Environment, Equipment, Monitoring, Documentation, Recovery and Discharge

For mixed adult and paediatric emergency departments with busy resuscitation rooms, securing a quiet child-friendly area with appropriate paediatric life support equipment may prove challenging. Likewise a quiet recovery area can be hard to come by in modern emergency medicine. The former is certainly considered essential for procedural sedation in children using either benzodiazepine/opioid combinations or ketamine; the latter may be over emphasized. Note the monitoring requirement in the College guideline – ECG, BP, respiration and pulse oximetry. Supplemental oxygen should be given and suction must be available.

Recovery should be complete between 60 and 120 minutes, depending on the dose and route used. The child can be safely discharged once they are able to ambulate and vocalise/converse at pre-sedation levels. An advice sheet should be given to the parent or guardian advising rest, quiet and supervised activity for the remainder of that day. The child should not eat or drink for two hours after discharge because of the risk of nausea and vomiting.

Downloadable appendices for information sheets of the parents and discharge advice from parents exist within the RCEM guideline.

Governance

You should subject your departmental practice to the same governance standards for paediatric procedural sedation as outlined for adults (section 6). A specific exemplar departmental guide/ monitoring chart for paediatric ketamine sedation is available on the RCEM website.

Learning Bite

• RCEM supports the use of 1 mg/kg IV ketamine for procedural sedation in children.
• Laryngospasm is a rare but real side effect of ketamine use, and its management should be incorporated within a regular training programme.