IM Ketamine for pediatric sedation

[RoyBasch]

Anybody use IM ketamine for pediatric procedural sedation?

Here's a clinical situation I encounter on occasion.

School age kid, let's say 3-13. Needs a urgent but not emergent procedure, either laceration repair or I&D.

Plan A is LET, distraction, etc. But some kids just ain't havin' it. Patient is already yelling and screaming before you even walk in the room. Maybe some of you are pediatric whisperers, but I'm not and I don't think it's getting better at this point in my career. I'm definitely more of an adult ER physician.

I feel very comfortable with using IV ketamine for pediatric sedation, but sometimes it seems starting an IV in a patient in this age range is just as difficult/more difficult than doing the procedure.

Is it safe/reasonable to just give a slug of ketamine IM? Again, I am not talking about an adult high on PCP in agitated delirium tearing the hospital apart, I am talking about a medically totally stable pediatric patient who needs a painful procedure.

It seems kind of irresponsible to do a sedation without IV access, but again most children are healthy with good airways. Maybe I'm just being unreasonable here. Curious what other's experience is.

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[ShockIndex]

When in Afghanistan, I’d line about 10-20 kids up in a row and dart them with 4mg/kg of IM ketamine. Then, my team (mostly medics and a couple of PAs) would go down the line and perform burn wound care and dressing changes. Rinse and repeat 3X per week for 6 months. I had one LifePak monitor, a pump suction, a small oxygen cylinder, and a airway kit that I never needed. Occasionally, I’d get a puker, but always after awakening enough to protect the airway.

Never had a single major complication over what was hundreds of uses in this context.

Parents also seemed satisfied too. Of course, I told them that I’d call in an air strike on their entire village if someone sent them a Press Ganey survey and they returned anything less than all 5s…😉

 

[Fox800]

Anybody use IM ketamine for pediatric procedural sedation?

Here's a clinical situation I encounter on occasion.

School age kid, let's say 3-13. Needs a urgent but not emergent procedure, either laceration repair or I&D.

Plan A is LET, distraction, etc. But some kids just ain't havin' it. Patient is already yelling and screaming before you even walk in the room. Maybe some of you are pediatric whisperers, but I'm not and I don't think it's getting better at this point in my career. I'm definitely more of an adult ER physician.

I feel very comfortable with using IV ketamine for pediatric sedation, but sometimes it seems starting an IV in a patient in this age range is just as difficult/more difficult than doing the procedure.

Is it safe/reasonable to just give a slug of ketamine IM? Again, I am not talking about an adult high on PCP in agitated delirium tearing the hospital apart, I am talking about a medically totally stable pediatric patient who needs a painful procedure.

It seems kind of irresponsible to do a sedation without IV access, but again most children are healthy with good airways. Maybe I'm just being unreasonable here. Curious what other's experience is.

Yes, fairly regularly. 2 mg/kg IM is great for unruly screaming kids that need procedures done. I haven't had much luck with IN midazolam and we don't have nitrous. Some kids just make that stuff impossible.

Have them on the monitor and all of your usual airway adjuncts and a backup device. Know how to treat laryngospasm and have a plan in your mind to go up to and including RSI.

IV is a judgment call but is not a hard requirement. I agree that sometimes the act of the IV insertion can be as anxiety-provoking as the painful procedure itself. I will frequently do these without an IV. What are the chances you will emergently need an IV mid-procedure? There is no reversal agent for ketamine. I suppose if you (infinitely small chance) needed to push a paralytic...

I feel comfortable with 1-2 nurses in the room, IV supplies, and an IO kit readily available.

 

[RustedFox]

All the time.
Don't even think about it.

 

[cyanide12345678]

Dosage 2-4 mg/kg. IM is usually my go to in kids, though usually I'll have someone hold, papoose, and be quick about it. IM ketamine means they will be in your department for 2-3 hours minimum, and then it takes away one nurse for me as well who stays in the room for a pretty long time

 

[Janders]

Its fine to use IM Ketamine.
But be immediately prepared for the potential issues:
(1) copious secretions [suction, reposition, etc]
(2) vomiting [most likely when emerging, as above]
(3) laryngospasm [rare, but I know of one case second hand from IM ketamine in a young child that was… suboptimal]

I usually talk through these 3 things with the RN primarying the sedation with me before hand, over like 90 seconds, so we are on the same page and act as a coordinated unit if things go slightly sideways. You should have a plan of what to do with severe laryngospasm, despite the rarity.

 

[Angry Birds]

When in Afghanistan, I’d line about 10-20 kids up in a row and dart them with 4mg/kg of IM ketamine. Then, my team (mostly medics and a couple of PAs) would go down the line and perform burn wound care and dressing changes. Rinse and repeat 3X per week for 6 months. I had one LifePak monitor, a pump suction, a small oxygen cylinder, and a airway kit that I never needed. Occasionally, I’d get a puker, but always after awakening enough to protect the airway.

Never had a single major complication over what was hundreds of uses in this context.

Parents also seemed satisfied too. Of course, I told them that I’d call in an air strike on their entire village if someone sent them a Press Ganey survey and they returned anything less than all 5s…😉

good ole’ imperialist humor

 

[GassYous]

Just make sure you have atropine, sux and airway stuff nearby. Also a big muscular person if the kid is a fatty.

 

[turkeyjerky]

I feel like hospital/nursing protocols drive this stuff primarily.

I'd be comfortable using IM ketamine for a sedation. Why not intranasal though?

I wonder about using IM ketamine to facilitate putting the iv in. (and possibly aborting it, once you've already done the procedure)

I remember my first year out. I wanted to give IN fent/midaz for a pediatric lac repair. The nurses turned it into a huge fiasco and were about to start an IV...

 

[GassYous]

I feel like hospital/nursing protocols drive this stuff primarily.

I'd be comfortable using IM ketamine for a sedation. Why not intranasal though?

I wonder about using IM ketamine to facilitate putting the iv in. (and possibly aborting it, once you've already done the procedure)

I remember my first year out. I wanted to give IN fent/midaz for a pediatric lac repair. The nurses turned it into a huge fiasco and were about to start an IV...

Why not im fent

 

[DrDrummer]

It works great but lasts forever at higher doses. And the rare potential airway stuff, which I have never seen.

For lacerations I like midazolam, given early at the higher end of the dosing range. Tell the parents it’s like a shot or two of tequila so they need to make sure the little one doesn’t face plant. I find this + a iPhone video chills out the kid and outside of working on super complex facial lacerations or directly around the eye I’ve never K-Holed a toddler for a lac. I have given midazolam PO twice with a longer lead time but I don’t think that’s worth it, better to just spray it if you have the concentrated kind.

 

[turkeyjerky]

Why not im fent

Doesn’t really help much with the anxiety—which is typically the bigger issue. Sometimes you really need them still and it’s hard to immobilize certain areas (for lac repair), eg face, hand.

 

[Mount Asclepius]

I’ve become a big proponent of IN Versed. I’ve often done this with the plan to just obtain the IV for the Ketamine sedation, but found with the Versed alone I could just knock out the lack repair and avoid a sedation with prolonged recovery and monitoring. In rare circumstances where IN Versed isn’t sufficient, and can’t obtain an IV easily, then have gone the IM Ketamine route without difficulty as others have mentioned.

 

[GeneralVeers]

I don't like IN Versed. It seems to require repeat dosing often enough, and some kids get sleepy but still are able to move/scream when the procedure is painful. Ketamine is my go-to. One and done.

I also like Etomidate in adults. Typically one 10mg dose is good for most people. Much quicker than dosing, and re-dosing propafol in 50mg increments.

 

[RoyBasch]

When in Afghanistan, I’d line about 10-20 kids up in a row and dart them with 4mg/kg of IM ketamine. Then, my team (mostly medics and a couple of PAs) would go down the line and perform burn wound care and dressing changes. Rinse and repeat 3X per week for 6 months. I had one LifePak monitor, a pump suction, a small oxygen cylinder, and a airway kit that I never needed. Occasionally, I’d get a puker, but always after awakening enough to protect the airway.

Never had a single major complication over what was hundreds of uses in this context.

Parents also seemed satisfied too. Of course, I told them that I’d call in an air strike on their entire village if someone sent them a Press Ganey survey and they returned anything less than all 5s…😉

Wow, I think I'm being a huge wuss about IM ketamine.

 

[RoyBasch]

It works great but lasts forever at higher doses. And the rare potential airway stuff, which I have never seen.

For lacerations I like midazolam, given early at the higher end of the dosing range. Tell the parents it’s like a shot or two of tequila so they need to make sure the little one doesn’t face plant. I find this + a iPhone video chills out the kid and outside of working on super complex facial lacerations or directly around the eye I’ve never K-Holed a toddler for a lac. I have given midazolam PO twice with a longer lead time but I don’t think that’s worth it, better to just spray it if you have the concentrated kind.

I thought about IN midaz, but the stuff I had wasn't concentrated, so the volume (given the dose) wasn't practical for IN in the kid (25kg). Also I'm not sure IN is that much less noxious to give than starting an IV. If the kid is fighting/struggling/blowing it all out, I wonder how much you can really get in. Some kids also with paradoxical excitation with benzos.

 

[Groove]

IM ketamine all the time for kiddos (if no IV). I try to have parents step out of room if possible for the kids that go bonkers d/t emergence agitation. That way I don't get dirty looks. Otherwise, I warn them that they may be agitated upon waking and that it's normal and will be transient.

I used to use 4mg/kg but I've found 2mg/kg does the job just fine and they wake up sooner.

 

[GeneralVeers]

I use 2mg/kg as well....sometimes 3mg/kg if they are particularly bratty.

 

[gamerEMdoc]

All the time, honestly its just easier than having to start an IV on a kid anyways. I usually use 2 mg/kg instead of 4. For one main reason, IM has a slower onset, but it takes forever to wear off and the more you give the longer the effect lasts. So unless you want an hour long sedation, I go with the lower dose. You can always give more.

 

[CoolDoc1729]

When I had my own 3 year old in the ER for a facial lac repair I used LET and 12.5 of PO Benadryl. He sat on my husbands lap and ate a popsicle and I put 7 sutures in his eyebrow. I was truly shocked that it worked though.

 

[oslersbag]

I will add a plug for oral Versed. Needs higher dosing 0.7 mg/kg (max 20mg). Takes about 30 minutes for onset compared to 20 for IN. With some kids, the IN is so noxious that you lose them before you even start the procedure.

 

[xaelia]

My own kid has had IM ketamine twice in his life for face lac repairs.

I will happily do it IM in select cases. Try everything else first – distraction, nitrous can work wonders – because tying up a nurse for sedation + recovery is best avoided.

 

[GatorCHOMPions]

Wow, I think I'm being a huge wuss about IM ketamine.

To OP, if you’re nervous to try IM ketamine, why not plan to establish IV access immediately once sedation occurs to hedge for any (rare) complications that need immediate intervention? In the age group you mentioned, getting an IV should be easy once the setting is controlled, and taking it out afterward is nbd. This might convince any resistant nurses to go along with it too. After a few successes this way, maybe it will be easier to make IM ketamine routine (without IV) at your shop.

Like others, in my experience IN midazolam has had very mixed results and often requires repeat dosing. Overall I consider it very unreliable.

 

[Fox800]

To OP, if you’re nervous to try IM ketamine, why not plan to establish IV access immediately once sedation occurs to hedge for any (rare) complications that need immediate intervention? In the age group you mentioned, getting an IV should be easy once the setting is controlled, and taking it out afterward is nbd. This might convince any resistant nurses to go along with it too. After a few successes this way, maybe it will be easier to make IM ketamine routine (without IV) at your shop.

Like others, in my experience IN midazolam has had very mixed results and often requires repeat dosing. Overall I consider it very unreliable.

I'm running into this idiocy at my current shop where the nurses attempt to continually redefine what is "procedural sedation" - no, IN midazolam is not procedural sedation. Neither is an oral benzodiazepine. If I can have oral lorazepam to get LASIK at an ophthalmology clinic without cardiac monitoring and being on capnography with an IV in place, then this 4 year old can do it hooked up to a pulse oximeter.

I had one nurse the other shift who did the whole sedation packet after IN midazolam. I declined to document it as such. I declined to do the proc sed procedure note and wrote "anxiolysis" in the chart. I'm not playing their game just because they want to "protect their license". RN went so far as to filing an incident report that I did not do the "full procedural sedation package". Which my director promptly dismissed. Thanks, nursing. Really builds camaraderie and confidence in you.

Have also had particular nurses that start an IV despite the physician specifically telling them NOT to. There's a mythical "policy" that says sedation has to have an IV in place, despite the fact that this is a physician order. Physician orders trump "guidelines". The point of IM ketamine is to not have to do an IV.

 

[Rekt]

Pediatric whisperers are more annoying than vegans.

IM ketamine. Everything else is a waste of everyone's time and saves my hearing.

 

[bravotwozero]

I had one nurse the other shift who did the whole sedation packet after IN midazolam. I declined to document it as such. I declined to do the proc sed procedure note and wrote "anxiolysis" in the chart. I'm not playing their game just because they want to "protect their license". RN went so far as to filing an incident report that I did not do the "full procedural sedation package". Which my director promptly dismissed. Thanks, nursing. Really builds camaraderie and confidence in you.

I'm sorry, but I'm going to kidnap your medical director and make him work at my shop...

 

[TheComebacKid]

This is anecdotal but I find IM dosing of ketamine to be unpredictable. I prefer the IV approach and then can give as little as I want or as much as I want with repeat dosing. Sure, you could go big or go home, but IM ketamine will keep them in the ED longer, and sometimes they get by with much lower dosing, and come around quicker with less vomiting or emergence type of stuff. You can also hit them with some IV zofran after if needed.

Maybe I'm a terrible human being, but I don't care about putting IVs in kids. They can throw a temper tantrum if they want. The idea that we can't put in an IV in a kid because it's "sooo traumatic" is really just about patient satisfaction scores and is dictated by hospital administrators. These kids eventually become adults who continue to throw hissy fits in the ED when they need labs drawn. Peoples aversion to needles is just something I've lost patience for.

I've had very poor results with IN versed. The vomiting with nitrous is also just very annoying. Again, not worth trying these lesser methods just to avoid poking poor little Timmy.

If I never see a kid in the ED ever again I'll be really content.

 

[pkwraith]

oral versed +/0 Nitrous for lac repair, I+D. Ketamine IM for simple reduction.

 

[RoyBasch]

Logistically speaking, let's say you give 2mg/kg IM for sedation, how long do you wait before re-dosing another 1-2mg/kg? Also what is the overall expected time from med push to patient adequately sedated for procedure to begin? It seems a lot slower/less precise compared to IV where its usually with 1-2 minutes.

 

[TheComebacKid]

Logistically speaking, let's say you give 2mg/kg IM for sedation, how long do you wait before re-dosing another 1-2mg/kg? Also what is the overall expected time from med push to patient adequately sedated for procedure to begin? It seems a lot slower/less precise compared to IV where its usually with 1-2 minutes.

In my opinion redosing IM ketamine defeats the whole purpose of administering the agent with a single stick. If they are going to require multiple doses, just put the IV in.

A lot of people like to give the full 2mg/kg IV up front for procedural sedation in kids (or adults for that matter). I on the other hand always underdose it, starting out with 0.5mg/kg. In some 200kg people that has completely put them out for me. And if it doesn't, or they start wigging out, you can always give more.

IM ketamine is better served in linebackers with excited delirium in whom you can't get access and antipsychotics take too long to work (although Droperidol is really a game changer). I love ketamine, but that being said, I think we have gotten so comfortable with it to the point that we definitely overshoot, and especially IM dosing most definitely results in patients sometimes needing to be intubated unnecessarily.

 

[Dred Pirate]

We do IM ketamine all the time. We used to have a policy that any sedation requires an IV BEFORE the sedation started. So we had to put a kid through the IV stick, just to give him the IM ketamine. Which defeated some of the purpose of doing IM. We did finally change that policy. I know things could go wrong that you need IV access, but (luckily) we haven't had one yet. And you can argue that with about any procedure/med.

We do 2 mg/kg if we want a quick short procedure, and 4 mg/kg for something longer - this generally seems to be somewhere in the neighborhood of 15-20 minutes sedation - which seems more common. I have seen it for facial lacs all the time - one of the funiest things was when a parent said "you are going to put my kid in the k hole?" Makes me curious as to what their previous experience is.

 

[e30ftw]

I use IN versed for the autistic (or generally misbehaved) kids with lacs/abscesses. I have never sedated a kid for lac repair.

Worst case give IN versed and if it doesn't work, brutane while telling the parents, "Don't worry they won't remember this.."

Propofol or ketofol for peds ortho reductions. IM ketamine sounds very effective though, would just worry a little about nursing compliance since we don't use it regularly on peds (usually use it on violent meth/psych pts and very effective.)

 

[Fox800]

I use IN versed for the autistic (or generally misbehaved) kids with lacs/abscesses. I have never sedated a kid for lac repair.

Worst case give IN versed and if it doesn't work, brutane while telling the parents, "Don't worry they won't remember this.."

Propofol or ketofol for peds ortho reductions. IM ketamine sounds very effective though, would just worry a little about nursing compliance since we don't use it regularly on peds (usually use it on violent meth/psych pts and very effective.)

You're pushing homemade ketofol but you aren't doing IM ketamine? Seems a bit backwards.