Intramuscular ketamine to facilitate pediatric central vascular access

Pediatrics

CJEM 2004;6(4):259-262

Abstract

Résumé

Introduction

Obtaining prompt vascular access in young children presenting to the emergency department (ED) is frequently both necessary and technically challenging. This is particularly true of medically complicated children, a population that is presenting to the ED with increasing frequency.^1-4 It has been recognized for more than 15 years that an intraosseous needle may be the preferred route for obtaining vascular access in comatose children who lack a peripheral intravenous (IV) catheter.^5,6 However, the placement of an intraosseous needle may not be well tolerated in children who are conscious.⁵ When peripheral IV access cannot be established in a timely fashion, a reasonable option is to place a central venous catheter.^4,7 Although simple physical restraint may be adequate for other procedures in the ED,⁸ the need for a relatively motionless patient during central venous catheter placement makes this approach suboptimal.

Studies dating to 1974 have documented the use of ketamine administered intramuscularly (IM) for pediatric procedural sedation in the ED.^9-11 Only one of these described the use of IM ketamine to facilitate central venous access, and, although the authors studied over 1000 children in total, only 8 underwent central venous catheter placement and the details of these cases were not reported.¹¹ In 2001, Green and colleagues reported a series of 442 consecutive ketamine administrations in a pediatric intensive care unit.¹² Of these, 118 involved the placement of central venous catheters. However, most (86%) of the 442 cases received IV rather than IM ketamine, and the authors did not specify which, if any, of the central venous catheter patients received IM ketamine.

The objective of the current study was to describe our ED experience using IM ketamine to facilitate central venous catheter placement in children requiring prompt vascular access.

Methods

We performed a retrospective medical record review of all pediatric patients <18 years of age who presented to our tertiary care pediatric ED between May 1, 1998, and August 7, 2003, and underwent the placement of a central venous catheter. During the study period, detailed nursing assessments were recorded for each patient undergoing sedation in our hospital, and this assessment is a part of the standard medical record. From this cohort, those subjects who underwent procedural sedation based on the billing code were identified and those to whom ketamine was administered were reviewed. Subjects who received IV ketamine and those for whom medical records were unavailable were excluded. The remaining subjects had received IM ketamine prior to the placement of a central venous catheter and constituted the main study cohort. The abstracted data included: age in months for those children less than 2 years of age and age in years for children 2 years of age and older, gender, ketamine dosing, adverse reactions to the administration of ketamine, vascular access sites of both successful and unsuccessful attempts, and related diagnoses. Given the objective nature of the data, inter-rater reliability testing was not performed. No statistical analyses were required for this small case series. This study was approved by our Institutional Review Board.

Results

During the study period, 208 children underwent central venous catheter placement in our ED. Eighteen (9%) had procedural sedation for the line placement. Of these, 3 were excluded because of unavailable medical records and 4 were excluded because they received IV rather than IM ketamine. Table 1 shows that most of the 11 children included in our case series were young and medically complicated. Although 4 children required attempts at more than one vascular access site, all children ultimately had a central venous catheter placed by the emergency physician. A single adverse event occurred: an 8-year-old boy vomited.

Six children received only a single 4 mg/kg IM ketamine dose, while 3 received an additional 4 mg/kg dose. One child received a first 4 mg/kg IM dose and a second 2 mg/kg dose. One child received three 3.5 mg/kg IM ketamine doses.

Discussion

IM ketamine appears to have been helpful to facilitate central vascular catheter placement in our ED. Although this was a relatively uncommon indication, with only 11 cases over a 5-year period, emergency physicians were universally successful in obtaining central venous access when ketamine was used.

IM ketamine has been shown to be safe when administered to healthy children in the ED,¹¹ to children with congenital heart disease in the catheterization lab,^12,13 to children with hemorrhagic shock in the operating room,¹⁴ to children undergoing procedures in the gastrointestinal lab,¹⁵ and to neonates requiring surgery.¹⁶ IM ketamine has been safely administered by dentists,¹⁷ radiologists,^18,19 gastroenterologists,¹⁵ cardiologists,¹³ anesthesiologists,¹³ pediatric intensivists^20,21 and emergency physicians.^11,21-24 In relevant studies that included ASA (American Society of Anesthesiologists') classification 21 and IV patients, no complications were reported,^11,15 and in our small case series, only one patient had an adverse reaction (vomiting).

Based on the study by Green and colleagues, who reviewed over 1000 IM ketamine sedations and concluded that a dose of 4 to 5 mg/kg was optimal, we typically use an initial IM dose of 4 mg/kg.²⁵ Of note, the only patient in this series who required 3 ketamine injections had been given initial doses lower than 4 mg/kg. Four patients in this series had peripherally inserted central catheters (PICCs). These are typically used for long-term IV antibiotic therapy or parenteral nutrition, therefore may be less familiar to emergency physicians.¹⁶ Due to the discomfort associated with inserting the catheter through a peripheral puncture into the central circulation, sedation is frequently required. All 4 patients who underwent PICC placement had no complications and tolerated the procedures well.

Limitations

In a retrospective study, the potential for incomplete records and missing data exists. This may include undocumented adverse events or central venous access attempts. Because we had no control over the patient selection process, we cannot provide clear indications as to which specific patients are most likely to benefit from ketamine-facilitated central access. During our study period, there were likely other children who would have benefited from IM ketamine but did not receive it.

During a 5-year period, we found only 11 children who received ketamine for central venous access procedures. In a previous 9-year study, Green and colleagues found only 8 such children.¹¹ These numbers are not sufficient to demonstrate safety; however, we believe the safety of IM ketamine in the ED has been adequately demonstrated by other authors.^11,21

Conclusion

IM ketamine appears to be helpful to facilitate the placement of central venous catheters in children who do not have peripheral venous access.

References

1. Reynolds S, Desguin B, Uyeda A, Davis AT. Children with chronic conditions in a pediatric emergency department. Pediatr Emerg Care 1996;12:166-8.
2. Sacchetti A, Gerardi M, Barkin R, Santamaria J, Cantor R, Weinberg J, et al. Emergency data set for children with special needs. Ann Emerg Med 1996;28:324-7.
3. Celermajer DS, Robinson JT, Taylor JF. Vascular access in previously catheterized children and adolescents: a prospective study of 131 consecutive cases. Br Heart J 1993;70:554-7.
4. Chiang VW, Baskin MN. Uses and complications of central venous catheters inserted in a pediatric emergency department. Pediatr Emerg Care 2000;16:230-2.
5. Glaeser PW, Losek JD, Nelson DB, Bonadio WA, Smith DS, Walsh-Kelly C, et al. Pediatric intraosseous infusions: impact on vascular access time. Am J Emerg Med 1988;6:330-2.
6. Brunette DD, Fischer R. Intravascular access in pediatric cardiac arrest. Am J Emerg Med 1988;6:577-9.
7. Wilson-Storey D. Just a 'wee prick' with a needle. J R Coll Surg Edinb 1996;41:412-3.
8. McGlone RG, Ranasinghe S, Durham S. An alternative to "brutacaine": a comparison of low dose intramuscular ketamine with intranasal midazolam in children before suturing. J Accid Emerg Med 1998;15:231-6.
9. Caro DB. Trial of ketamine in an accident and emergency department. Anaesthesia 1974;29:227-9.
10. Dailey RH, Stone R, Repert W. Ketamine dissociative anesthesia -- Emergency department use in children. JACEP 1979;8:57-8.
11. Green SM, Rothrock SG, Lynch EL, Ho M, Harris T, Hestdalen R, et al. Intramuscular ketamine for pediatric sedation in the emergency department: safety profile in 1,022 cases. Ann Emerg Med 1998;31:688-97.
12. Morray JP, Lynn AM, Stamm SJ, Herndon PS, Kawabori I, Stevenson JG. Hemodynamic effects of ketamine in children with congenital heart disease. Anesth Analg 1984;63:895-8.
13. Jobeir A, Galal MO, Bulbul ZR, Solymar L, Darwish A, Schmaltz AA. Use of low-dose ketamine and/or midazolam for pediatric cardiac catheterization. Pediatr Cardiol 2003;24:236-43.
14. McGown RG. A technique of anaesthesia in haemorrhagic shock. Illustrative cases histories and a discussion. Anaesthesia 1975;30:616-23.
15. Green SM, Klooster M, Harris T, Lynch EL, Rothrock SG. Ketamine sedation for pediatric gastroenterology procedures [published erratum appears in J Pediatr Gastroenterol Nutr 2001;32(2):234]. J Pediatr Gastroenterol Nutr 2001;32(1):26-33.
16. Chowdhary SK, Parashar K, Buick RG, Gornall P, Corkery JJ. Central-venous access through the peripheral route in surgical neonates: an audit of 125 consecutive lines from a regional neonatal centre. Pediatr Surg Int 2001;17:433-5.
17. Lu DP, Lu GP, Reed JF 3rd. Safety, efficacy, and acceptance of intramuscular sedation: assessment of 900 dental cases. Compendium 1994;15:1348,1350,1352.
18. Cotsen MR, Donaldson JS, Uejima T, Morello FP. Efficacy of ketamine hydrochloride sedation in children for interventional radiologic procedures. AJR Am J Roentgenol 1997;169:1019-22.
19. Mason KP, Michna E, DiNardo JA, Zurakowski D, Karian VE, Connor L, et al. Evolution of a protocol for ketamine-induced sedation as an alternative to general anesthesia for interventional radiologic procedures in pediatric patients. Radiology 2002;225:457-65.
20. Green SM, Denmark TK, Cline J, Roghair C, Abd Allah S, Rothrock SG. Ketamine sedation for pediatric critical care procedures. Pediatr Emerg Care 2001;17:244-8.
21. Green SM, Nakamura R, Johnson NE. Ketamine sedation for pediatric procedures: Part 1, A prospective series. Ann Emerg Med 1990;19:1024-32.
22. Pitetti RD, Singh S, Pierce MC. Safe and efficacious use of procedural sedation and analgesia by nonanesthesiologists in a pediatric emergency department. Arch Pediatr Adolesc Med 2003;157:1090-6.
23. Pruitt JW, Goldwasser MS, Sabol SR, Prstojevich SJ. Intramuscular ketamine, midazolam, and glycopyrrolate for pediatric sedation in the emergency department. J Oral Maxillofac Surg 1995;53:13-7.
24. McCarty EC, Mencio GA, Walker LA, Green NE. Ketamine sedation for the reduction of children's fractures in the emergency department. J Bone Joint Surg Am 2000;82-A:912-8.
25. Green SM, Hummel CB, Wittlake WA, Rothrock SG, Hopkins GA, Garrett W. What is the optimal dose of intramuscular ketamine for pediatric sedation? Acad Emerg Med 1999;6:21-6.