Do you know 3 myths about ketamine, children?
Ketamine makes children act crazy. The drug is more dangerous than other ED sedatives. Patients can get addicted from being sedated with ketamine.
These are all common "ketamine myths," says Steve Green, MD, FACEP, professor of emergency medicine and pediatrics at Loma Linda (CA) University Medical Center & Children’s Hospital and author of recently published clinical guidelines on use of ketamine for sedation of children in the ED.1
"Ketamine is now well established as an extremely safe ED sedative," he says. "You can effectively perform very painful procedures with ketamine that you simply cannot with narcotics or benzodiazepines."
The Dallas-based American College of Emergency Physicians (ACEP) recently released a clinical policy for ED procedural sedation and analgesia that endorsed ketamine with their highest Level A rating.2 By contrast, midazolam, fentanyl, and propofol were assigned Level B, and etomidate was assigned Level C.
Many misconceptions remain, however, says Green. "Because its properties are different than those of other ED sedatives, sometimes physicians and nurses unfamiliar with ketamine are apprehensive about starting to administer it," he says.
Ketamine is a short-acting, dissociative sedative that preserves normal spontaneous respirations and airway reflexes, says Chris Yoshida-McMath, RN, clinical educator for the pediatric ED at Loma Linda University Children’s Hospital. "So it is perfect for procedures such as suturing complex lacerations, reducing fractures, and removal of foreign bodies," she says.
When ketamine is used to sedate children at Loma Linda University Children’s ED, the following steps occur, says Yoshida-McMath:
- The nurse sets up the safety equipment, including suction, bag valve mask, oxygen, and monitors; gathers the equipment necessary for the procedure; starts an intravenous (IV) line on the patient if the drug is to be given IV rather than intramuscularly (IM); and educates and reassures the family as to what they may see.
- The ED physician comes to the bedside to administer the ketamine. The nurse monitors and documents vital signs and the patient’s condition, monitors the airway, and administers oxygen or performs suctioning as necessary.
- Once the procedure is complete, the nurse recovers the patient and educates the family on what to expect until the patient becomes fully awake.
To improve care of patients sedated with ketamine, consider the following:
- Know what to expect during recovery.
Although negative recovery reactions such as nightmares and hallucinations have been reported in adults, this problem is extremely rare with pediatric patients, says Green. "For reasons that are not well established, such unpleasant reactions essentially never occur in children," he says. "Children do sometimes hallucinate during recovery, but these experiences are almost always associated with fascination and wonder rather than fear."
Still, children sedated with ketamine "don’t look like kids sedated with anything else," says Green. "Even though the child doesn’t look asleep,’ their brain is temporarily disconnected from all outside stimuli, including all pain," he explains. "Instead of looking relaxed and asleep as with benzodiazepines, opioids, or propofol, they instead look catatonic."
Muscle tone is preserved and sometimes accentuated, eyes are open with a blank stare and frequent nystagmus, and patients may randomly move their arms or legs, says Green. "ED nurses must learn to be comfortable with this unusual appearance and to educate and forewarn parents on how their children will appear," he says.
- Give a single loading dose rather than titration.
All other sedatives are carefully titrated to avoid dose-related cardiopulmonary depression, but ketamine is the exception to this rule, says Green. "Ketamine doesn’t depress respirations, unless pushed rapidly intravenously, and actually increases blood pressure," he says. "Therefore, it is not only acceptable but preferred to give single loading doses of ketamine, rather than titrating to effect."
- Remember that the drug has very rapid onset.
Don’t administer ketamine until the physician is at the bedside ready to begin the procedure, as the full onset of the dissociative state after IV administration occurs typically within one minute, and within three to five minutes for IM administration, says Green.
- Be aware of potential for dosage errors.
Since ketamine comes in three concentrations (10 mg/ml, 50 mg/ml, and 100 mg/ml), inadvertent overdoses have occurred as a result of mixing up the bottles, says Green. "Fortunately, no adverse outcomes have occurred," he says. "The principal adverse effect of these overdoses was prolonged sedation."
- Know that coadministered benzodiazepines are unnecessary.
For many years, a benzodiazepine was given concurrently with ketamine in an attempt to suppress recovery reactions, and some EDs still coadminister the medications, says Green. "However, studies have shown that there is no benefit to this and, in fact, the benzodiazepine introduces respiratory depression on its own," he says.3,4
- Reassure patients who have fears about addiction.
Adults or teenagers who have heard of ketamine may ask, "Is this the same thing as the street drug Special K’? Can I become addicted?" says Yoshida-McMath.
Patients are informed that it is the same drug, but used legitimately as the pharmaceutical companies intended, she reports. "I’ve had to reassure them that ketamine is a controlled substance from a pharmaceutical company and is used for procedural sedation for medical procedures," she says. "Also, that they cannot become addicted by receiving this medication one time."
References
- Green SM, Krauss B. Clinical practice guideline for emergency department ketamine dissociative sedation in children. Ann Emerg Med 2004; 44:460-471.
- American College of Emergency Physicians: Clinical policy: Procedural sedation and analgesia in the emergency department. Ann Emerg Med 2005; 45:177-196.
- Sherwin TS, Green SM, Khan A, et al. Does adjunctive midazolam reduce recovery agitation after ketamine sedation for pediatric procedures? A randomized, double-blind, placebo-controlled trial. Ann Emerg Med 2000; 35:239-244.
- Wathen JE, Roback MG, Mackenzie T, et al. Does midazolam alter the clinical effects of intravenous ketamine sedation in children? A double-blind, randomized, controlled emergency department trial. Ann Emerg Med 2000; 36:579-588.
Sources
For more information on ketamine use in the ED, contact:
- Steven Green, MD, FACEP, Loma Linda University Medical Center, A-108, 11234 Anderson St., Loma Linda, CA 92354. E-mail: [email protected].
- Chris Yoshida-McMath, RN, Clinical Educator, Pediatric Emergency Department, Loma Linda University Children’s Hospital, 11234 Anderson St., P.O. Box 2000, Loma Linda, CA 92354. Telephone: (909) 558-8387. E-mail: [email protected].
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