procedural sedation in peds

[stoic]

Advertisement - Members don't see this ad

alright, what are the rules? when can i do it? i hate the way they jump around and cry and how mom stares me down as i hurt her baby.

not for simple sutures, obviously. but specifically a case comes to mind where i wish i could/would have sedated the kid. 9yo female with an abcess about 3cm below her belly button. she was numb (couldn't tell when i was cutting) but still screamed and squirmed the whole time.

could i have reasonably sedated her? not like full on midazolam/fentanyl, but something more mild? the ed where i put in my time still uses a lot of demerol ... and i was sooo tempted to give that kid some before I&D'ing her.

 

[12R34Y]

alright, what are the rules? when can i do it? i hate the way they jump around and cry and how mom stares me down as i hurt her baby.

not for simple sutures, obviously. but specifically a case comes to mind where i wish i could/would have sedated the kid. 9yo female with an abcess about 3cm below her belly button. she was numb (couldn't tell when i was cutting) but still screamed and squirmed the whole time.

could i have reasonably sedated her? not like full on midazolam/fentanyl, but something more mild? the ed where i put in my time still uses a lot of demerol ... and i was sooo tempted to give that kid some before I&D'ing her.

You absolutely should be sedating kids for painful procedures. Some old fogies believe that papoosing the kid and letting them scream through the whole thing is "the way to go", but in our kids ER we sedate for all kinds of stuff with versed/fentanyl or ketamine. Ketamine is amazing stuff. Nitrous oxide works well too.

Kids need sedation just like you'd want sedation for something painful. You can sedate kids for sutures as well. Especially for long/complicated repairs etc...

later

 

[deleted109597]

Yeah, but he specifically said that this procedure wasn't painful. So in that instance, would procedural sedation still be ok?

 

[JackBauERfan]

alright, what are the rules? when can i do it? i hate the way they jump around and cry and how mom stares me down as i hurt her baby.

not for simple sutures, obviously. but specifically a case comes to mind where i wish i could/would have sedated the kid. 9yo female with an abcess about 3cm below her belly button. she was numb (couldn't tell when i was cutting) but still screamed and squirmed the whole time.

could i have reasonably sedated her? not like full on midazolam/fentanyl, but something more mild? the ed where i put in my time still uses a lot of demerol ... and i was sooo tempted to give that kid some before I&D'ing her.

I had the same situation with a 7-8 yo girl that had an abscess right below the belly button, I tried without but since she was squirming around so much, we ended up just using Ketamine and worked out well.

 

[southerndoc]

I sedate anyone if it causes them distress... adults or pediatric patients.

 

[USCDiver]

Propofol

 

[kbrown]

we have a staff that uses etomidate for adults for reductions, major suture-jobs, i&d's, etc...

a place i rotated as a 4th year used ketamine in kids. worked great. kind of weird though cuz it doesn't put the "out" just makes them dazed. i lanced an abscess on the eyelid with the kid staring at me. didn't move an inch, just stared off in space.

 

[ERMudPhud]

I use ketamine for anything distressful in kids. Sutures, I&D, reductions, CT scans, LP's you name it. The safety profile of the drug is outstanding. Supposedly you can massively overdose without respiratory depression or other untoward effects. Just use 2mg/kg IV or 4mg/kg IM. Don't forget to add atropine or glycopyrolate to prevent hypersalivation. If my kids were having anything stressful done I would insist on it. That's also why my kids will go to a children's hospital if they ever have anything serious wrong with them.

Propofol, Etomidate, Fent/versed all are commonly used in kids but I think the safety of Ketamine can't be beat

 

[stoic]

I use ketamine for anything distressful in kids. Sutures, I&D, reductions, CT scans, LP's you name it. The safety profile of the drug is outstanding. Supposedly you can massively overdose without respiratory depression or other untoward effects. Just use 2mg/kg IV or 4mg/kg IM. Don't forget to add atropine or glycopyrolate to prevent hypersalivation. If my kids were having anything stressful done I would insist on it. That's also why my kids will go to a children's hospital if they ever have anything serious wrong with them.

Propofol, Etomidate, Fent/versed all are commonly used in kids but I think the safety of Ketamine can't be beat

gracias.

i'm going with this.

and if my attendings ask for sources, i'm pointing them this direction. (kidding, kidding).


do you need to give peds any benzo before the ketamine? do they wake up ok without the adjunct?

 

[mikecwru]

I use ketamine for anything distressful in kids. Sutures, I&D, reductions, CT scans, LP's you name it. The safety profile of the drug is outstanding. Supposedly you can massively overdose without respiratory depression or other untoward effects. Just use 2mg/kg IV or 4mg/kg IM. Don't forget to add atropine or glycopyrolate to prevent hypersalivation. If my kids were having anything stressful done I would insist on it. That's also why my kids will go to a children's hospital if they ever have anything serious wrong with them.

Propofol, Etomidate, Fent/versed all are commonly used in kids but I think the safety of Ketamine can't be beat

I unfortunately have seen a big ketamine overdose (10x). The kid did ok.

I also have seen the anticholenergic forgotten or given "too late" to work. Not much increased secretion. I wonder how much of it is a practical occurence?

mike

 

[KidDr]

gracias.

i'm going with this.

and if my attendings ask for sources, i'm pointing them this direction. (kidding, kidding).


do you need to give peds any benzo before the ketamine? do they wake up ok without the adjunct?

You can add Versed 0.1 mg/kg to the Ketamine/Atropine if you want to, but it's not necessary, most kids will still wake up just fine. If the kid starts to wig out when they're waking up, you can give Versed then.

I agree with the others who prefer Ketamine in kids to all the alternatives (Propofol, Fent/Versed, Etomidate, etc)--it's so dang safe, no major CV effects other than tachycardia (ie no hypotension), no IV required, quick recovery...I love Ketamine. Granted kids still move sometimes and their eyes roll around and they might make some noise, and they can act weird coming out of it, but as long as you foreward parents (and have a good holder during the procedure) it's not a problem.

 

[Sessamoid]

I use ketamine for kids. If you think the abscess was completely numb, you're kidding yourself. Abscesses never get completely numb. Just ask your adult patients. Lidocaine doesn't work well in the acidic environment of infected soft tissue.

I've had a few remarkable failures with etomidate in the pediatric population, primarily in adolescents. I had one kid a gave a dose that would have allowed me to intubate an adult but this kid, he just stayed awake the whole time. That's happened to me two or three times, once with a school-age kid and the other two were adolescents. I eventually ended up using ketamine, and I've used ketamine ever since.

 

[TeleoDeum]

I am a Peds EM fellow, and I love Ketamine! We use tons of it in our ED - any painful procedure, reductions, LP in older kids, laceration repair, etc.

In general I give Atropine as an adjunct if the kid has any signs or history of a snotty nose. You can give the Atropine 20-30 min before the sedation if you have the IV, or when you are giving your other drugs.

As for the Versed, this is a physician preference thing in our department. The literature says that in kids younger than 4 yrs old, the incidence of emergence reaction/agitation is low, so you can skip the Versed. In older kids there is around a 5-10% incidence of emergence reaction/ vivid hallucinations / feeling of out of body experience. Most docs in our ED give the Versed on the front end out of convention, but the literature suggests having it at the bedside and giving it only if needed while the patient is waking up. The reason is that giving Versed in addition to Ketamine prolongs your overall recovery time and time until discharge, thus tying up a room and a nurse.

Again, as ERMudPhud and KidDr said, the safety profile is great!

We also use some Propofol in our ED, but it is a pain in the butt, as the Chair of Anesthesia still requires special sedation privlegdes for its use. The potential benefit is the quicker time to recovery and discharge.

PS - Remember that you cannot be both the Surgeon and the Anesthesiologist!

Peace,
Greg

 

[Sessamoid]

PS - Remember that you cannot be both the Surgeon and the Anesthesiologist!

Well, you can't charge for both services yourself, but not only can you be both, a lot of us in single coverage situations have no other choice.

 

[TeleoDeum]

Sessamoid,

Yep, single coverage has its pros and cons. We are fortunate to have good residents for the procedures, so we bill for both sedation and procedure. Not sure of the leaglity of this though. I will investigate. Do you guys in the real world use a good nurse in your ED, one that you are comfortable letting manage airway if needed? Again, just a question as I am starting to investigate job opportunities and practice settings.

Peace,
Greg

 

[The White Coat Investor]

I unfortunately have seen a big ketamine overdose (10x). The kid did ok.

I also have seen the anticholenergic forgotten or given "too late" to work. Not much increased secretion. I wonder how much of it is a practical occurence?

mike

I don't routinely use the anticholinergic and I have yet to run into a serious hypersalivation problem.

 

[ERMudPhud]

I work a lot of single coverage. We alway have RT present to monitor and assist the airway if needed, a nurse to push drugs and watch the rest of the monitors, and a tech to provide extra hands. If any problems develop you drop what you are doing and deal with the problem but so far that hasn't happened.

I agree with what was said before about educating parents a head of time. I probably spend 5 minutes before we start telling them what to expect. I talk about nystagmus, tachycardia, emergence phenomenon, etc... Spend a lot of time describing what might happen ahead of time and if it does happen the parents will be much less stressed. I've seen one bad emergence reaction in ten years and I tell every parent about it. I had a 4-5 year old girl who wouldn't stop screaming and crying for over an hour. I mean really loud screaming. No amount of benzos would make it stop. In the end it appears she remembered very little about what happened except to say she thought her parents had turned into monsters who were trying to steal her away. So the more they tried to hug and comfort her the more she wigged out. I don't know if it really helps but I try to turn off the lights in the room and have the kids in a very quite part of the ER after the procedure as the ketamine wears off. I tell parents to quietly comfort them but not be too smothering. I've had no bad reaction doing that in the last 7 years or so.

My only experience with ketamine overdose is a stray cat from my backyard that I tried to catch by putting ketamine in its food. It is supposedly as orally bioavailable as IM. I gave it close to 50mg/kg and although it was clearly stoned it was still way to fast for me to catch.

 

[stoic]

My only experience with ketamine overdose is a stray cat from my backyard that I tried to catch by putting ketamine in its food. It is supposedly as orally bioavailable as IM. I gave it close to 50mg/kg and although it was clearly stoned it was still way to fast for me to catch.

just out of curiosity, did the ketamine come from your personal stash or do you have a buddy who's a vet?

 

[ERMudPhud]

just out of curiosity, did the ketamine come from your personal stash or do you have a buddy who's a vet?

Could have been either. We used to use it in lab to sedate mice. It was mailed to us unsecured in a plain brown box and we didn't have to prove anything to the supplier to get it. After it arrived in lab it sat unsecured and unaudited on a shelf. Things are stricter now. At the time though a friend who was a vet let me use some of his since the cat was too smart to get caught in a live trap.

 

[docB]

Ketamine's the way to go in kids. I just had a 3 yo with an 8 cm lac to the sole of the foot. No way was I going to jack around with that witout sedation. You never would have been able to do the irrigation and exploration necessary for that one with brutane.

 

[docB]

I unfortunately have seen a big ketamine overdose (10x). The kid did ok.

I also have seen the anticholenergic forgotten or given "too late" to work. Not much increased secretion. I wonder how much of it is a practical occurence?

mike

So 2 instances of errors in administration of Ketamine without any bad outcome. That speaks to the overall safety of the drug. The big thing to fear is laryngospasm which you are supposed to be able to bag over until the effect wears off.

 

[spyderdoc]

I absolutely love administering ketamine for procedural sedation. Had a couple of kids recently between 3 and 4 years old that I had to do septic/meningitis workups on. Basically, I gave them the the IM ketamine and then did a lumbar puncture, cath urine, and started IV all during the sedation time which worked out great. The kids woke up, and everything was done.

I did have one ketamine complication approximately 6 months ago. I had a 3-year-old with a large through and through lip laceration for which I gave ketamine 4mg/kg IM with atropine. Approximately 5 minutes into the procedure, he desaturated into the 80s. I basically stop what I was doing and BVM ventilated him for a couple of minutes and he was over it. I was able to continue with the procedure and the kid made an uneventful recovery.

As far as a billing, I do think there are codes allow you to bill both for the sedation and the procedure without a second physician being present. I will have to look into that more....

 

[Joejitsu]

I don't routinely use the anticholinergic and I have yet to run into a serious hypersalivation problem.

I second that...Do my peds in a children's hospital ER with all ER/Peds ER trained staff and we rarely use atropine with the ketamine sedations. Every once in a while if we have specific concern. I think the anticholinergic adjunct to ketamine is an older way of thinking that is falling out of favor. Otherwise we also use propofol and etomidate just depending on preference. Sometimes versed/morphine too.

 

[deleted6669]

agree with ketamine. just remember that these kids are awake though and still require local anesthesia in addition to the ketamine for painful procedures(big lacs, etc). the ketamine just prevents voluntary muscle use. it does squat for pain.

 

[DropkickMurphy]

although it was clearly stoned it was still way to fast for me to catch.

Now THAT is a funny image.

 

[FISKUS]

One of the greatest benefits of ketamine is that it is a potent anesthetic AND analgesic. You do not have to give additional meds for pain. I have seen surgeons ( in a third world country) do entire procedures ( laparotomy, C-section, ORIF) under nothing but a ketamine drip. In places where narcotics are unavailable or black marketed - ketamine is very often used to treat chronic pain.

If a child is adequately sedated ( 5mg/kg IM ) - you do not need local to sew up that complex facial lac or reduce an angulated fracture.

 

[deleted6669]

One of the greatest benefits of ketamine is that it is a potent anesthetic AND analgesic. You do not have to give additional meds for pain. I have seen surgeons ( in a third world country) do entire procedures ( laparotomy, C-section, ORIF) under nothing but a ketamine drip. In places where narcotics are unavailable or black marketed - ketamine is very often used to treat chronic pain.

If a child is adequately sedated ( 5mg/kg IM ) - you do not need local to sew up that complex facial lac or reduce an angulated fracture.

at the dosages approved for use in my dept( single dose 1 mg/kg iv or 4 mg/kg im -not a drip) you definitely need some lido before sewing up a lac or the kid will wake up crying in pain as soon as the ketamine wears off.

 

[FLTDOC1]

"the ketamine just prevents voluntary muscle use. it does squat for pain."

WTF?

I probably use more ketamine than most EM physicians ( hundreds of sedations)- both in the ED and prehospital. If used in adequate dosage ( 1-1.5 mg kg/IV 4-5 mg/kg IM) I have RARELY had to supplement analgesia.

It is a potent analgesic.

In fact it is ideal for complex facial lacs - you dont have to distort the anatomy by infiltrating the wound with lidocaine


30 years in EM
Former EMT-B and military medic
15 years as a RT/BC EM physician
15 years as an attending flight physician

 

[DropkickMurphy]

Do you guys in the real world use a good nurse in your ED, one that you are comfortable letting manage airway if needed?

This is exactly the reason why RT's at a facility I formerly worked were required to be able to intubate before being allowed to cover the ER or ICU (this is the facility where the "dog humping your leg" analogy case I described in a previous thread occured at). As ERMudPhud pointed out, a lot of places require an RT in the room for any procedural sedation outside of the OR.

 

[deleted6669]

"the ketamine just prevents voluntary muscle use. it does squat for pain."

WTF?

I probably use more ketamine than most EM physicians ( hundreds of sedations)- both in the ED and prehospital. If used in adequate dosage ( 1-1.5 mg kg/IV 4-5 mg/kg IM) I have RARELY had to supplement analgesia.

It is a potent analgesic.

In fact it is ideal for complex facial lacs - you dont have to distort the anatomy by infiltrating the wound with lidocaine


30 years in EM
Former EMT-B and military medic
15 years as a RT/BC EM physician
15 years as an attending flight physician

ok.....I will give it a try......maybe it's just a regional thing....I have never seen anyone use ketamine alone here......

 

[Quimby2]

I believe that ketamine in low dosages will sedate/dissociate the patient, but its analgesic propeties don't kick in until higher doses. i.e. 1 mg/kg = sedation and 2mg/kg will give more analgesia as well (though, likely depends on the pt too).

The question I have is this: How much can you re-dose if the procedure takes longer than expected. Can I just keep redosing as they begin to wake up, or do i hit a max allowable in a day.

Also, what is the current literature in support of NOT using atropine empircally (i.e. no h/o asthma, URI, etc)?

 

[KidDr]

What about nitrous for more minor procedures (IV starts, bladder caths, etc)? Anyone work in an ED that uses it? I've heard of some Children's hospitals that use it routinely. Sounds like it's safe and pretty easy to administer. Any thoughts?

 

[docB]

What about nitrous for more minor procedures (IV starts, bladder caths, etc)? Anyone work in an ED that uses it? I've heard of some Children's hospitals that use it routinely. Sounds like it's safe and pretty easy to administer. Any thoughts?

Nitrous is great but when it became a requirement to use a scavenging system for delivery the cost went up and a lot of places dropped it. It works well but unless you do a lot of procedures with it it's cost prohibitive.

 

[traumajunkie01]

I generally use the following concoction:

1.) Versed

2.) Meperidine, morphine or ketamine

3.) and some atropine or benadryl to dry them up👍

 

[kate_g]

I also have seen the anticholenergic forgotten or given "too late" to work. Not much increased secretion. I wonder how much of it is a practical occurence?

I feel somewhat qualified to make an observation about ketamine. 😉 Veterinarily speaking, there seems to be quite a bit of variation in how much individual animals salivate while on ketamine. Sometimes you forget the atropine and nothing much happens; sometimes you end up with the Niagara Falls of drool. Could be there's similar variation in kids and you've seen the "lucky" end of the spectrum?

 

[EctopicFetus]

FWIW we dont usually pretreat here, we just have the suction ready. I have used it a handful of times without problem.