Indications for procedural sedation

You should again consider alternative strategies to sedation including the role of topical local anaesthetic agents for wound toilet,6-9 and steristrips or glue for wound closure. The role of music,10 hypnosis,11,12 confusing tactile stimuli13 and blowing away pain14 are well described distraction techniques in young children. Information regarding the procedure can also be relayed to the child in the form of a story.15 A game on a parents phone may substitute.

The modern day all-in-one-fix-it is a tablet loaded with Minions or Frozen movies (authors personal opinion). The help of an experienced nurse and capable parent cannot be underestimated. You should consider the use of intranasal diamorphine on presentation for more painful conditions,16 as well as paracetamol and ibuprofen. You might diminish the pain on infiltration of (warmed) local anaesthetics by injecting slowly and using a fine gauge needle.

At risk children

The contraindications to ketamine sedation as listed in the RCEM guideline are illustrated below in Table 9.

With specific regard to fasting, and consistent with your approach to adults, a case-by-case risk benefit assessment is more consistent with the current literature than setting an arbitrary fasting period.17

Table 9: Contraindications to ketamine for procedural sedation19

In addition to general contraindications:

  • Pulmonary Hypertension
  • Age less than 12 months due to an increased risk of laryngospasm and airway complications
  • A high risk of laryngospasm (active respiratory infection, active asthma)
  • Unstable or abnormal airway. Tracheal surgery or stenosis.
  • Active upper or lower respiratory tract infection
  • Proposed procedure within the mouth or pharynx
  • Patients with severe psychological problems such as cognitive or motor delay or severe behavioural problems
  • Significant cardiac disease (angina, heart failure, malignant hypertension)
  • Intracranial hypertension with CSF obstruction
  • Intra-ocular pathology (glaucoma, penetrating injury)
  • Previous psychotic illness
  • Uncontrolled epilepsy
  • Hyperthyroidism or Thyroid medication
  • Porphyria
  • Prior adverse reaction to ketamine 5 Ketamine Procedural Sedation for Children in The Emergency Department (Feb 2020)
  • Altered conscious level due to acute illness or injury
  • Drug / alcohol intoxication