Daily Bolus of LR: Ketamine use for procedural sedation

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May 26, 2011 by dailybolusoflr

Ketamine
·         Ketamine is a dissociative anesthetic that is used more commonly in children for the performance of procedures
·         It is rapidly absorbed by the cerebral tissue and metabolized by the liver
·         Administration
o   In the ED, we typically use either IV or IM administration
o   It can also be given rectally and orally
·         Dose, Onset and Duration
o   IV 1-2mg/kg; onset 1 minute; duration 15-30 minutes
o   IM 4-6mg/kg; onset 5 minutes; duration 30-40 minutes
o   Repeat doses at half the intial dose are recommended as needed
·         Complications and Side Effects
o   Emergence Phenomenon
§  more commonly seen in patients over the age of 10
§  less common with IM injection
§  most recent report was just under 40% of adult patients had this in the small sample of patients in the 2010 study comparing propofol and ketamine (citation at the bottom)
§  pre-treatment recommended with benzodiazepines for adults, for children- unclear that it is necessary
o   Hypersalivation
§  Previous guidelines had  pre-treatment with low dose atropine or glycopyrrolate (anticholinergic)
§  Most recent clinical practice guidelines do not support prophylactic use, but rather when situational need occurs
o   Respiratory Depression
§  Rare- treat with oxygen as needed
o   Laryngospasm
§  Rare, but if occurs- BVM attempts and if failed, consider paralytics
o   Emesis
§  Rare
§  Appears to be at its peak in early adolescents
§  Higher associated with IM
o   Elevated HR and BP
§  Frequent
§  Related to ketamines ability to block reuptake of circulating catecholamines
ACADEMIC EMERGENCY MEDICINE 2010; 17:604–611 (propofol and ketamine)
Ann Emerg Med. 2011;57:449-461 (practice guidelines- nice article summary)
Linda Regan, MD FACEP
Program Director, Emergency Medicine Residency
Johns Hopkins Medical Institutions

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