Indications for procedural sedation

You should again consider alternative strategies to sedation including the role of topical local anaesthetic agents for wound toilet10-13, and steristrips or glue for wound closure. The role of music14, hypnosis15,16, confusing tactile stimuli17 and blowing away pain18 are well described distraction techniques in young children. Information regarding the procedure can also be relayed to the child in the form of a story19. A game on a parent’s phone may substitute.

The modern day all-in-one-fix-it is a tablet loaded with minions or frozen movies (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 conditions20, 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 10.

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 period21.

Table 10: Contraindications to ketamine for procedural sedation
Age less than 12 months

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

Recent significant head injury or reduced level of consciousness

Intracranial hypertension with CSF obstruction

Intra-ocular pathology

Previous psychotic illness

Uncontrolled epilepsy

Hyperthyroidism or thyroid medication

Porphyria

Prior adverse reaction to ketamine