Pediatric Procedural Sedation with Ketamine: Time to Discharge after Intramuscular versus Intravenous Administration

Abstract

Objectives: Ketamine is an attractive agent for pediatric procedural sedation. There are limited data on time to discharge comparing intramuscular (IM) vs. intravenous (IV) ketamine. The authors set out to determine whether IM or IV ketamine leads to quicker discharge from the emergency department (ED) and how side effect profiles compare.Methods: All patients who had received ketamine IM or IV at a tertiary children's hospital ED during the 3-year study period (2004)(2005)(2006)(2007) were identified. Prospective sedation registry data, retrospective medical records, and administrative data were reviewed for drug dosages, use of additional agents, time of drug administration to discharge, total ED time (triage to discharge), and adverse events. A subgroup analysis for patients requiring five or fewer sutures (short suture group) was performed.Results: A total of 229 patients were enrolled (60% male) with median age of 2.8 years (IQR = 1.8-4.3 years) and median weight of 15.7 kg (range = 8.7-74 kg). Ketamine was most frequently employed for laceration repair (80%) and foreign body removal (9%). Overall, 48% received ketamine IM and 52% received it IV. In the short-suture subgroup, 52% received ketamine IM, while 48% received it IV. Multivariate linear regression analysis determined time from drug administration to patient discharge as 21 minutes shorter for IV compared with IM administration, adjusted for age and number of additional doses (R 2 = )0.35; 95% CI = )0.5 to )0.19; p < 0.001). Total time in the ED (triage to discharge) comparing IV versus IM administration, adjusting for age and gender and number of additional doses, was not significantly different (p = 0.16). In the short-suture subgroup, time to discharge from administration was also shorter in the IV ketamine group (R 2 = )0.454; 95%CI = )0.66 to )0.25; p < 0.001) but similar for total time in ED (p = 0.16). Overall, adverse events occurred in 35% (95% CI = 27% to 45%) of the IM group and 20% (95% CI = 13% to 28%) of the IV group (p = 0.01). Only one patient required brief bag-mask ventilation. Conclusions:In this institution, time from drug injection to discharge was shorter in the IV compared to IM ketamine group, both overall and for the short-suture group. However, time from triage to discharge was similar.

Rapid Administration Technique of Ketamine for Pediatric Forearm Fracture Reduction: A Dose-Finding Study

“…These ketamine doses are smaller than those used in most clinical studies in children 1,3,4,6-8,23 and what is recommended in a widely accepted clinical practice guideline 4 . We believe that similar to propofol and other intravenous anesthetic induction drugs, rapid infusion of smaller doses of ketamine achieves clinical effectiveness because it likely achieves a similar ketamine concentration at the site of action in the brain as larger doses more slowly infused 9,10 and rapid re-distribution of this smaller dose of drug out of the brain leads to shorter recovery.…”

“…A recent clinical practice guideline for emergency department ketamine sedation 4 recommends an intravenous loading dose of 1.5- 2 mg/kg, administered over 30-60 seconds for children of all ages. This regimen achieves effective sedation for 5-10 minutes but is associated with variably defined recovery to discharge readiness times ranging from 16 to 110 minutes 5-8 . The prolonged recovery found in most studies strains emergency department staffs and work flow.…”

Review article: Intravenous vs intramuscular ketamine for pediatric procedural sedation by emergency medicine specialists: a review

“…Ramaswamy et al. (16) found a statistically significant and clinically relevant difference in the time to discharge after administration of ketamine, with the IM group staying on average 42 min longer than the IV group ( P = 0.0019).…”

Paediatric procedural sedation based on nitrous oxide and ketamine: sedation registry data from Australia

“…Our registry data show that ketamine has an adverse events rate similar to published data. The major drawback of ketamine is the prolonged recovery time, irrespective of its use via the intramuscular or intravenous route 17 28. Although no patient required endotracheal intubation or experienced any long-term sequelae, the number of desaturations encountered during ketamine sedation supports the focus of the education and credentialling programme on removing high-risk patients from consideration, requiring senior ED staff to participate in all ketamine sedations and with staff being very familiar with the agent and its adverse events profile.…”

“…As part of a comprehensive sedation programme developed with the support of the hospital insurer,10 16 we prospectively collated all emergency department (ED) sedations in a registry for ongoing quality assurance and observational sedation research 17 18. We analysed 4 years of sedation registry data to determine the overall sedation practice and adverse events profile in a large paediatric ED.…”