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Pediatric Imaging |
1 From the Departments of Anesthesia (K.P.M., J.A.D.), Radiology (K.P.M., V.E.K., L.C., P.E.B.), and Biostatistics (D.Z.), The Children’s Hospital, 300 Longwood Ave, Boston, MA 02115-5737; and Department of Anesthesia, Brigham and Women’s Hospital, Boston, Mass (E.M.). From the 2001 RSNA scientific assembly. Received November 5, 2001; revision requested December 3; revision received February 26, 2002; accepted April 2. Address correspondence to K.P.M. (e-mail: keira.mason@tch.harvard.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSIONAPPENDIX A: Ketamine Sedation...APPENDIX B: "Ketamine Sedation...REFERENCES |
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MATERIALS AND METHODS: This study was conducted in two phases. The goal of the first phase was to develop a sedation protocol to replace that of using general anesthesia for specified pediatric interventional procedures. Ketamine was administered intravenously (with intermittent bolus or continuous infusion) or intramuscularly. Sedation induction times, adverse events, doses, and sedation and recovery durations were recorded. In phase 2, the results of phase 1 were reviewed and a formal ketamine protocol was developed.
RESULTS: Neither sedation failures nor substantial adverse events occurred in phase 1. Mean duration of all sedations was 52 minutes, and median recovery room time was 0 minutes. In phase 2, the results of phase 1 were reviewed and a sedation protocol was proposed to a hierarchy of hospital committees before final approval from the medical staff executive committee. Subsequently, standard order forms for radiology nurse administration of ketamine with radiologist supervision were prepared for exclusive use by the pediatric interventional radiology department.
CONCLUSION: Ketamine-induced sedation may be a safe and effective alternative to general anesthesia for some interventional radiologic procedures in pediatric patients. Collaboration between anesthesia and radiology departments is important for development of a safe and successful ketamine sedation program. To the authors’ knowledge, this is the first report describing the intravenous infusion of ketamine for sedation in pediatric patients and the only report describing the establishment of a protocol for ketamine administration by credentialed radiology nurses with radiologist supervision.
© RSNA, 2002
Index terms: Anesthesia • Interventional procedures, in infants and children, **.1262
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSIONAPPENDIX A: Ketamine Sedation...APPENDIX B: "Ketamine Sedation...REFERENCES |
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Ketamine may be administered through intravenous, intramuscular, oral, rectal, nasal, epidural, or intrathecal routes. The use of ketamine to induce sedation and analgesia in pediatric patients has been described in various non–operating room settings, including emergency department (4), oncologic (5), dental (6), radiation therapy (7), and radiology suite (8) settings. A review of the literature reveals that despite the widespread use of ketamine by nonanesthesiologists, there is no consistent protocol for ketamine administration.
At The Children’s Hospital, Boston, Mass, there are clearly defined guidelines for nurse-facilitated sedation. The agents used in our sedation protocol include chloral hydrate (Pharmaceutical Associates, Greenville, SC), pentobarbital (Nembutal; Abbott, North Chicago, Ill), fentanyl citrate (Sublimaze; Janssen, Titusville, NJ), and midazolam hydrochloride (Versed; Hoffman-LaRoche, Nutley, NJ). Occasionally, we encounter a pediatric patient who meets the criteria for nurse-facilitated sedation for an interventional procedure but in whom this protocol will not result in adequate analgesia because of limitations in our current sedation protocol. As a result, these children are referred to the anesthesia service to receive a general anesthetic agent.
To induce adequate analgesia and sedation in this patient population, our anesthesia and radiology departments collaborated to develop a protocol with which ketamine could be administered by credentialed radiology nurses with radiologist supervision. Historically at our institution, nurses have administered ketamine only to intubated patients in the intensive care unit, according to the orders of intensive care physicians. Intensive care physicians, anesthesiologists, and emergency department physicians have been the only physicians prescribing this medication.
Our goal was to develop a ketamine sedation program in our radiology department in two consecutive phases. During phase 1, an anesthesiologist (K.P.M.), in conjunction with the nurses (L.C.) and radiologists (P.E.B.), induced ketamine sedation in pediatric patients who met the criteria for nurse-facilitated sedation but in whom this protocol would not result in adequate analgesia. Ketamine doses and administration techniques were refined during this phase. During phase 2 of the study, a protocol for nurse-facilitated sedation during interventional radiologic procedures was developed, presented, and promoted to a successive hierarchy of hospital sedation committees: radiology sedation committee, hospital sedation task force, pharmacy and therapeutics committee, and finally, medical staff executive committee. The final accomplishment of phase 2 was marked by the formal approval of a ketamine sedation program for pediatric interventional radiologic procedures.
The purpose of our study was to establish a sedation protocol for credentialed radiology nurses to administer ketamine with radiologist supervision.
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MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSIONAPPENDIX A: Ketamine Sedation...APPENDIX B: "Ketamine Sedation...REFERENCES |
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All adverse events, including those reported at routine 24-hour and 7-day follow-ups, are reviewed at bimonthly meetings of the radiology sedation committee for quality assurance and to make recommendations for changes in protocol, if necessary. Because ketamine has unique characteristics, a supplemental database was created to track potential adverse events. The form used to gather information for this database is presented in Appendix A.
Phase 1: Development of Sedation Protocol
Phase 1 was instituted in the interventional radiologic procedure rooms after approval was obtained from the radiology sedation committee, hospital sedation task force, and institutional review board. All radiology nurses (L.C.) were certified in adult and pediatric life support (basic life support and advanced pediatric life support), and most had extensive experience in providing pediatric or neonatal intensive care. Any radiologist who supervised sedation was also certified in basic and pediatric life support. Before this study was initiated, a credentialing program specifically for ketamine administration was established: Participating radiology nurses (L.C.) and physicians (P.E.B.) attended a didactic informational presentation on ketamine that was given by the supervising anesthesiologist (K.P.M.) and were required to read an informational handout that outlined the clinical applications of and potential complications associated with ketamine. The radiology nurses were required to successfully answer all of the questions on the "Ketamine Post-Test" (Appendix B).
After the participating radiologists (P.E.B.) and nurses were credentialed through the described program, a standard of care for the administration of ketamine and the monitoring of patients during administration was established. During this phase, the ketamine doses and administration methods were refined according to patient outcomes. The radiology nurses who were responsible for screening patients for suitability for enrollment in the study initiated the patient recruitment. As with the protocol for any patient who was being evaluated for suitability for any form of nurse-facilitated sedation, the medical, surgical, and sedation histories and current review of systems, medication, allergy, and fasting statuses of the patients were recorded.
If the patient met the sedation guidelines, a physical examination was performed and the relevant laboratory data were acquired. Findings were reviewed by the nurses and attending interventional radiologist (P.E.B.). Patients eligible for the study included all patients who met the described established medical guidelines for nurse-facilitated sedation and to receive ketamine—that is, they did not have any of the contraindications listed in Figure 1—but for whom general anesthesia would be required because of the anticipated need for a degree of analgesia greater than that induced according to the existing sedation guidelines. Exclusion criteria for ketamine administration are listed in Figure 1. Before a patient received final approval for enrollment in the study, his or her medical data were reviewed individually by the designated anesthesiologist (K.P.M.). Signed informed consent was obtained from the parents of all participating patients.
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Between November 2000 and January 2001, the designated anesthesiologist induced ketamine sedation in 38 infants and children for interventional radiologic procedures that typically would have required general anesthesia. Ketamine was administered through an intramuscular route in only those patients (n = 6) in whom intravenous access proved challenging (ie, more than three failed intravenous attempts) and for whom placement of a peripheral intravenous catheter was the intended procedure. All of these patients received a single dose only of a combination of 3–6 mg/kg of ketamine mixed with 0.005 mg/kg of glycopyrrolate (Robinul; Baxter Healthcare, Richmond, Va) that was injected into the deltoid muscle with a 22-gauge needle. Patients older than 5 years (n = 3) received, in addition, 0.1 mg/kg of midazolam hydrochloride (maximum, 3 mg) in the initial intramuscular injection.
For sedation durations shorter than 10 minutes, ketamine was administered intravenously in an intermittent bolus. At least 1 minute before the intravenous administration of ketamine, 0.005 mg/kg of glycopyrrolate was administered intravenously. Doses of ketamine (0.5–1.0 mg/kg) were intravenously administered at 1–15-minute intervals, as determined by the anesthesiologist, after the assessment of responses to painful stimuli (ie, either deep nail-bed pressure or the interventional procedure). Patients older than 5 years received an initial dose of 0.1 mg/kg of midazolam hydrochloride (maximum, 3 mg), which was administered again every 60 minutes.
For procedures that required more than 10 minutes of sedation, an initial intravenously administered bolus of 1–2 mg/kg of ketamine was immediately followed by an intravenous infusion of 25–150 µg/kg of ketamine per minute for the duration of the surgical stimulation. Patients in this group who were older than 5 years received 0.1 mg/kg of midazolam hydrochloride (maximum, 3 mg) at 60-minute intervals during the procedure. Glycopyrrolate was administered prior to ketamine to minimize the increased salivary and tracheobronchial tree secretions. Midazolam hydrochloride was administered concomitantly with ketamine in the children older than 5 years to reduce the risk of adverse psychologic disturbances that may result from ketamine administration and include delusions, hallucinations, agitation, and emergent delirium. Sedation induction times, sedation durations, procedure durations, recovery times, and adverse events (including failed sedation and psychologic disturbances) during the procedure, in the recovery room, and at home (according to 24-hour and 7-day follow-up calls) were recorded by the radiology nurse.
Definition of Terms
Failed sedation was defined as the failure to successfully perform a given procedure because of inadequate analgesia or unacceptable patient movement.
Prolonged sedation was defined as failure to meet the criteria for discharge from the recovery room 3 hours after receiving the last dose of ketamine or failure to return to baseline mental status after 24 hours.
Abnormal oxygen saturation was defined as a greater than 5% decrease in oxygen saturation from the baseline level in a patient who was unresponsive to oxygen delivered through a face mask at 6 L/min.
Need for resuscitation was defined as a decrease in respiratory rate and oxygen saturation that necessitated either assisted positive pressure ventilation, cardiopulmonary resuscitation, or the administration of resuscitation medications.
The occurrence of nightmares, hallucinations, and/or delusions was determined by observing patient responses and by means of direct patient communication.
Gastrointestinal problems were specified as vomiting, aspiration, or diarrhea.
Allergic reactions were defined as unexplained rashes or clinical symptoms that developed following ketamine administration and were consistent with anaphylaxis.
Induction time was defined as the time (in minutes) from initial administration of ketamine to achievement of adequate sedation and analgesia, as determined on the basis of a minimal response to painful stimuli (ie, nail-bed pressure).
Duration of sedation administration was defined as the time (in minutes) from administration of the initial ketamine dose to termination of surgical stimulation. Ketamine administration was always discontinued at the termination of the surgical stimulation.
Duration of procedure was defined as the time (in minutes) from initiation of the interventional procedure (including sterile preparation of patient) to termination of the procedure (ie, end of painful stimuli).
Recovery time was defined as the interval (in minutes) from the time the patient arrived in the recovery room to the time he or she fulfilled the established criteria for discharge from the recovery room.
Statistical Analyses: Phase 1
All continuous variables were tested for normality by using the Kolmogorov-Smirnov goodness-of-fit test (10). Variables that did not have a normal distribution, including intravenous bolus dose, induction time, and recovery time, were presented in terms of the median and range, and the intravenous bolus group was compared with the intravenous bolus plus intravenous infusion group by using the nonparametric Mann-Whitney U test (11). Age, weight, duration of sedation, and duration of interventional procedure were expressed as mean values ± SDs, and groups were compared by using the two-sample Student t test. Differences in number of adverse events and number of failed sedations were compared by using the Fisher exact test. Categorical data, including ASA physical status grade and procedure type and location, were compared by using the Pearson 
2 test. Statistical analysis was performed by using a computer software package (SPSS version 11.0; SPSS, Chicago, Ill). A two-tailed P value of less than .05 was considered to indicate a statistically significant difference.
Phase 2: Establishment and Committee Acceptance of Sedation Protocol
After review of the statistical results, outcomes, ketamine doses, and adverse events, a formal ketamine protocol was established. Before the protocol was approved as a formal nursing sedation protocol for interventional radiologic procedures, it had to be accepted by four successive committees: radiology sedation committee, hospital sedation task force, pharmacy and therapeutics committee, and medical staff executive committee. After each presentation of the protocol to each committee, the protocol was amended or clarified, as required, according to the recommendations of the given committee. Following these amendments, the protocol was re-presented to the given committee for acceptance before it could proceed to be reviewed by the next committee in the hierarchy.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSIONAPPENDIX A: Ketamine Sedation...APPENDIX B: "Ketamine Sedation...REFERENCES |
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSIONAPPENDIX A: Ketamine Sedation...APPENDIX B: "Ketamine Sedation...REFERENCES |
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Our protocol requires that glycopyrrolate be administered prior to ketamine to minimize the increased salivary and tracheobronchial secretions that occur in response to ketamine administration and, rarely, lead to laryngospasm. Administering anticholinergic agents such as glycopyrrolate diminishes this risk. Treatment for laryngospasm should include positive pressure ventilation with high-flow oxygen until assistance with the anesthesia can be acquired (12,13).
Hallucinations, delusions, nightmares, and emergent delirium are commonly described potential side effects of ketamine administration in adults (14,15). The occurrence of these adverse events in pediatric patients is a controversial subject (16,17). In adults, the concomitant administration of a benzodiazepine (eg, midazolam hydrochloride or diazepam) with ketamine has been shown to decrease the incidence of these events. The utility of benzodiazepines in reducing these events in children is controversial (18–21). Some reports indicate that the addition of benzodiazepines leads to an increased incidence of oxygen desaturation events (22). Because of the lack of a clearly documented benefit of supplementing ketamine with a benzodiazepine for sedation and to reduce the risk of adverse events that result from the concomitant administration of a benzodiazepine, we arbitrarily reserved the use of benzodiazepines for children older than 5 years. It is this patient population who may be at increased risk of experiencing psychologic disturbances in response to ketamine (23).
The majority of published experiences with ketamine in pediatric patients are in the emergency medical literature. The intramuscular injection of a combination of ketamine (3 mg/kg), midazolam hydrochloride (0.05 mg/kg), and glycopyrrolate (0.005 mg/kg) has been reported to induce reliable sedation in children aged 12 months to 7 years within approximately 6 minutes, with no respiratory or cardiovascular complications. To our knowledge, no emergent delirium or hallucinations have been noted. In addition, respiratory drive and protective airway tone have remained intact with this combination (24). In a review of 1,022 cases of intramuscular ketamine–induced sedation in the pediatric emergency department, intramuscularly administered ketamine doses of 4 mg/kg reportedly resulted in acceptable sedation in 98% of the cases and in transient airway complications, including airway malalignment, laryngospasm, apnea, and respiratory depression, in 1.4% of the cases (13). All complications were treated without intubation or sequelae. In addition, airway reflexes were maintained in all patients. Only 1.6% of the patients experienced moderate to severe recovery agitation, and none demonstrated signs of hallucinations or delirium (13). There was no difference in time to discharge or adverse events between the patients who received 4 mg/kg of ketamine intramuscularly and those who received 5 mg/kg intramuscularly.
In other studies, intravenously administered ketamine (1.0–2.0 mg/kg) has induced sedation and analgesia within 2 minutes, with no deleterious cardiopulmonary or respiratory effects. A review of 11,589 cases of children who received ketamine revealed no major cardiovascular complications (20). It is important to realize, however, that large doses of ketamine can induce a state of general anesthesia.
Our exclusion criteria did not prohibit the use of ketamine in children who were at risk of having seizures or epilepsy. Recent evidence demonstrates that ketamine may control seizures in patients who have prolonged epileptic seizures that do not respond to phenobarbital (25,26). Ketamine may be safely administered in neonates and is often the medication of choice for the induction or maintenance of anesthesia in infants with cardiac disease (27,28).
In conclusion, close collaboration between the anesthesia and radiology departments has resulted in a protocol for radiologist-supervised nurse administration of ketamine to induce sedation in a select group of patients who would otherwise require general anesthetic agents for sufficient sedation and analgesia. This protocol has given both the radiologists and the nurses alternative methods of inducing efficacious and safe analgesia and sedation. In addition, we have provided some parents and patients with an alternative to general anesthesia. The implementation of this ketamine sedation program has given radiologists a new level of independence in scheduling and performing interventional procedures. We recommend that an anesthesiologist or other person with expertise in airway management be immediately available to provide assistance on the rare occasion that apnea, laryngospasm, or other airway complication occurs. Further studies to evaluate the success of our pilot program are in progress.
To our knowledge, this is the first published report, by individuals in a specialty other than anesthesiology, that describes the establishment of a formal nursing protocol for the administration of ketamine to induce sedation and analgesia in pediatric patients. This is also, to our knowledge, the only published report describing the intravenous infusion of ketamine for sedation in pediatric patients undergoing radiologic interventional procedures.
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APPENDIX A: Ketamine Sedation Data Sheet |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSIONAPPENDIX A: Ketamine Sedation...APPENDIX B: "Ketamine Sedation...REFERENCES |
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Nurse
Medical Problems
_brain tumor
_seizures
_developmental delay
_behavior problems
_osteomyelitis
_osteosarcoma
_gall bladder problem (magnetic resonance cholangiogram)
_fracture study
_cardiac problem
(please specify)
_retropharyngeal mass
_hearing loss (precochlear implant study)
_gastroesophageal reflux
_vomiting
_pneumonia
_other
(please specify)
Weight _kg Taking anticonvulsant medications? Y/N
ASA level _(level 1–4, refer to following classification guidelines)
ASA 1 Healthy
ASA 2 Mild systemic disease that does not limit normal activity
ASA 3 Severe systemic disease that limits normal activity
ASA 4 Severe systemic disease that is constant threat to life
ASA procedure (must be specified):
_peripheral central intravenous catheter placement
_rectal drainage
_percutaneous gastrostomy or jejunostomy tube placement
_chest tube placement
_liver biopsy
_renal biopsy
_lung biopsy
_angiography
_embolization
_sclerotherapy
_hip tap
_lumbar puncture
_other
Sedation Data
Were airway manipulations needed during the sedation? Y/N
If so, please identify:
_jaw thrust
_chin lift
_supplemental oxygen (blow by) for O2 saturation decrease > 5% from baseline
_shoulder roll
_positive pressure ventilation
Time needed to sedate: _min
Duration of procedure: _min
Duration of sedation: _min
Total dose of ketamine infusion: _mg
Total dose of ketamine bolus: _mg
Total dose of midazolam hydrochloride administered: _mg
Adverse effects during sedation? Y/N
Prolonged sedation:_
Abnormal O2 saturation (>5% decrease from baseline): _%
Need for resuscitation:
Cardiovascular complications resulting from sedation:
Intravenous access problems: >3 attempts___ Infiltrate___ Dislodged___
Gastrointestinal symptoms:
Vomiting_ Aspiration_
Failed sedation:
_Patient resistant
_Failure to sedate with recommended dose
_Patient awakened before examination completed
Allergic or paradoxical reaction:
Laryngospasm:
Other:
Comments:
Unplanned admission:
Recovery Room and Discharge Times:
Military time: arrival in recovery room_
Military time: discharge criteria met
Military time: patient actually leaves recovery area_
Military time: patient vomits_
Recovery Room Data
_emergent agitation
_vomiting (if yes, military time _)
_nausea
_delirium
_hallucinations
_airway manipulations needed (ie, jaw thrust, shoulder roll, chin lift)
_supplemental oxygen needed for O2 saturation < 94%
_inhalers or nebulizers required
_antiemetic (ondansetron hydrochloride) for vomiting required
_laryngospasm
_Other
(please specify)
Delayed adverse effects (at 24-hour follow up)? Y/N
Prolonged drowsiness:
Nightmares:
Change in sleep pattern:
Change in behavior:
Vomiting:
If yes, how long after discharge from hospital? _hours
Hyperactivity:
Irritability:
Other: ___ Comments:
Able to contact patient? Y/N
Delayed adverse effects (at 7-day follow up)? Y/N
Prolonged drowsiness:
Nightmares:
Change in sleep pattern:
Change in behavior:
Vomiting:
If yes, how long after discharge from hospital? _hours
Hyperactivity:
Irritability:
Other:
Comments:
Able to contact patient? Y/N
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APPENDIX B: "Ketamine Sedation Post-test" |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSIONAPPENDIX A: Ketamine Sedation...APPENDIX B: "Ketamine Sedation...REFERENCES |
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(Circle as many as apply)
1. Ketamine may cause the heart rate to increase because:
a. It should not cause the heart rate to increase.
b. it stimulates the sympathetic nervous system.
c. patients become stimulated or anxious.
2. Ketamine may cause the blood pressure to increase because:
a. It should not cause the blood pressure to increase.
b. it stimulates the sympathetic nervous system.
c. patients become excited or anxious.
3. Ketamine can cause vomiting:
a. Vomiting usually occurs during the sedation.
b. Vomiting usually occurs during the late recovery period.
c. Vomiting occurs in approximately 7%–8% of children who receive ketamine.
d. Because of the risk of vomiting, children with gastroesophageal reflux and history of uncontrolled vomiting should not receive ketamine.
4. Ketamine causes deep sedation:
a. Children might not respond to deep nail-bed pressure.
b. Children still might move, despite being in a state of deep sedation and analgesia.
c. Movement during ketamine-induced sedation indicates that additional doses of ketamine should be administered.
d. Airway reflexes are maintained with ketamine-induced sedation.
e. I should be alarmed if the child does not respond to painful stimuli.
5. Ketamine can cause:
a. involuntary movements.
b. delusions.
c. hallucinations.
d. nightmares.
e. sleep disturbances.
6. Ketamine should always be administered with a benzodiazepine in children to minimize adverse effects:
a. True
b. False
7. In children, the risk of nightmares, hallucinations, and delusions are rare:
a. True
b. False
8. Midazolam hydrochloride is added to the ketamine protocol for children older than 5 years:
a. True
b. False
9. A 0.1 mg/kg-dose of midazolam hydrochloride should be administered to children older than 5 years:
a. only to a maximum of 3.0 mg of midazolam hydrochloride.
b. A repeat dose of midazolam hydrochloride should be administered 60–80 minutes after the first administration.
c. The repeat dose of midazolam hydrochloride should be the same as the initial dose.
d. If I do not believe that midazolam hydrochloride should be added, even in a child older than 5 years, I may omit it.
10. Glycopyrrolate:
a. Administration of glycopyrrolate can cause the heart rate to increase.
b. Administration of glycopyrrolate can lead to decreased secretions.
c. Administration of glycopyrrolate can lead to decreased salivary secretions and thus minimize the risk of laryngospasm.
d. The same dose of glycopyrrolate should be administered, regardless of whether it is given intravenously or intramuscularly.
e. Glycopyrrolate is administered in a dose of 0.005 mg/kg.
f. A repeat dose of glycopyrrolate should be administered after 60 minutes.
g. A repeat dose of glycopyrrolate should be administered whenever a repeat dose of ketamine is administered intramuscularly.
h. Glycopyrrolate should be administered only once, at the initiation of the sedation.
11. Ketamine may be administered in children who have:
a. brain tumors but no signs or symptoms of intracerebral hypertension or elevated intracranial pressure.
b. brain tumors, even when the child has elevated intracranial pressure.
c. gastroesophageal reflux or are vomiting.
d. asthma.
e. a history of seizures and epilepsy.
f. a current risk of seizures.
g. cerebral palsy.
h. autism.
i. Down syndrome.
j. mental retardation.
k. a history of bipolar disorder or schizophrenia.
12. Ketamine is a good choice for procedures in which absolute immobility is critical to performing the procedure and ensuring the safety of the patient (ie, embolization of cerebral arteriovenous malformation):
a. The choice of ketamine requires careful evaluation and discussion with the radiologist and patient.
b. Ketamine may not be a good choice.
c. Ketamine can cause involuntary movements, and, thus, probably would not be a good choice.
d. If I administer enough ketamine, the patient will be able to remain motionless.
13. When obtaining consent from parents to administer ketamine in their children, I should:
a. advise them of the risk of vomiting during the recovery phase, but tell them that this is not a cause for alarm.
b. advise them that their child’s pupils will enlarge following ketamine administration.
c. advise them that their child may have nystagmus that may last a few hours after ketamine administration.
d. advise them that for 4–6 hours after ketamine administration, their child may be unsteady on his or her feet and thus special care should be taken with the child.
e. encourage them to allow their child to eat immediately following the sedation.
f. discourage them from allowing their child to eat immediately following the sedation.
g. encourage them to keep their child from eating until the child’s mental status appears to have returned to baseline.
h. advise them that ketamine-induced sedation is different from other sedations in that their child may not appear to be asleep following the administration of this agent.
i. advise them that ketamine causes deep sedation, during which, to the observer, the child may appear to still be awake.
j. advise them that even if their child appears to be awake—that is, his or her eyes are open—he or she is actually deeply sedated and most likely will have no recollection of the procedure.
k. advise them that ketamine also induces amnesia from the time it is administered.
l. advise them that although their child appears to be awake, he or she will neither feel pain during the procedure nor have any recollection of the procedure.
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FOOTNOTES |
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Abbreviation: ASA = American Society of Anesthesiologists
Author contributions: Guarantors of integrity of entire study, all authors; study concepts, E.M., P.E.B., K.P.M.; study design, P.E.B., K.P.M., D.Z.; literature research, K.P.M.; clinical studies, P.E.B., L.C., K.P.M.; data acquisition, K.P.M., L.C., D.Z.; data analysis/interpretation, K.P.M., D.Z.; statistical analysis, D.Z.; manuscript preparation, all authors; manuscript definition of intellectual content, P.E.B., E.M., K.P.M.; manuscript editing, revision/review, and final version approval, all authors.
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSIONAPPENDIX A: Ketamine Sedation...APPENDIX B: "Ketamine Sedation...REFERENCES |
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H. Al-Takrouri, M. S. Siddiqui, J. F. Mayhew, K. P. Mason, E. Michna, J. A. DiNardo, D. Zurakowski, V. E. Karian, L. Connor, and P. E. Burrows Ketamine-induced Sedation [letter] * Dr Mason and colleagues respond: Radiology, August 1, 2003; 228(2): 595 - 595. [Full Text] [PDF]
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 C. Reichert Beyond halothane: an update on pediatric anesthesia pharmacology Can J Anesth, June 1, 2003; 50(90001): R10 - 10. [Full Text]
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