Ketamine Administration: IMRoute

Ketamine Administration: IMRoute
● Administer ketamine 4 to 5 mg/kg IMin children; the IV route is preferred for adults.
● Repeat ketamine dose (full or half dose IM) if sedation is inadequate after 5 to 10 minutes (unusual) or if additional doses are required.

Coadministered Medications
● Prophylactic anticholinergics are no longer recommended.
● Prophylactic benzodiazepines are no longer recommended for children; however, they should be available to treat rare, unpleasant recovery reactions, should
they occur. Prophylactic midazolam 0.03 mg/kg IV may be considered for adults (number needed to benefit 6).
● Prophylactic ondansetron can slightly reduce the rate of vomiting (number needed to benefit 9 or more).
Procedure
● Adjunctive physical immobilization may be occasionally needed to control random motion.
● Adjunctive local anesthetic is usually unnecessary when a dissociative dose is used.
● Suction equipment, oxygen, a bag-valve-mask, and age-appropriate equipment for advanced airway management should be immediately available.
Supplemental oxygen is not mandatory but may be used when capnography is used to monitor ventilation.
Interactive Monitoring
● Close observation of airway and respirations by an experienced health care professional is mandatory until recovery well established.
● Drapes should be positioned so that airway and chest motion can be visualized at all times.
● Occasional repositioning of the head or suctioning of the anterior pharynx may be indicated for optimal airway patency.
Mechanical Monitoring
● Maintain continuous monitoring (eg, pulse oximetry, cardiac monitoring, capnography) until recovery is well established.
● Pulse and respiratory rate should all be recorded periodically throughout the procedure. Blood pressure measurements after the initial value are generally
unnecessary because ketamine stimulates catecholamine release and does not depress the cardiovascular system in healthy patients.
Potential Adverse Effects
(Percentage estimates are for children; corresponding adult estimates are not yet reliable enough to report.)
● Airway misalignment requiring repositioning of head (occasional)
● Transient laryngospasm (0.3%)
● Transient apnea or respiratory depression (0.8%)
● Hypersalivation (rare)
● Emesis, usually well into recovery (8.4%)
● Recovery agitation (mild in 6.3%, clinically important in 1.4%)
● Muscular hypertonicity and random, purposeless movements (common)
● Clonus, hiccupping, or short-lived nonallergic rash of face and neck

Recovery
● Maintain minimal physical contact or other sensory disturbance.
● Maintain a 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
● Predischarge requirement of tolerating oral fluids or being able to ambulate independently not required or recommended after dissociative sedation
Discharge Instructions
● Nothing by mouth for approximately 2 hours
● Careful family observation and no independent ambulation for approximately 2 hours