Avoid adverse events with ketamine for pediatrics
Adverse events do not increase during pediatric ketamine sedation when children are pretreated with morphine analgesia, says a new study.1
Researchers looked at 858 children receiving ketamine for procedural sedation. The number of adverse events in the group receiving morphine pre-procedural analgesia were compared with a group of patients whom did not receive pre-procedural narcotic analgesia.
A total of 21 adverse events were recorded in the group of patients without morphine pretreatment vs. 13 adverse events in the group of patients receiving morphine pretreatment analgesia.
The study's findings support ED protocols for nurses administering narcotics in triage or immediately upon intravenous (IV) placement in patients with severe orthopedic emergencies likely to require reduction, says Marc Leder, MD, one of the study's authors and attending ED physician at Children's Hospital in Columbus, OH. "In our study, the time from morphine administration to definitive reduction was close to two hours," he adds. "If protocols to treat pain early are not established, there may be clear delays in patient pain management if no pain medications are given until procedural sedation begins."
ED nurses monitoring patient procedural sedation should be aware of narcotic pretreatment to anticipate potential complications such as prolonged sedation, says Leder. "Preparation to respond to hypoxia, apnea, or respiratory distress should always be in place as per standard practice of monitoring for procedural sedation."
At Children's Healthcare of Atlanta's ED, several medications are used for moderate sedation, including ketamine. "The process we follow for sedation includes a number of pre-procedural steps," says Marianne Hatfield, RN, BSN, system director of emergency services. They are as follows:
• The ED physician examines the patients to determine whether they are appropriate candidates for sedation. An informed consent form is signed by the parents that outlines the specific risks and benefits of the procedure.
• The ED nurse validates that the consent has been obtained and prepares the patients for the sedation procedure. The nurse makes sure that the appropriate equipment is available to manage emergency situations including suction, age- and size-appropriate airway equipment, age- and size-appropriate intravenous equipment, emergency medications, a pulse oximetry monitor, a cardiac monitor, a blood pressure monitoring device, age- and size-appropriate nasogastric tube, reversal medications, and an oxygen delivery system.
• The nurse obtains the ordered sedative from the ED's automated medication storage system, recalculates the ordered dose, and reviews the medication dose with a second nurse who serves as a "double-check" witness.
• The physician administers the medication at the bedside. The nurse documents the following items:
— level of consciousness;
— airway status;
— respiratory rate;
— heart rate;
— blood pressure;
— oxygen saturation;
— pain assessment;
— medication documentation (name, route, site, time, dose, and effect of administered medications);
— inspired concentration of oxygen, its duration, and method of administration;
— any adverse events occurring during the sedation process.
At Children's Medical Center of Dallas, ED nurses must have current pediatric advanced life support (PALS) certification and complete an annual competency to perform sedations, says Lanie St. Claire, RN, ED nurse and pre-hospital liaison.
Ketamine is commonly used for pediatric moderate sedations, often concurrently with atropine and versed, adds St. Claire. Maintaining the patient's protective reflexes, airway, and appropriate responses during a conscious sedation require bedside monitoring by the nurse or respiratory therapist for a minimum of one hour after the last dose of medication is given and Aldrete score requirements have been met, she says.
Morphine can potentiate the sedative effects of these drugs, says Jordan Whitehill, PharmD, a pharmacist in the ED. "However if the patient is in pain and cannot be safely sedated for reasons such as NPO status, morphine should not be withheld just because they are going to be sedated," Whitehill says.
If morphine was given at an outside facility or must be given on arrival for pain, it is important to obtain a complete history from paramedics, the parents, or the child's caregiver, says St. Claire. "The nurse and physician ordering and administering the drugs should be aware that morphine is on board," she says.
For a previously healthy child without airway compromise, you may notice little difference in recovery, other than it may take a few minutes longer for the child to arouse, says St. Claire. However, in a child with a significant health history, an anesthesiologist may be required to determine if a conscious sedation in the ED is appropriate or may elect to stay at bedside for the sedation, she says.
You must have the following items at the bedside "ready to go," says St. Claire: Oxygen, the correct size mask already placed on an anesthesia bag that can deliver 15 liters/min. for at least 60 minutes if needed, and suction with Yankauer already connected. "Respiratory rate, not pulse oximetry, will be the first indicator that your pediatric sedation is having difficulty," she says. Capnography also is recommended for the purpose of early recognition of decreased respiratory status, she sys. "This is why you must remain at the bedside until the patient is recovered," St. Claire says.
Push drugs slowly over one to two minutes with a slow intravenous push in between, she advises. "These drugs affect the respiratory drive via the central nervous system, so pushing them slower allows a less concentration of the drug to affect the central nervous system," St. Claire says. "This alone can prevent respiratory disaster."
Reference
- Waterman GD, Leder MS, Cohen DM, et al. Adverse events in pediatric ketamine sedations with or without morphine pretreatment. Ped Emerg Care 2006; 22:408-411.
Sources
For more information on pediatric sedation, contact:
- Marianne Hatfield, RN, BSN, System Director of Emergency Services, Children's Healthcare of Atlanta, 1001 Johnson Ferry Road N.E., Atlanta, GA 30342. Telephone: (404) 785-4968. E-mail: [email protected].
- Marc Leder, MD, Attending Physician, Emergency Department, Children's Hospital, 700 Children's Drive, Columbus, OH 43205. Telephone: (614) 722-4396. E-mail: [email protected].
- Lanie St. Claire, RN, Emergency Center, Children's Medical Center Dallas, 1935 Motor St., Dallas, TX 75235. Telephone: (214) 456-7308. E-mail: [email protected].
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