Considerations for physicians using ketamine for sedation of children in emergency departments

OBJECTIVE: Ketamine use in emergency departments (EDs) for procedural sedation and analgesia is becoming increasingly common. However, few studies have examined patient factors related to adverse events associated with ketamine. This study investigated factors for consideration when using ketamine to sedate pediatric ED patients. METHODS: The study included pediatric patients receiving ketamine for laceration repair in the ED. Before sedation, information was collected about upper respiratory tract infection symptoms, allergy history, and fasting time. Patients received 2 mg/kg ketamine intravenously or 4 mg/kg ketamine intramuscularly. The primary outcomes were adverse events due to ketamine. RESULTS: We studied 116 patients aged 8 months to 7 years (2.8±1.5 years). The group with adverse events was significantly younger on average than the group without adverse events (2.5±1.5 vs. 3.1±1.5, P=0.028). Upper respiratory tract infection symptoms were not significant variables affecting ketamine sedation (48.9% vs. 43.7%, P=0.719). There was no significant association between duration of fasting and adverse events (P=0.073 and P=0.897, respectively), or between food type and adverse events (P=0.734). However, the number of attempts to sedate and ketamine dose correlated with adverse events (P<0.001 and P=0.022, respectively). In multiple logistic regression analysis, intravenous injection and ketamine dose were significant factors (odds ratio, 16.77; 95% confidence interval, 1.78 to 498.54; odds ratio, 4.37; 95% confidence interval, 1.59 to 22.9, respectively). CONCLUSION: Emergency medicine physicians should consider injection type and ketamine dose when using ketamine sedation while suturing lacerations.

The Clinical Effects of Adjunctive Mida zolam During Ketamine Procedural Sedation in Pediatric Emergency Patients

PURPOSE: Despite widespread use of adjunctive benzodiazepines during ketamine sedation, their efficacy in children has never been studied in Korea. We compared the clinical characteristics and the side effects of as well as the physic i a n's satisfaction with, ketamine sedation in pediatric patients undergoing procedures involving ketamine with adjunctive midazolam. METHODS: The study was a prospective, randomized, clinical evaluation of the effect of adjunctive midazolam during ketamine sedation. We enrolled 60 children aged 8 months to 8 years. Subjects received either intramuscular ketamine (3 mg/kg) with atropine (0.01 mg/kg) (KA) or intramuscular midazolam (0.05 mg/kg) with ketamine and atropine (KMA). For the two groups, we evaluated the induction time, the recovery time, the sedation efficacy, the adverse effects, and the treating physicians' satisfaction. RESULTS: Forty-two (42) subjects received KMA, and 18 received KA. Potentially confounding variables were similar between the two groups, and the induction times and the recovery times were equivalent. The addition of midazolam led to better sedation efficacy (KA=18.8% versus KMA= 55.0%), more treating physician satisfaction (KA=35.4% versus KMA=69.2%), and a decreased incidence of recovery agitation (KA=27.8% versus KMA= 4.7%). CONCLUSION: The incidence of emergence phenomena and satisfaction was affected by the addition of midazolam. The addition of midazolam during ketamine sedation is efficacious and safe with high physician satisfaction for sedation of pediatric patients in the Emergency Department.