Morning Report: 9/6/2012

Here’s another Morning Report from Dr. Cioe. Man, is this guy ever coming back from Africa?!

Notes from Princess Marina Hospital, Gaborone, Botswana

Ketamine Sedation in the ED:

A 6 year old HIV positive child presents to the ED for multiple painful cutaneous abscesses. The child is afebrile, otherwise well appearing, but clearly uncomfortable. On attempt to examine the abscesses, the child screams into your stethoscope and flings himself on the floor. 3 of the abscesses are large enough to be drained…

Ketamine Sedation

Dissociative Sedation – Does not produce unconsciousness but rather a trance like state
- Characterized by profound analgesia and amnesia with retention of protective airway reflexes, spontaneous respirations and cardiopulmonary stability.
Indicated for short painful procedures or examination under sedation
Threshold dose: approximately 1.5 mg/kg in both pediatrics and adults.
- Below that, no sedation, some analgesia, above it, complete dissociative sedation. There is no dose effect like with sedative hypnotics.
Contraindictions – head trauma is not one of them!
- Age< 3 months
- Known or suspected schizophrenia or psychosis
- Major procedures that may stimulate the posterior pharynx
- History of airway instability
- Active airway disease (both lower and upper airway including URI)
- Known or suspected cardiovascular diseases
- CNS masses, abnormalities or hydrocephalus
- Glaucoma or acute globe injuries
- Porphyria, thyroid disorder or thyroid medications
- Radiologic procedures requiring that the patient remain completely still.
Notes on Sedation Procedure
- Consent
- Airway equipment, BVM, monitor
  - Leave O2 off if not using end-tidal CO2
- No premedication! No benzos no anticholinergics
- IV route is preferred especially in adults
- IM can be used for uncooperative and combative patients (but with more side effects)
DOSING
- IV 1.5mg/kg-2mg/kg in children during 30-60 seconds
- IV 1.5 mg/kg in adults during 30-60 seconds
- IV 0.5-1mg/kg incremental doses if initial dose inadequate
- IM 4-5mg /kg in children (IV preferred in adults)
Side effects
- Transient laryngospasm – 0.3% of patients, usually able to be managed with BVM and not intubation (longest documented case was partial obstruction for only 5 minutes)
- Airway misalignment requiring repositioning of head
- Transient apnea or respiratory depression
- Hypersalivation
- Emesis (during recovery)
- Recovery agitation
- Ataxia during recovery (common)
- Muscular hypertonicity and random purposeless movement (very common)
- Clonus, hiccups or short lived non allergic rash of face and neck
Recovery
- Should be in a quite dark place where possible
- Avoid stimulating children in recovery from sedation.
Disposition
- Discharged to a responsible family member if not being admitted
- No walking independently for several hours
- Full documentation in full of procedure done and the medication used

Reference:

Green, et al. Clinical Practice Guideline for Emergency Department Ketamine Dissociative Sedation: 2011 Update. Annals of emergency medicine 1 May 2011 (57:5. 449-461)