Does midazolam alter the clinical effects of intravenous ketamine sedation in children? A double-blind, randomized, controlled, emergency department trial.

STUDY OBJECTIVE: This study was conducted to investigate the frequency and severity of adverse effects, specifically emergence phenomena, experienced by patients receiving intravenous ketamine with or without midazolam for sedation in a pediatric emergency department. METHODS: Patients aged 4.5 months to 16 years receiving ketamine sedation were prospectively enrolled in a double-blind, randomized, controlled study at a university-affiliated children's hospital-pediatric ED. All patients received ketamine (1 mg/kg) and glycopyrrolate (5 microgram/kg) intravenously. Patients were randomly assigned to receive midazolam (0.1 mg/kg) intravenously or no midazolam. Total time of sedation, sedation efficacy, and adverse effects were recorded. Adverse effects were compared between patients receiving ketamine versus those who received ketamine and midazolam. Additional comparisons were made based on age and number of ketamine doses administered. RESULTS: Two hundred sixty-six patients were studied; 129 received ketamine and 137 patients received ketamine and midazolam. Time of sedation and efficacy of sedation were equivalent between groups. Overall, adverse effects with ketamine sedation included respiratory events (12 [4.5%]), vomiting (50 [18.7%]), emergence phenomena in the pediatric ED (71 [26.7%]), and emergence phenomena at home (60 [22.4%]). Significant emergence phenomena in the pediatric ED (ie, nightmares, hallucinations, and severe agitation) occurred in 7.1% of the ketamine group and in 6.2% of the ketamine-midazolam group, a rate difference of 0.8 (95% confidence interval [CI] -5.3 to 7.0). The addition of midazolam led to an increased incidence of oxygen desaturation events (ketamine 1.6% versus ketamine-midazolam 7.3%; rate difference -5.7, 95% CI -10.6 to -0.9) but a decreased incidence of vomiting (ketamine 19.4%, ketamine-midazolam 9.6%, rate difference 9.8, 95% CI 1.4 to 18.2). The incidence of emergence phenomena and significant emergence phenomena was not affected by the addition of midazolam. However, the addition of midazolam was associated with more agitation in the pediatric ED in children 10 years or older (ketamine 5.7% versus ketamine-midazolam 35.7%; rate difference -30.0, 95% CI -10.7 to -49.3). Age breakdown further showed 6.3% (95% CI 0.9 to 11.6) more episodes of oxygen desaturation in the ketamine-midazolam group in children younger than 10 years, and 12.1% (95% CI 1.5 to 22.6) more vomiting episodes in the ketamine group in children younger than 10 years. CONCLUSION: Ketamine and combined ketamine and midazolam provided equally effective sedation. The addition of midazolam did not alter the incidence of emergence phenomena. Vomiting occurred more frequently in the ketamine only group, whereas oxygen desaturation occurred more frequently in the ketamine-midazolam group. These findings were more pronounced in patients younger than 10 years. Parental and physician satisfaction remained high for all patients receiving intravenous ketamine sedation.

Delivery of albuterol in a pediatric emergency department.

STUDY OBJECTIVE: To determine if albuterol delivery by the combination of a metered-dose inhaler (MDI) with a spacer is equal in effectiveness to nebulization in a pediatric emergency department setting. DESIGN: Prospective series. SETTING: Urban children's hospital emergency department. PARTICIPANTS: Patients > or = six years of age with the diagnosis of acute asthma exacerbation. Exclusion criteria consisted of impending respiratory failure and corticosteroid administration within the preceding seven days. INTERVENTIONS: Patients were randomized into either the nebulizer treatment group or one of two MDI-spacer treatment groups (two spacers were evaluated). Each patient received three albuterol treatments administered evenly over one hour. The dose ratio for albuterol by nebulizer versus MDI-spacer was 6.9:1. Outcome was assessed by comparing the pre- and posttreatment percent predicted respiratory rate and percent predicted peak expiratory flow rate (PEFR) for each patient. RESULTS: Sixty patients were enrolled in the study. All three treatment groups showed significant improvement following albuterol therapy in both percent predicted respiratory rate and percent predicted PEFR. When comparing the three groups against each other in regard to outcome, no significant differences were found in improvement of percent predicted respiratory rate (P = 0.3258) or percent predicted PEFR (P = 0.9362). CONCLUSION: In a pediatric emergency department setting, aerosolized albuterol delivered by MDI-spacer was equal in effectiveness to nebulization in the acute asthma management of children > or = six years of age.