  • Advanced practice clinician - Monitor sedation
  • Clinician - Preform procedure
  • Assistant/RN
  • Emergency equipment
  • Oxygen
  • Bag-mask system
  • Laryngoscope with appropriately sized blades and endotracheal tubes
  • Suction catheters and apparatus
  • Emergency cart with appropriate medications
  • Defibrillator

Complications

  • Vomiting
  • Tachycardia / hypertension
  • Airway obstruction
  • Apnea
  • Laryngospasm
  • Hallucinations
  • Anaphylaxis

Increased intracranial pressure

  • Very weak evidence ties ketamine to increased ICP and recent studies show that ketamine is safe in patients at risk for increased ICP.

Consult advanced airway practitioner

Midazolam premedication

  • Midazolam have not been shown to decrease adverse effects.

Ketamine-induced neuroapoptosis

  • Concerns regarding neuroapoptosis have been reported in experimental models, however these models do not represent the usual situation of procedural sedation (supratheraputic doses for very long duration in fetal animals) and most providers discount this as a risk for the use of ketamine.

Anticholinergic premedication

  • Atropine and glycopyrrolate have not been shown to decrease adverse effects.

Discharge criteria

  • Reassuring vital signs
  • Tolerating PO
  • Well-appearing
  • No social/family concerns
  • Reliable follow up in 24 hours
  • Parents comfortable and understand discharge plan
  • Provider comfortable with outpatient therapy

Consult advanced airway practitioner

ASA classification

  • Class I – A normally healthy patient
  • Class II – A patient with mild systemic disease
  • Class III – A patient with severe systemic disease
  • Class IV – A patient with severe systemic disease that is a constant threat to life
  • Class V – A moribund patient who is not expected to survive without the operation

NPO criteria

  • Two hours after clear liquids
  • Four hours after breast feeding
  • Six hours after ingesting solid foods, formula, or milk other than human milk.

Of note, there are very, very few cases of aspiration during ketamine sedation with and without waiting for the above NPO times. Ketamine maintains airway/swallowing reflexes making the risk of aspiration low even with disassociation and occasional vomiting. Emergent procedures should, of course, not be delayed for NPO times. However, if waiting for NPO status is otherwise a judgment call for procedural sedation with ketamine.




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