Monitoring Ketamine

[Perrotfish]

Question from a Pediatrician: what do you guys think is appropriate monitoring for pediatric patients given moderate sedation with Ketamine for minor procedures? Specifically:

1) How long do you watch them for?

2) Does the doctor need to be an anesthesiologist? If not should they be sedation certified through some kind of internal training or can anyone give Ketamine?

3) Do you need to have a nurse involved?

4) Do they need 1:1 care by an MA or nurse while they're being monitored?

5) Do they need to be on monitors while you're watching them?

6). What is the youngest age you would give Ketamine for procedural sedation?

I have gotten some very different answers on this subject from different people so I thought I would poll you guys to see if I could get a consensus.

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[leaverus]

1) Depends
2) Depends
3) Depends
4) Depends
5) Yes
6) Depends

 

[Perrotfish]

1) Depends
2) Depends
3) Depends
4) Depends
5) Yes
6) Depends

Depends on what? Age? Dosage? Procedure performed? Could you give some examples of what you think is reasonable?

 

[Mman]

Depends on what? Age? Dosage? Procedure performed? Could you give some examples of what you think is reasonable?

I believe CMS guidelines require hospitals to have specific policies covering granting of privileges for moderate sedation and what sort of education must be given to physicians before they can be allowed to administer it. Your questions should all be covered by local policy.

 

[Perrotfish]

I believe CMS guidelines require hospitals to have specific policies covering granting of privileges for moderate sedation and what sort of education must be given to physicians before they can be allowed to administer it. Your questions should all be covered by local policy.

The reason I am asking is per our local policy moderate sedation is almost as hard to give as general anesthesia. You need an anesthesiologist or sedation certified ER doc, a sedation nurse, 1:1 monitoring for hours, etc. Basically we hold all of our kids down for procedures because it's such a pain to give sedation. This seems unreasonable to me, but it's also not my specialty so I am not sure.

I am wondering what other people do because I would like to know if I can/should change our policy.

 

[Mman]

The reason I am asking is per our local policy moderate sedation is almost as hard to give as general anesthesia. You need an anesthesiologist or sedation certified ER doc, a sedation nurse, 1:1 monitoring for hours, etc. Basically we hold all of our kids down for procedures because it's such a pain to give sedation. This seems unreasonable to me, but it's also not my specialty so I am not sure.

I am wondering what other people do because I would like to know if I can/should change our policy.

I believe the CMS guidelines require that the department of anesthesiology be involved in the creation and implementation of the guidelines. The only reason I remember this is because we had to create guidelines for our non-anesthesiology colleagues to use. We had to make policies for what types of procedures and what sorts of drugs could be used in what kinds of doses and what monitoring was required and what education was needed.

I believe in our hospital the only peds docs credentialed for moderate sedation are the PICU attendings and the Peds ED docs.

 

[Perrotfish]

I believe the CMS guidelines require that the department of anesthesiology be involved in the creation and implementation of the guidelines. The only reason I remember this is because we had to create guidelines for our non-anesthesiology colleagues to use. We had to make policies for what types of procedures and what sorts of drugs could be used in what kinds of doses and what monitoring was required and what education was needed.

I believe in our hospital the docs the only peds docs credentialed for moderate sedation are the PICU attendings and the Peds ED docs.

I am planning to involve the anesthesia department (who, in my hospital, is one guy). I am trying to get more of a sense of what I should be asking for. Just curious what you guys think.

 

[dhb]

Question from a Pediatrician: what do you guys think is appropriate monitoring for pediatric patients given moderate sedation with Ketamine for minor procedures? Specifically:

1) How long do you watch them for?

2) Does the doctor need to be an anesthesiologist? If not should they be sedation certified through some kind of internal training or can anyone give Ketamine?

3) Do you need to have a nurse involved?

4) Do they need 1:1 care by an MA or nurse while they're being monitored?

5) Do they need to be on monitors while you're watching them?

6). What is the youngest age you would give Ketamine for procedural sedation?

I have gotten some very different answers on this subject from different people so I thought I would poll you guys to see if I could get a consensus.

1. Peak action lasts 20min, tail is 2h...

 

[Ezekiel2517]

Based on the questions you're asking and how you're asking them, I don't think you should be in a position to have any determination or input about a moderate sedation policy. No offense. There's just a significant lack of knowledge/insight evidenced here. Ketamine isn't a simple drug. Peds isn't a simple patient population. So combining the two can certainly complicate matters. Let the appropriate specialists and experts deal with this.

 

[WholeLottaGame7]

1) Depends
2) Depends
3) Depends
4) Depends
5) Yes
6) Depends

This is probably the best answer, because you ARE asking a vague question, and the answer does depend. But to be fair, out of all the drugs non-anesthesiologists want to use for procedural sedation, ketamine is one of the ones I'm most OK with. Way easier to hurt people, especially kids, with propofol/opioids/benzos.

Honestly, most hospital guidelines for procedural sedation are not very stringent. Complete some online module, pass the test, have someone check a box, and as long as you follow the rules, you're good to go. I think both hospitals I have been at have allowed PICU, peds ED, and select pediatricians the privilege. I'm sure there are many hospitals that have their guidelines for procedural sedation online if you want to find them.

 

[Orin]

A lot of folks freaked out about ketamine, but it seems to be getting a bit of a revival.

I assume you mean peds as in > 3 mo, kids coming into the ED?

There are some ED based guidelines for ketamine usage already published that I would build off if I were in your shoes.

Clinical practice guideline for emergency department ketamine dissociative sedation: 2011 update. - PubMed - NCBI