Hmm....interesting
I've had a couple of failures with the initial IM ketamine, though I've never had to repeat a whole 4mg/kg. My worry with IM is the depot effect. I used to use IM, but now much prefer IV, it feels much cleaner and you are that much more confident about sending them home at 90 minutes. I seem to be able to get away with 1mg/kg. I now only use ketamine IM if access is clearly impossible.
The other slight problem we've had is with some genius taking away our 100mg/kg prepartion because of a dosing error....no chance someone got the wrong bottles?
I normally put some local in as the first thing after sedation onset and this seems to reduce the sedative requirements, I have only rarely to give subsequent doses
If you want to look at our guideline feel free to ask me off list (slightly off the point but might be interesting)
Adrian
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>All,
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>Not sure how many of you are working in paediatric EM, or a mixed adult / paediatric ED, but I just thought I’d share the following with you.
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>I had an almost 2 year old girl with a nasty laceration on the bridge of her nose that required a careful wound repair.
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>Her weight was 12.7 kg.
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>It is my practice to use ketamine as a sedative / anaesthetic agent in this situation. Personally, I use it IM as getting an IV in is often more trouble than it is worth. I use 4mg / kg. I don’t use any additional agents, eg midazolam or atropine (so, we haven’t accidentally given the wrong drug or wrong mixture).
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>I gave the child 50mg IM.
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>10 minutes later, she appeared to be anaesthetized sufficiently. As soon as I put a stitch in the wound, she woke up and was clearly not sufficiently sedated to proceed.
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>So, I gave her a second dose of 4 mg/kg – 50mg.
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>10 minutes later (20 minutes after the first dose), having had 100mg of ketamine, she was still calling for her sister and trying to sit up. There was some nystagmus, but really it appeared that she had been significantly *underdosed* with ketamine.
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>I’m not hugely experienced with ketamine. I have given it to a total of about 50 children. I’ve never had to actually give a second dose of ketamine, let alone have it fail.
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>I’ve spoken to a number of colleagues who are more experienced and none have ever had 2x 4mg/kg doses of ketamine fail to provide adequate sedation.
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>A bit more information – I personally watched both doses come out of the vials in the process of being drawn up, and it was, indeed, ketamine, and it was in date.
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>I reckon we have a ‘dud’ vial of ketamine.
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>Has anyone else ever encountered a similar situation?
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>Kind regards
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>Paul Bailey
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>________________________________________________________________________ National Patient Safety Agency - supporting Doctors.net.uk members in safe practice. http://www.doctors.net.uk/NPSA ________________________________________________________________________
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________________________________________________________________________
National Patient Safety Agency - supporting Doctors.net.uk members in safe practice.
http://www.doctors.net.uk/NPSA
_______________________________________________________________________
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