Paediatric Procedural Sedation in the Emergency Department
Flowcharts
Procedural Sedation Flowchart
Procedural Sedation Checklist
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Introduction, Scope & Purpose
Ketamine is a phencyclidine (PCP) derivative that acts as a dissociative sedative through binding of the N-methyl-D-aspartate (NMDA) receptor. It has anxiolytic, analgesic, amnesic and dissociative properties with a wide safety margin.
Ketamine is a safe and effective procedural sedation option for children in the Emergency Department. Under specific circumstances it allows for treatment of injuries requiring emergency and urgent intervention and may negate the need for a general anaesthetic and hospital admission.
Before ketamine procedural sedation is used all other options should be fully considered, including analgesia, reassurance, distraction, nitrous oxide/ Entonox®, intranasal diamorphine, and play therapy (1).
Clinicians must have experience of using ketamine for sedation in the ED, be aware of potential side effects, and be in a position to confidently treat them where necessary. Ketamine should not be used for sedation in the Emergency Department for children under the age of 1 year. Ketamine should be only be used by clinicians with significant relevant experience in the use of ketamine when performing procedural sedation in children aged between 2-5 years (1). Other standard safety requirements related to the safe sedation of all patients in the Emergency Department also apply (minimum staffing, monitoring etc).
This guidance is to assist experienced Emergency Medicine physicians to provide safe procedural sedation to children in the Emergency Department. It largely pertains to the use of ketamine as a sedative agent. However, it is recognised that older children who are expected to behave more physiologically like young adults may be suitable for sedation with an alternative agent such as propofol. Emergency physicians who are experienced in sedation with propofol may consider this as appropriate. For standardisation of care however, we would encourage the use of the accompanying guidance and checklist for all paediatric patients.
The aim of this document is to standardise and improve the delivery of safe procedural sedation for children presenting to the Emergency Department.
This document summarises the following, based on the most up to date RCEM guidance:
Ketamine is a safe and effective procedural sedation option for children in the Emergency Department. Under specific circumstances it allows for treatment of injuries requiring emergency and urgent intervention and may negate the need for a general anaesthetic and hospital admission.
Before ketamine procedural sedation is used all other options should be fully considered, including analgesia, reassurance, distraction, nitrous oxide/ Entonox®, intranasal diamorphine, and play therapy (1).
Clinicians must have experience of using ketamine for sedation in the ED, be aware of potential side effects, and be in a position to confidently treat them where necessary. Ketamine should not be used for sedation in the Emergency Department for children under the age of 1 year. Ketamine should be only be used by clinicians with significant relevant experience in the use of ketamine when performing procedural sedation in children aged between 2-5 years (1). Other standard safety requirements related to the safe sedation of all patients in the Emergency Department also apply (minimum staffing, monitoring etc).
This guidance is to assist experienced Emergency Medicine physicians to provide safe procedural sedation to children in the Emergency Department. It largely pertains to the use of ketamine as a sedative agent. However, it is recognised that older children who are expected to behave more physiologically like young adults may be suitable for sedation with an alternative agent such as propofol. Emergency physicians who are experienced in sedation with propofol may consider this as appropriate. For standardisation of care however, we would encourage the use of the accompanying guidance and checklist for all paediatric patients.
The aim of this document is to standardise and improve the delivery of safe procedural sedation for children presenting to the Emergency Department.
This document summarises the following, based on the most up to date RCEM guidance:
- Indications
- Contraindications
- Side effects
- Complications
- The procedure
Definitions
Procedural sedation
Use of a sedative agent to achieve a level of anxiolysis, analgesia, amnesia and sedation in order to carry out a painful (or frightening) procedure.
Behaviour or developmental problems
ASA classification
A system for assessing the fitness of patients before surgery which was developed by the American Society of Anaesthesiologists. There are 6 categories:
Use of a sedative agent to achieve a level of anxiolysis, analgesia, amnesia and sedation in order to carry out a painful (or frightening) procedure.
Behaviour or developmental problems
ASA classification
A system for assessing the fitness of patients before surgery which was developed by the American Society of Anaesthesiologists. There are 6 categories:
- Healthy person.
- Mild systemic disease.
- Severe systemic disease.
- Severe systemic disease that is a constant threat to life.
- A moribund person who is not expected to survive without the operation.
- A declared brain-dead person whose organs are being removed for donor purposes.
Ketamine
Ketamine is a dissociative sedative agent which can be used for analgesia, sedation and general anaesthesia. Ketamine is fundamentally different from other procedural sedation agents, and does not conform to the continuum tenet. Dissociation is either present or absent, with a narrow transition zone (1). Ketamine has a wide margin of safety and at doses described in this setting, patients can be expected to maintain their airway reflexes and haemodynamic stability. There is a significant risk of a failure of sedation if the procedure is prolonged. Onset of action is typically by one minute, providing effective sedation for 10 to 20 minutes. Time to recovery and fitness for discharge is 90 minutes on average (1). Side effects and risks are mentioned in more detail below.
Characteristics of ketamine sedation include the following:
The literature recommends a dose of ketamine of 1mg/kg by slow intravenous injection over at least one minute (more rapid administration is associated with respiratory depression). Successful sedation for short procedures can be achieved with lower doses such as 0.6-0.8 mg/kg. Supplemental doses of 0.5mg/kg by slow IV injection, may be required after 5-10 minutes to achieve the required dissociative state (1).
The recommendations in this guidance are in line with an RCEM update in 2020. They recognise IM ketamine as a pragmatic option when used by a senior decision maker. Consideration must be taken into account of the perceived safety benefits of having IV access from the start of the procedure to mitigate a rare adverse event. IM ketamine has a higher risk of emesis and longer recovery time. This guidance aims to standardise care and support safe practice but recognises that experienced individual clinicians may prefer to use the IM route in certain circumstances. The accompanying checklist and guidance can still be used.
Characteristics of ketamine sedation include the following:
- Dissociation – trance-like state with eyes open but not responding
- Catalepsy – normal or slightly increased muscle tone maintained
- Analgesia – excellent analgesia is typical
- Amnesia – usually total
- Airway reflexes maintained
- Cardiovascular state – blood pressure and heart rate increase slightly
- Nystagmus is typical, usually horizontal; eyes remain open and glazed
The literature recommends a dose of ketamine of 1mg/kg by slow intravenous injection over at least one minute (more rapid administration is associated with respiratory depression). Successful sedation for short procedures can be achieved with lower doses such as 0.6-0.8 mg/kg. Supplemental doses of 0.5mg/kg by slow IV injection, may be required after 5-10 minutes to achieve the required dissociative state (1).
The recommendations in this guidance are in line with an RCEM update in 2020. They recognise IM ketamine as a pragmatic option when used by a senior decision maker. Consideration must be taken into account of the perceived safety benefits of having IV access from the start of the procedure to mitigate a rare adverse event. IM ketamine has a higher risk of emesis and longer recovery time. This guidance aims to standardise care and support safe practice but recognises that experienced individual clinicians may prefer to use the IM route in certain circumstances. The accompanying checklist and guidance can still be used.
Indications
Children over 12 months of age requiring a painful or frightening procedure, after all other options have been considered.
May be used as an alternative to a general anaesthetic for a definitive treatment, or if the child requires a procedure prior to theatre e.g. manipulation of a limb with neurovascular compromise, application of traction or insertion of nerve block.
The procedure should be completed within 20 minutes. If this is unlikely, a general anaesthetic would be more appropriate.
May be used as an alternative to a general anaesthetic for a definitive treatment, or if the child requires a procedure prior to theatre e.g. manipulation of a limb with neurovascular compromise, application of traction or insertion of nerve block.
The procedure should be completed within 20 minutes. If this is unlikely, a general anaesthetic would be more appropriate.
Contraindications
Staffing and departmental safety requirements are discussed in further detail below.
- Age less than 1 year (increased risk of laryngospasm and airway complications)
- A high risk of laryngospasm (active respiratory infection, active asthma)
- Proposed procedure within the mouth or pharynx
- Altered conscious level due to illness, injury, alcohol or substances
- Previous adverse reaction to ketamine
- Patients with an ASA classification of II or above. This includes the following, although the list is not exhaustive:
- Unstable or abnormal airway. Tracheal surgery or stenosis
- Patients with severe psychological problems such as cognitive or motor delay or severe behavioural problems
- Previous psychotic illness
- Significant cardiac disease (angina, heart failure, malignant hypertension)
- Pulmonary hypertension
- Intracranial hypertension with CSF obstruction
- Intra-ocular pathology (glaucoma, penetrating injury)
- Uncontrolled epilepsy
- Hyperthyroidism or taking thyroid medication
- Porphyria
- Unstable or abnormal airway. Tracheal surgery or stenosis
Side Effects
- Mild agitation (20%)
- Hypersalivation and lacrimation (<10%)
- Involuntary movements / ataxia (5%)
- Transient rash (10%)
- Vomiting (5 to 10% will vomit in the recovery phase). Ondansetron can be given if required.
All resolve in the vast majority of cases and will simply require observation.
Complications
- Apnoea can occur following rapid administration of ketamine intravenously, but is rare (0.3%). Administration over one minute is advised to eliminate this risk.
- Airway misalignment/ noisy breathing have been described as “ketamine breathing” characterised by deep sighing which may be mistaken for stridor. Head repositioning is usually sufficient to resolve this uncommon complication (<1%)
- Laryngospasm is a rare complication (0.3%) and should be managed by stopping the procedure, repositioning the airway and suctioning any secretions in the first instance. Application of PEEP with a bag-valve mask or Ayre’s T-piece may be required. In the vast majority of cases, the laryngospasm will resolve and the procedure can be completed. If persistent however, a muscle relaxant such as suxamethonium or rocuronium may be required with assisted ventilation until recovery. Preparations for potential intubation should be made and a 2222 call put out for rapid anaesthetic assistance. This can be at the discretion of the senior clinician and will vary on a case by case basis.
- Emergence Phenomena is recognised as agitation and hallucinations as the dissociative effects of ketamine wear off. In children under 10 years, it is uncommon (1.6%). Incidence increases from mid-adolescence with up to 1 in 3 adults experiencing a degree of emergence. It can largely be reduced by maintaining a calm, low-stimulus environment and encouraging positive imagery before the procedure. Prophylactic benzodiazepine use is not recommended. However, if severe agitation occurs, small increments of midazolam can be given up to 0.05- 0.1mg/kg IV.
The Procedure
The Department
It must be agreed with the senior clinician and nurse in charge that the current state of the Emergency Department with regard to staffing and workload is safe to provide procedural sedation for a child. This risk threshold for this will depend upon the urgency of the procedure.
The child should be managed in a high dependency or resuscitation area with immediate access to resuscitation equipment including oxygen, suction and a resuscitation trolley.
Staff
A minimum of 3 competent staff are required for the duration of the sedation:
Procedural sedation of a child should only be carried out by clinicians experienced in its use. It is recommended that only a senior clinician with dedicated training in paediatric sedation should undertake sedation of a child under 5 years of age. Any clinician undertaking procedural sedation should be sufficiently trained and competent in managing any complications, particularly apnoea and laryngospasm. They should be an ST4 doctor above or equivalent and have a minimum of 6 months experience in anaesthesia or intensive care, or evidence of equivalent competency. They should be up to date with APLS.
Pre-Procedure
This should include confirming appropriateness of procedural sedation, adequate analgesia, working intravenous access and consent. It is preferable to have an actual weight but an estimated weight can be used in order to print a SORT drug calculator for the child. Appropriate dose of ketamine should be drawn up and checked by 2 members of staff.
A pre-assessment should be made to look for potential airway complications, with particular reference to previous anaesthetics, current or past illness, and allergies. Medications given during this current presentation should be noted. Fasting status should be noted but is not a contraindication to sedation.
Airway equipment, monitoring, oxygen and suction should be checked. Staff in the immediate area should be aware that a procedural sedation is planned in order to minimise noise and stimulation as best possible. Where time allows, use of a topical anaesthetic to minimise pain from cannulation is beneficial. It is often helpful to cannulate the child in an intial assessment area before moving to the high dependency or resuscitation room. The environment should be as calm as possible with the parent or carer encouraged to engage and calm the child as appropriate.
Consent
The procedure and sedation should be discussed with the patient and/ or carer. Risks should be discussed along with alternative options. Consent should be written. It is useful to explain to the parent or carer that nystagmus and shouting out are expected and are a common response to ketamine.
Monitoring
The following should be monitored at 5 minute intervals:
The Sedation
Supplemental oxygen should be given prior to and during the procedure, recognising that on occasion the procedure (e.g. facial suturing) may prevent the use of an oxygen mask. However, it should be recognised that there is clear evidence for the safety of using only ‘room air’ only during ketamine in procedural sedation (1).
Ketamine should be administered by slow intravenous injection over one minute to prevent apnoea. Evidence of dissociation is usually seen by 1 to 2 minutes and painful procedures should not begin until 2 minutes after administration. Top up increments of 0.5mg/kg may be required depending on response, up to a total of 1.5mg/kg. Adequate sedation is usually indicated by nystagmus, loss of response to verbal stimuli and a rise in heart rate, blood pressure and respiration. Local anaesthesia should be used where indicated.
Post-Procedure
Once the procedure is complete, the child should recover in a quiet, observed and monitored area under continuous observation of a trained nurse. Recovery should be complete between 60 and 120 minutes. Any further imaging should be arranged, as well as follow up if the child is to be discharged home.
The child can be safely discharged once they meet the following criteria:
An advice sheet should be given to the parent or carer to advise what to expect and how to manage the child for the next 24 hours.
Documentation of the procedure should be completed as well as any local audit data. Any adverse events should be documented and reviewed; a clinical incident report should be considered as appropriate.
It must be agreed with the senior clinician and nurse in charge that the current state of the Emergency Department with regard to staffing and workload is safe to provide procedural sedation for a child. This risk threshold for this will depend upon the urgency of the procedure.
The child should be managed in a high dependency or resuscitation area with immediate access to resuscitation equipment including oxygen, suction and a resuscitation trolley.
Staff
A minimum of 3 competent staff are required for the duration of the sedation:
- A suitably trained clinician to sedate the patient and manage any complications
- A clinician to perform the procedure
- An experienced nurse to monitor the patient, document in the notes, and support the patient and carers.
Procedural sedation of a child should only be carried out by clinicians experienced in its use. It is recommended that only a senior clinician with dedicated training in paediatric sedation should undertake sedation of a child under 5 years of age. Any clinician undertaking procedural sedation should be sufficiently trained and competent in managing any complications, particularly apnoea and laryngospasm. They should be an ST4 doctor above or equivalent and have a minimum of 6 months experience in anaesthesia or intensive care, or evidence of equivalent competency. They should be up to date with APLS.
Pre-Procedure
This should include confirming appropriateness of procedural sedation, adequate analgesia, working intravenous access and consent. It is preferable to have an actual weight but an estimated weight can be used in order to print a SORT drug calculator for the child. Appropriate dose of ketamine should be drawn up and checked by 2 members of staff.
A pre-assessment should be made to look for potential airway complications, with particular reference to previous anaesthetics, current or past illness, and allergies. Medications given during this current presentation should be noted. Fasting status should be noted but is not a contraindication to sedation.
Airway equipment, monitoring, oxygen and suction should be checked. Staff in the immediate area should be aware that a procedural sedation is planned in order to minimise noise and stimulation as best possible. Where time allows, use of a topical anaesthetic to minimise pain from cannulation is beneficial. It is often helpful to cannulate the child in an intial assessment area before moving to the high dependency or resuscitation room. The environment should be as calm as possible with the parent or carer encouraged to engage and calm the child as appropriate.
Consent
The procedure and sedation should be discussed with the patient and/ or carer. Risks should be discussed along with alternative options. Consent should be written. It is useful to explain to the parent or carer that nystagmus and shouting out are expected and are a common response to ketamine.
Monitoring
The following should be monitored at 5 minute intervals:
- Sedation level and pain
- ECG, Oxygen Saturations and Non-invasive blood pressure
- Respiratory and pulse rate
- Capnography
The Sedation
Supplemental oxygen should be given prior to and during the procedure, recognising that on occasion the procedure (e.g. facial suturing) may prevent the use of an oxygen mask. However, it should be recognised that there is clear evidence for the safety of using only ‘room air’ only during ketamine in procedural sedation (1).
Ketamine should be administered by slow intravenous injection over one minute to prevent apnoea. Evidence of dissociation is usually seen by 1 to 2 minutes and painful procedures should not begin until 2 minutes after administration. Top up increments of 0.5mg/kg may be required depending on response, up to a total of 1.5mg/kg. Adequate sedation is usually indicated by nystagmus, loss of response to verbal stimuli and a rise in heart rate, blood pressure and respiration. Local anaesthesia should be used where indicated.
Post-Procedure
Once the procedure is complete, the child should recover in a quiet, observed and monitored area under continuous observation of a trained nurse. Recovery should be complete between 60 and 120 minutes. Any further imaging should be arranged, as well as follow up if the child is to be discharged home.
The child can be safely discharged once they meet the following criteria:
- Airway patent
- Haemodynamically stable
- Vital signs within normal limits
- Child is conscious, alert and responds appropriately
- Child walking/mobilising (limited only by e.g. cast)
An advice sheet should be given to the parent or carer to advise what to expect and how to manage the child for the next 24 hours.
Documentation of the procedure should be completed as well as any local audit data. Any adverse events should be documented and reviewed; a clinical incident report should be considered as appropriate.
References
- Royal College of Emergency Medicine Best Practice Guideline: Ketamine procedural sedation for children in the Emergency Department; February 2020.
- Royal College of Anaesthetists and Royal College of Emergency Medicine Working Party on Sedation Analgesia and Airway Management in the Emergency Department. Safe Sedation of Adults in the Emergency Department: CEM6911 London: Royal College of Emergency Medicine; 2012.
- National Institute for Health and Care Excellence. Sedation in children and young people: Sedation for diagnostic and therapeutic procedures in children and young people guidance.nice.org.uk/cg112: NICE; 2010.
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Document Version:
1.1 Lead Authors: Crystal Collings, Paed Emergency Medicine Trainee Alan Charters, Consultant Nurse PEM, QAH David Patel – Consultant Paed Emergency Medicine, QAH Clarissa Chase – Consultant Paed Emergency Medicine, UHS |
Approving Network:
Wessex Paediatric Emergency Medicine Clinical Network Date of Approval: March 2022 Review Due: March 2025 |
PIER Contact |
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