Ketamine is indicated for painful or frightening procedures in children, after all other options have been considered. Suitable procedures include suturing, fracture reduction, burn dressings, incision and drainage, chest drain insertion, and foreign body removal. It is not appropriate for children who need theatre.

Contraindications:

• Age <12 months (increased risk of laryngospasm)
• Active URTI or respiratory infection
• Abnormal airway
• Raised intracranial pressure
• Pulmonary hypertension
• Unstable cardiovascular disease
• Severe psychiatric illness
• Porphyria
• Uncontrolled epilepsy
• Hyperthyroidism
• Prior adverse reaction to ketamine
• Altered consciousness from injury or intoxication

IV: 1mg/kg over 60 seconds. Supplemental dose: 0.5mg/kg by slow injection if further sedation is required.

Clinical onset is approximately 1 minute. Effective sedation lasts 10–20 minutes. Most children are ready for discharge around 90 minutes post-dose.

Rapid IV bolus is associated with respiratory depression — always administer over 60 seconds.

Minimum 3 staff: one to sedate and manage the airway, one to perform the procedure, and one to monitor. The sedating clinician must be experienced in ketamine use and capable of managing its complications.

Ketamine sedation must take place in a high dependency or resuscitation area with full resuscitation facilities available.

Pre-sedation assessment: co-morbidities, current medications, allergies, previous sedation or anaesthesia history, and ASA grade.

Evidence shows that complications are reduced if the child is fasted. However, recent food intake is NOT a contraindication to ketamine sedation. Fasting should not delay emergency procedures.

Continuous monitoring: respiration, heart rate, SpO2, 3-lead ECG, capnography, and blood pressure.

The degree of dissociative sedation should be recorded. Observations are taken every 5 minutes. Supplemental oxygen should be administered before and during the procedure.

Capnography is essential — it detects hypoventilation before desaturation occurs.

Laryngospasm (0.3%)

Presents with inspiratory stridor, chest wall movement without adequate air entry, and desaturation. On ETCO2, look for an obstructive sawtooth pattern or sudden loss of waveform.

Ketamine breathing — the benign mimic

Periodic, noisy breathing that is benign. The child has adequate air entry and normal SpO2/ETCO2. The key distinction: check air entry, not just noise.

Other complications:

• Apnoea after rapid IV bolus
• Vomiting (5–15%)
• Emergence phenomena — more common in adults and older children
• Agitation (25%), nystagmus (1/3), involuntary movements (5%) — all benign

1. STOP THE PROCEDURE — alerts the team, directs attention to the airway
2. Airway repositioning, gentle suctioning, high-flow O2 with reservoir bag
3. If saturating — observe. If stridor worsens or desaturating — BVM ventilation, call for help
4. If SpO2 <92% — gentle BVM ventilation, apply PEEP, prepare for RSI
5. If worsening further — suxamethonium and RSI

Intractable vomiting

Usually occurs during recovery. Treat with IV ondansetron 0.1mg/kg (max 4mg) by slow injection. Place the child in the recovery position to protect the airway.

Emergence phenomena

Agitation, hallucinations, and distress on waking. Prevention: calm environment, dim lights, speak softly, minimise sensory input. Encourage parents to describe pleasant scenes during sedation. Let the child “choose a dream” as they drift off.

If severe: midazolam 0.05–0.1mg/kg in small increments. Routine midazolam prophylaxis is NOT recommended.

• Conscious and responding appropriately
• Able to walk unaided (older children)
• Vital signs within normal limits
• Respiratory status not compromised
• Pain controlled
• No food or drink for 2 hours post-discharge
• No cycling or increased risk activities for 24 hours (older children should not drive)