Mercy Hospital of Pittsburgh
Department of Emergency Medicine

Conscious Sedation Guidelines (Ketamine) 1/99

Contraindications
 - Age <= 3 months
 - History of airway instability, tracheal surgery, or tracheal stenosis
 - Procedures involving stimulation of the posterior pharynx
 - Active pulmonary infection or disease
   (including upper-respiratory infection, exception is for asthma)
 - Full meal in 3 hours preceding procedure
 - Cardiovascular disease including angina, heart failure, and hypertension
 - Head injury associated with loss of consciousness, altered mental status,
   or emesis
 - Central nervous system masses, abnormalities, or hydrocephalus
 - Poorly controlled seizure disorder
 - Glaucoma or acute globe injury
 - Psychosis, porphyria, thyroid disorder, or thyroid medication

Environment
 - Area with suction, oxygen, and equipment for advanced airway management
 - Physician immediately available who is adept at advanced airway management
 - Intravenous access and supplemental oxygen optional
 - Ketamine administration
  + PO 10mg/kg, max 250mg IM 4mg/kg
    may repeat 2-4mg/kg after 10 minutes, if needed
  + IV 1mg/kg give slowly, add 0.5mg/kg/h as needed for prolonged procedures
  + Atropine 0.01mg/kg (min 0.1mg, max 0.5mg) ,can be mixed with Ketamine in
    the same syringe for IV or IM injections
  + Addition of minimal dose of Benzodiazepine may be useful in decreasing
    psychic reaction (e.g., Versed = midazolam 0.05 mg/kg)
    [Though a recent study shows Versed doesn't help. --KC]

Onset
 - PO 30-45 minutes
 - IM 2-8 minutes
 - IV immediate

Monitoring
 - Close observation of airway and respirations by an experienced health care
   professional until recovery well-established
 - Drapes positioned such that airway and chest motion can be visualized at
   all times
 - Continuous pulse oximetry until recovery is well-established
 - Continuous cardiopulmonary monitoring until recovery is well-established

Possible complications
 - laryngospasm/stridor
 - emesis
 - random motion - extremities, head
 - hypersalivation
 - transient rash
 - nystagmus
 - hypertoxicity
 - respiratory depression

Recovery area
 - Minimal physical contact or other psychic disturbance Quiet area with dim
   lighting if possible
 - Advise parents or caretakers not to stimulate patient prematurely

Discharge criteria
 - Return to pretreatment level of verbalization and awareness
 - Return to pretreatment level of purposeful neuromuscular activity
 - Discharge instructions Nothing by mouth for 2 hours
 - Careful family observation and no independent ambulation for 2 hours

References:

1. Efficacy of oral Ketamine for -providing sedation and analgesia to 
children requiring laceration repair. Pediatric
Emergency Care, April 1998.

2. Intramuscular Ketamine for Pediatric sedation in ED safety profile in 
1,022 cases. Annals of Emergency
Medicine, June 1998, September 1990. .

3. IV Ketamine for pediatric sedation in ED safety profile with 156 cases. 
Academic Emergency Medicine, October
1998.

4. Ketamine in the Emergency Department. S Green, et al. Annals Emergency 
Medicine. 19:1024,1990.

5. Ketamine Sedation for Pediatric Procedures. Annals Emergency Medicine, 
September 1990.