Use of Intranasal Ketamine in Pediatric Patients in the Emergency Department

Abstract

Objectives: Ketamine is a safe and widely used sedative and analgesic in the pediatric emergency department (ED). The use of intranasal (IN) ketamine in exchange for the administration of intravenous sedatives or analgesics for procedural sedation in pediatric patients is not commonplace. The goal of this study was to evaluate provider perceptions and patient outcomes at varying doses of IN ketamine for anxiolysis, agitation, or analgesia.Methods: From January 2018 to May 2018, we performed a prospective survey and chart review of pediatric patients receiving IN ketamine. The primary outcome was to determine provider satisfaction with using IN ketamine. Secondary objectives included comparing outcomes stratified by dose, adverse events, assessing for treatment failure, and ED length of stay (LOS). As a secondary comparison, patients receiving IN ketamine whom otherwise would have required procedural sedation with intravenous sedatives or analgesics were placed into a subgroup. This subgroup of patients was compared with a cohort who received intravenous sedatives or analgesics for procedural sedation during a similar period the preceding year (January 2017 to June 2017).Results: Of the 196 cases, 100% of the providers were comfortable using IN ketamine. The median overall provider satisfaction was 90 out of 100, the perception of patient comfort was 75 out of 100, and perceived patient comfort was maximized when using doses between 3 and 5 mg/kg. There were 15 (7.7%) patients who experienced ketamine treatment failure. Overall, the rate of adverse events was 6%, but were considered minor [nausea (n = 3; 1.5%), dizziness (n = 2; 1%), and drowsiness (n = 2; 1%)]. No patients required respiratory support or intubation. The mean LOS was 237.9 minutes, compared with those who underwent procedural sedation with an LOS of 332.4 minutes ( P < 0.001). Conclusions:This study demonstrates that IN ketamine was able to provide safe and successful analgesia and anxiolysis in pediatric patients in an ED setting. In addition, providers expressed a high degree of satisfaction with using IN ketamine (90 out of 100) in addition to a high degree of patient comfort during the procedure (75 out of 100). Intranasal ketamine provides an alternative to intravenous medication normally requiring more resourceintensive monitoring. Procedural sedations are resource and time intensive activities that increase ED LOS. Intranasal ketamine used for anxiolysis and analgesia offers the benefits of freeing up resources of staff and monitoring while enhancing overall throughput through a pediatric ED.

Intranasal Dexmedetomidine Use in Pediatric Patients for Anxiolysis in the Emergency Department

“…The median (IQR) behavior score before administration was 1 (1-3), which correlates with "crying and resisting". It improved to a median (IQR) score 30 minutes after administration to 6 (3.5-7), which correlates with "drowsy, sleepy, and lethargic", and finally it recovered with a median (IQR) score of 4.5 (3)(4)(5), which is between "calm and cooperative" and "alert and awake". Dexmedetomidine Use for Anxiolysis in the ED and 2 minutes after receiving 0.46 mg/kg IV ketamine for procedural sedation, he experienced bradycardia with a lowest documented heart rate of 65 beats per minute and respiratory depression with lowest documented respiratory rate of 12 breaths per minute.…”

“…4 Ketamine can also be used for analgesia or anxiolysis in pediatric patients, and respiratory depression is relatively uncommon. 5 However, ketamine may cause nausea and vomiting, and at high doses may cause a dissociative reaction, adding to distress in an agitated patient.…”

“…However, benzodiazepines may cause respiratory depression and are known to have negative sequela with long-term exposure in pediatric patients 4 . Ketamine can also be used for analgesia or anxiolysis in pediatric patients, and respiratory depression is relatively uncommon 5 . However, ketamine may cause nausea and vomiting, and at high doses may cause a dissociative reaction, adding to distress in an agitated patient.…”

Safety and efficacy of pediatric sedation protocol for diagnostic examination in a pediatric emergency room: A retrospective study

“…Although this study found that orally administered choral hydrate was safe, implementation of a non-invasive modality requires a relatively clear dose–response relationship, an agent with a short half-life, and fewer AEs such as vomiting. [27–31] Large-scale, prospective multicenter studies are needed to establish the safety and efficacy of oral chloral hydrate in pediatric patients undergoing sedation for diagnostic testing.…”

Safety and Efficacy of Pediatric Sedation Protocols for Painless Diagnostic Examination in A Pediatric Emergency Room of A Single Tertiary Hospital

“…These ndings suggest that the usefulness of chloral hydrate for sedation is dependent on the treatment protocol. Although this study found that orally administered choral hydrate was safe, implementation of a noninvasive modality requires a relatively clear dose-response relationship, an agent with a short half-life, and fewer AEs such as vomiting [23][24][25][26][27]. Large-scale, prospective multi-center studies are needed to establish the safety and e cacy of oral chloral hydrate in pediatric patients undergoing sedation for diagnostic testing.…”