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

Dose-dependent side effects of prehospital analgesia with ketamine for winter sports injuries - an observational study

BACKGROUND

Ketamine is one of the most used drugs in trauma patients after skiing accidents. However, the environmental conditions for these patients are often rough, with numerous unpleasant sensory impressions (e.g. noise from the helicopter, cold, wind, etc.), raising concerns about the adverse psychological side effects of ketamine. Moreover, it has not yet been established whether these side effects are dose-dependent, and the supplementary administration of benzodiazepines remains controversial. We analysed the subjective perception of side effects after administration of ketamine during helicopter emergency medical service missions involving trauma patients after ski accidents.

METHODS

In this retrospective observational study, data was collected from emergency services protocols and questionnaires filled out by patients. The primary outcome was defined as the patients' subjective perceptions of ketamine-associated side effects. The subjective intensity of twelve common classes of side effects was recorded on a five-point Likert scale. In addition, we conducted a linear regression analysis, with side effect intensity as the outcome and gender, age, type of injury, use of midazolam and fentanyl, ketamine dosage and relative pain reduction as covariates.

RESULTS

A total of 69 patients were identified who were treated with ketamine during the winter months of 2023/2024, after suffering trauma while doing alpine winter sports. Of these, 49 patients (71%) could be included. The side effects reported were mostly mild, with two-thirds of the patients describing them as "no [side effects]" or "mild". Only 6% described them as "barely tolerable" or "unbearable". No statistically significant association could be demonstrated between the ketamine dose and the total reported side effect score. The regression model identified the additional administration of midazolam as a significant covariate for fewer side effects. With regard to prehospital care, 85% of the patients stated that they had always felt safe, while two-thirds were satisfied with the prehospital pain therapy.

CONCLUSION

Ketamine seems to be a suitable option for pain therapy in the case of injuries during alpine winter sport activities. Side effects reported by patients in this study were rare, not dose-dependent and described by most patients as subjectively well tolerable. The supplementary administration of midazolam could potentially further reduce these side effects.

Safety and Depth of Sedation With Ketamine Alone Versus Ketamine With Midazolam in Pediatric Fracture Reduction: A Retrospective Chart Review

OBJECTIVES

Pediatric patients with extremity fractures often require sedation for fracture reduction in the pediatric emergency department (PED). Although orthopedic literature suggests combination sedation regimens may be more effective for fracture reduction, some pediatric literature suggests adverse events are more frequent. The primary objective of this study is to determine the comparable depth of sedation and incidence of adverse events when intravenous ketamine is used alone versus with midazolam for pediatric procedural sedation and orthopedic fracture reduction.

METHODS

This is a retrospective cohort study of pediatric patients 2-18 years old who underwent sedation for fracture reduction in the PED at a single level 1 trauma center over a 2-year period. Medical records were reviewed, and occurrence of adverse events, depth of sedation (Ramsey score), midazolam dose, total ketamine administration, opiate administration, total sedation time, and time to PED discharge were compared in patients who received ketamine alone versus those who received ketamine with midazolam. Logistic regression models were adjusted to evaluate for potential confounders.

RESULTS

There was a statistically significant increase in the occurrence of hypoxia with coadministration of midazolam (5% vs 0%). When hypoxia occurred, it was mild and resolved with repositioning or administration of supplemental oxygen. Length of sedation was increased in sedations with coadministration of benzodiazepines by approximately 3.5 minutes. Time to PED discharge was not significantly different. There was no significant difference in depth of sedation, ketamine dose administered, end-tidal CO 2 measurements, administration of positive pressure ventilation, vomiting, agitation, or overall occurrence of adverse events. No patients developed apnea or laryngospasm.

CONCLUSIONS

This study showed a low rate of adverse events in pediatric sedation for orthopedic reduction with ketamine alone or ketamine with midazolam. There was an increased occurrence of hypoxia with coadministration of midazolam and an increase in the length of sedation. This study showed no difference in depth of sedation based on Ramsay scores when midazolam was coadministered. Information on the orthopedic reduction and provider satisfaction was not collected.

Intravenous Sedation and Analgesia in a Pediatric Emergency Department: A Retrospective Descriptive Study

Background Painful procedures in the pediatric emergency department often require the use of sedation and analgesia to ensure adequate pain control, a right of children and adolescents. This study aims to describe the procedural sedation and analgesia with intravenous medications performed in a pediatric emergency department. Methods This is a retrospective descriptive study of intravenous sedoanalgesia used in a pediatric emergency department of a level II district hospital in the Lisbon metropolitan area from October 2018 to December 2023. The type of intervention, drugs used, and adverse events were analyzed. Results A total of 615 patients were included in the study; 65.7% (n=404) were male with a median age of 6 years. The most frequently performed procedures were wound suturing (50.9%, n=313) and fracture reduction (36.3%, n=223). The drugs used for sedation and analgesia were ketamine (99.2%, n=610), midazolam (95.8%, n=589), propofol (1.6%, n=10), and morphine (0.5%, n=3). The majority of patients received midazolam and ketamine in association (93.8%, n=577). A total of 50 adverse events (8.1%) were recorded in 42 patients. The most frequent side effects were transient oxygen desaturation (2%, n=12), vomiting (1.5%, n=9), apnea/bradypnea (1%, n=6), and hallucinations (0.8%, n=5). The occurrence of adverse events was not dose-dependent (p >0.05). Respiratory complications resolved without requiring invasive interventions. Children were sedated by a pediatric intensivist in 68.1% (n=419), by a general pediatrician in 26.7% (n=164), and by a pediatric resident in 2% (n=12). Conclusions The results of this study demonstrate that intravenous sedoanalgesia, particularly the combination of ketamine and midazolam, is a safe method for sedation in pediatric patients, with a low rate of adverse events.

Association of ketamine use during procedural sedation with oxygen desaturation and healthcare utilisation: a multicentre retrospective hospital registry study

BACKGROUND

We investigated the effects of ketamine on desaturation and the risk of nursing home discharge in patients undergoing procedural sedation by anaesthetists.

METHODS

We included adult patients who underwent procedures under monitored anaesthetic care between 2005 and 2021 at two academic healthcare networks in the USA. The primary outcome was intraprocedural oxygen desaturation, defined as oxygen saturation <90% for ≥2 consecutive minutes. The co-primary outcome was a nursing home discharge.

RESULTS

Among 234,170 included patients undergoing procedural sedation, intraprocedural desaturation occurred in 5.6% of patients who received ketamine vs 5.2% of patients who did not receive ketamine (adjusted odds ratio [ORadj] 1.22, 95% confidence interval [CI] 1.15-1.29, P<0.001; adjusted absolute risk difference [ARDadj] 1%, 95% CI 0.7-1.3%, P<0.001). The effect was magnified by age >65 yr, smoking, or preprocedural ICU admission (P-for-interaction <0.001, ORadj 1.35, 95% CI 1.25-1.45, P<0.001; ARDadj 2%, 95% CI 1.56-2.49%, P<0.001), procedural risk factors (upper endoscopy of longer than 2 h; P-for-interaction <0.001, ORadj 2.91, 95% CI 1.85-4.58, P<0.001; ARDadj 16.2%, 95% CI 9.8-22.5%, P<0.001), and high ketamine dose (P-for-trend <0.001, ORadj 1.61, 95% CI, 1.43-1.81 for ketamine >0.5 mg kg-1). Concomitant opioid administration mitigated the risk (P-for-interaction <0.001). Ketamine was associated with higher odds of nursing home discharge (ORadj 1.11, 95% CI 1.02-1.21, P=0.012; ARDadj 0.25%, 95% CI 0.05-0.46%, P=0.014).

CONCLUSIONS

Ketamine use for procedural sedation was associated with an increased risk of oxygen desaturation and discharge to a nursing home. The effect was dose-dependent and magnified in subgroups of vulnerable patients.

Pharmacological agents for procedural sedation and analgesia in the emergency department and intensive care unit: a systematic review and network meta-analysis of randomised trials

BACKGROUND

We aimed to evaluate the comparative effectiveness and safety of various i.v. pharmacologic agents used for procedural sedation and analgesia (PSA) in the emergency department (ED) and ICU. We performed a systematic review and network meta-analysis to enable direct and indirect comparisons between available medications.

METHODS

We searched Medline, EMBASE, Cochrane, and PubMed from inception to 2 March 2023 for RCTs comparing two or more procedural sedation and analgesia medications in all patients (adults and children >30 days of age) requiring emergent procedures in the ED or ICU. We focused on the outcomes of sedation recovery time, patient satisfaction, and adverse events (AEs). We performed frequentist random-effects model network meta-analysis and used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to rate certainty in estimates.

RESULTS

We included 82 RCTs (8105 patients, 78 conducted in the ED and four in the ICU) of which 52 studies included adults, 23 included children, and seven included both. Compared with midazolam-opioids, recovery time was shorter with propofol (mean difference 16.3 min, 95% confidence interval [CI] 8.4-24.3 fewer minutes; high certainty), and patient satisfaction was better with ketamine-propofol (mean difference 1.5 points, 95% CI 0.3-2.6 points, high certainty). Regarding AEs, compared with midazolam-opioids, respiratory AEs were less frequent with ketamine (relative risk [RR] 0.55, 95% CI 0.32-0.96; high certainty), gastrointestinal AEs were more common with ketamine-midazolam (RR 3.08, 95% CI 1.15-8.27; high certainty), and neurological AEs were more common with ketamine-propofol (RR 3.68, 95% CI 1.08-12.53; high certainty).

CONCLUSION

When considering procedural sedation and analgesia in the ED and ICU, compared with midazolam-opioids, sedation recovery time is shorter with propofol, patient satisfaction is better with ketamine-propofol, and respiratory adverse events are less common with ketamine.

Patient-reported side effects and satisfaction of pre-hospital analgesia with low-dose esketamine: a cross-sectional study

BACKGROUND

Analgesia is a core intervention in emergency medicine. Pain is subjective, so patient-reported experience with pain and analgesia is essential for healthcare professionals. The aim of this study was to evaluate patient-reported side effects and satisfaction associated with pre-hospital analgesia with low-dose esketamine.

METHODS

This is an observational cross-sectional study conducted as part of quality assurance measures of the German Red Cross Emergency Medical Service, Reutlingen, Germany. The survey was administered to all patients who received prehospital esketamine analgesia from paramedics. Addresses were obtained from medical records and mailed 10 days after the event. Patient feedback was anonymous and could not be linked to operational documentation.

RESULTS

A total of 201 patients were contacted, and 119 responses were received via the online questionnaire and postal mail (response rate 59%). The mean age of the patients was 68±13 years, with 64.7% (n=77) being female. The main diagnosis reported was fractures of the extremities in 69.7%. Patients reported initial median pain intensity on a Numeric Rating Scale (NRS) of 10 [8-10]. Pain was unbearable for 96.3% of patients. After administration of analgesia, 95.3% were satisfied or very satisfied. Patients reported no side effects in 78.5%, minor side effects in 10.0%, significant but well tolerable side effects in 11.3%, borderline tolerable side effects in 0.2%, and no unbearable side effects. Borderline tolerable nausea was reported in 2% of patients along with dreams in 0.8%. No nightmares were reported. Further analysis showed that patients older than 80 years reported significantly more side effects (p < 0.001) and were thus less satisfied with the analgesia.

CONCLUSIONS

Both patient perception and analgesia with few side effects were important for both safety and satisfaction. In the present study, low-dose esketamine analgesia was associated with low side effects and high patient satisfaction.

COMPARISON OF INTRAMUSCULAR VERSUS INTRAVENOUS KETAMINE FOR SEDATION IN CHILDREN UNDERGOING MAGNETIC RESONANCE IMAGING EXAMINATION

OBJECTIVE

The aim: To compare efficacy of intramuscular (IM) versus intravenous (IV) ketamine for sedation in children undergoing brain MRI scanning in children.

PATIENTS AND METHODS

Materials and methods: Children who required elective brain MRI were selected for this study. They were randomly divided into two groups; group I received 1.5 mg/kg IV Ketamine and group II received 4 mg/kg IM ketamine. In each group supplementary 0.1 mg/kg midazolam intravenously before positioning on MRI table was given. Patients were monitored for pulse rate, SPO2, and respiratory wave.

RESULTS

Results: Children who received IM ketamine had significantly shorter scan time and a greater success rate of sedation with first dose than the IV group. The proportions of scan interruption and scan repeat were significantly higher among the IV group than in the IM group. The scan time was longer among the IV group than in the IM group with significantly more scan interruption and repeat. Satisfaction with sedation as expressed by the technicians was significantly more in the IM group than in IV group (98.1% vs. 80.8%, P= 0.004).

CONCLUSION

Conclusions: Intramuscular ketamine injection was predicted to have a better sedative success rate and takes less time to complete than intravenous admin¬istration. This makes IM ketamine more appealing in certain conditions.

Advantages of ketamine in pediatric anesthesia

Although ketamine is primarily used for induction and maintenance of general anesthesia, it also presents sedative, amnestic, anesthetics, analgesic, antihyperalgesia, neuroprotective, anti-inflammatory, immunomodulant, and antidepressant effects. Its unique pharmacodynamics and pharmacokinetic properties allow the use of ketamine in various clinical settings including sedation, ambulatory anesthesia, and intensive care practices. It has also adopted to manage acute and chronic pain management. Clinically, ketamine produces dissociative sedation, analgesia, and amnesia while maintaining laryngeal reflexes, with respiratory and cardiovascular stability. Notably, it does not cause respiratory depression, maintaining both the hypercapnic reflex and the residual functional capacity with a moderate bronchodilation effect. In the pediatric population, ketamine can be administered through practically all routes, making it an advantageous drug for the sedation required setting such as placement of difficult vascular access and in uncooperative and oppositional children. Consequently, ketamine is indicated in prehospital induction of anesthesia, induction of anesthesia in potentially hemodynamic unstable patients, and in patients at risk of bronchospasm. Even more, ketamine does not increase intracranial pressure, and it can be safely used also in patients with traumatic brain injuries. This article is aimed to provide a brief and practical summary of the role of ketamine in the pediatric field.

Opioids Safety in Pediatric Procedural Sedation with Ketamine

OBJECTIVE

To evaluate the effects of pre- and intraprocedural opioids on adverse events in children undergoing procedural sedation with ketamine in the emergency department (ED).

STUDY DESIGN

We conducted a retrospective cohort study of all children aged 0-18 years who underwent procedural sedation with intravenous ketamine alone, or in combination with an opioid, at a tertiary-care pediatric ED between June 1, 2018, and August 31, 2020. We explored predictors of serious adverse events (SAEs), desaturation or respiratory intervention, and vomiting.

RESULTS

Of 1164 included children (694 male, 59.6%; median age 5.0 years [IQR 2.0-8.0]), 80 (6.8%) vomited, 63 (5.4%) had a desaturation or required respiratory interventions, and 6 (0.5%) had SAEs. Pre- and intraprocedural opioids were not independent predictors of sedation-related adverse events. A concurrent respiratory illness (aOR 3.73; 95% CI 1.31-10.60, P = .01), dental procedure (aOR 3.05; 95% CI 1.25-7.21, P = .01), and a greater total ketamine dose (aOR 1.75; 95% CI 1.21-2.54, P = .003) were independent predictors of desaturation or respiratory interventions. A greater total ketamine dose (aOR 1.86; 95% CI 1.16-2.98, P = .01) and older age (aOR 1.15; 95% CI 1.07-1.24, P < .001), were independent predictors of vomiting.

CONCLUSIONS

Pre- and intraprocedural opioids do not increase the likelihood of sedation-related adverse events. SAEs are rare during pediatric procedural sedation with ketamine in the ED.

Ketamine use in critically ill patients: a narrative review

Ketamine is unique among anesthetics and analgesics. The drug is a rapid-acting general anesthetic that produces an anesthetic state characterized by profound analgesia, preserved pharyngeal-laryngeal reflexes, normal or slightly enhanced skeletal muscle tone, cardiovascular and respiratory stimulation, and occasionally a transient and minimal respiratory depression. Research has demonstrated the efficacy of its use on anesthesia, pain, palliative care, and intensive care. Recently, it has been used for postoperative and chronic pain, as an adjunct in psychotherapy, as a treatment for depression and posttraumatic stress disorder, as a procedural sedative, and as a treatment for respiratory and/or neurologic clinical conditions. Despite being a safe and widely used drug, many physicians, such as intensivists and those practicing in emergency care, are not aware of the current clinical applications of ketamine. The objective of this narrative literature review is to present the theoretical and practical aspects of clinical applications of ketamine in intensive care unit and emergency department settings.

Current State of Analgesia and Sedation in the Pediatric Intensive Care Unit

Critically ill pediatric patients often require complex medical procedures as well as invasive testing and monitoring which tend to be painful and anxiety-provoking, necessitating the provision of analgesia and sedation to reduce stress response. Achieving the optimal combination of adequate analgesia and appropriate sedation can be quite challenging in a patient population with a wide spectrum of ages, sizes, and developmental stages. The added complexities of critical illness in the pediatric population such as evolving pathophysiology, impaired organ function, as well as altered pharmacodynamics and pharmacokinetics must be considered. Undersedation leaves patients at risk of physical and psychological stress which may have significant long term consequences. Oversedation, on the other hand, leaves the patient at risk of needing prolonged respiratory, specifically mechanical ventilator, support, prolonged ICU stay and hospital admission, and higher risk of untoward effects of analgosedative agents. Both undersedation and oversedation put critically ill pediatric patients at high risk of developing PICU-acquired complications (PACs) like delirium, withdrawal syndrome, neuromuscular atrophy and weakness, post-traumatic stress disorder, and poor rehabilitation. Optimal analgesia and sedation is dependent on continuous patient assessment with appropriately validated tools that help guide the titration of analgosedative agents to effect. Bundled interventions that emphasize minimizing benzodiazepines, screening for delirium frequently, avoiding physical and chemical restraints thereby allowing for greater mobility, and promoting adequate and proper sleep will disrupt the PICU culture of immobility and reduce the incidence of PACs.

Retrospective Comparison of Intranasal Fentanyl and Inhaled Nitrous Oxide to Intravenous Ketamine and Midazolam for Painful Orthopedic Procedures in a Pediatric Emergency Department

OBJECTIVES

To compare the efficacy and adverse events of 2 pharmacological strategies: intranasal fentanyl and nitrous oxide (FN) inhaled against intravenous ketamine and midazolam (KM) as procedural sedation and analgesia (PSA) in painful orthopedic procedures in the pediatric emergency department (ED).

METHODS

This is an observational retrospective cohort study. Patients were included that submitted to PSA for carrying out a painful orthopedic procedure in the ED of a tertiary hospital over a period of 2 years. The main outcome variable was efficacy and adverse events of the PSA procedure.

RESULTS

Eighty-three patients were included. Fifty-two patients received FN and 31 KM. The PSA strategy was considered efficacious in 82.7% of the patients in the KM group and 80.6% in the FN cohort. No differences between both strategies were found (P = 0.815). Seventeen children showed early adverse events, 2 in the FN cohort and 15 in the KM group (relative risk of the KM strategy, 23.48; 95% confidence interval (CI), 3.24-169.99). The average of satisfaction obtained by the families was of 10 (CI, 10-10) in the KM cohort and of 9 (CI, 8-9.5) in the FN group (P = 0.152). The length of stay in the ED was longer in the KM cohort (P < 0.001). Hospital admission rate differences were not statistically different (9.6% vs 22.6%, P = 0.144) in the KM versus FN cohort.

CONCLUSIONS

Both PSA strategies presented similar efficacy. The FN strategy was associated with a lower risk of adverse events and shorter ED length of stay than KM in this ED setting.

Rapid Administration of Ketamine for Abscess Drainage in Children-A Dose Finding Study

STUDY OBJECTIVE

To estimate the minimum dose and total sedation time of rapidly infused ketamine that achieves 3 to 5 minutes of effective sedation in children undergoing abscess incision and drainage in the emergency department.

METHODS

The Up-Down method was used to estimate the dose of intravenous ketamine infused over 5 seconds or less that provided effective sedation in 50% (ED50) and 95% (ED95) for healthy children aged 2 to 5 years and 6 to 11 years undergoing abscess incision and drainage. None were pretreated with opioids. Three investigators blinded to ketamine dose independently graded sedation effectiveness by viewing a video recording of the first 5 minutes of sedation. Recovery was determined when patients reached a Modified Aldrete score of 10.

RESULTS

We enrolled 20 children in each age group. The estimated ED50 was 0.9 and 0.6 mg/kg for the 2 to 5 years and 6 to 11 years' groups and the estimated ED95 was 1.1 mg/kg for both groups. The median time to full recovery for the 2 groups was 20.5 and 17.5 minutes when only 1 dose of ketamine was administered and 27.5 and 35 minutes when additional doses of ketamine were administered. No participants experienced serious adverse events.

CONCLUSIONS

We estimated ED50 and ED95 for rapidly infused ketamine for 2 age groups undergoing abscess incision and drainage. Further studies are needed to get a more precise estimate of ED95. The total sedation time with this technique in the abscess group was shorter than most previous studies and is consistent with our previous observations in patients undergoing fracture reduction.

Sedative reduction method for children with intussusception

Intussusception is common emergency condition in children. Pneumatic or hydrostatic reduction (HR) is considered the first-choice management strategy in cases lacking indications for surgical intervention. Generally, sedatives are not used in children undergoing interventional radiology procedures. Surgical management is associated with long hospitalization durations and high costs, unlike nonsurgical reduction. To avoid surgery, reduction procedures are repeated despite initial treatment failure. However, in cases involving repeated failures, children should be referred for surgery.To ensure good response to reduction, we planned HR under sedation during the third reduction attempt. Sedative reduction (SR) was performed with the administration of ketamine, midazolam, and atropine. All patients with contraindications against HR underwent laparoscopic reduction (LR) without HR.During 3 years, SR was performed in 43 patients, and in 28 (65.1%), the treatment was successful. Among the 15 patients in whom the procedure failed, 14 underwent LR without intestinal resection. There was no significant risk factor contributing to failed reduction under sedation.During the second or third HR attempt, successful reduction may be ensured with the SR procedure with intravenous ketamine, midazolam, and atropine; this procedure may further reduce surgery rates in pediatric intussusception.

Randomized Trial of Intranasal Fentanyl Versus Intravenous Morphine for Abscess Incision and Drainage

OBJECTIVES

Abscess incision and drainage (I&D) are painful and distressing procedures in children. Intranasal (IN) fentanyl is an effective analgesic for reducing symptomatic pain associated with fractures and burns but has not been studied for reducing procedural pain during abscess I&D. Our objective was to compare the analgesic efficacy of IN fentanyl with intravenous (IV) morphine for abscess I&D in children.

METHODS

We performed a randomized noninferiority trial in children aged 4 to 18 years undergoing abscess I&D in a pediatric emergency department. Patients received IN fentanyl (2 μg/kg; maximum, 100 μg) or IV morphine (0.1 mg/kg; maximum, 8 mg). The primary outcome, determined independently by blinded assessors, was the Observational Scale of Behavioral Distress-Revised (OSBD-R). The prestated margin of noninferiority (Δ) was 1.80. Secondary outcomes included self-reported pain, treatment failure, and patient and parental satisfaction.

RESULTS

We enrolled 20 children (median age, 15.4 years), 10 in each group. The difference between total OSBD-R scores was -13.45 (95% confidence interval, -24.24 to -2.67), favoring IN fentanyl.There was less self-reported pain in patients who received IN fentanyl immediately after the procedure. Four patients (40%) receiving IV morphine had treatment failures and required moderate sedation or had the procedure terminated. More patients who received IN fentanyl were satisfied with the analgesic administered compared with those who received IV morphine.

CONCLUSIONS

In a small sample of children aged 4 to 18 years undergoing abscess I&D, IN fentanyl was noninferior, and potentially superior, to IV morphine for reducing procedural pain and distress.

A comparison of ketamine + midazolam to propofol for procedural sedation for lumbar puncture in pediatric oncology by nonanesthesiologists-a randomized comparative trial

BACKGROUND

Both ketamine-midazolam and propofol are frequently used in pediatric oncology units for procedural sedation. However, there are no prospective, randomized comparative trials (RCT) comparing the two groups when the procedure is performed by nonanesthesiologists.

OBJECTIVE

To compare ketamine + midazolam (group A) and propofol (group B) as sedative agents for intrathecal chemotherapy with regard to efficacy, side effects, time to induction, time to recovery, and smoothness of recovery.

METHODS

A partially-blinded RCT was conducted between August 2015 and March 2017 after gaining institutional ethics committee approval. Children aged 1-12 years requiring intravenous sedation for intrathecal chemotherapy were included. Patients were allocated to two treatment arms using computer-generated randomization tables, after obtaining written consent. The initial doses used were: ketamine 2 mg/kg, midazolam 0.2 mg/kg, and propofol 2.5 mg/kg, as per standard recommendations. The patient, parents, and person analyzing the data were blinded. Time to sedation, dose required, depth of sedation, vital parameters, time and smoothness of recovery, and emergence phenomena were documented.

RESULTS

We enrolled 152 patients (76 each in group A and B). Nine patients had a failure of sedation (all in group B). Mean time to sedation and recovery was shorter in group B (P < 0.001). Transient drop in saturation was more frequent in group B, without statistical significance (P = 0.174). Mean depth of sedation was greater in group A (P < 0.001). Emergence symptoms were more frequently experienced in group A (P < 0.001).

CONCLUSIONS

Ketamine-midazolam combination is safer and more effective. Propofol is faster in onset and recovery, and has smoother emergence with poor efficacy at recommended initial doses.

S(+)-ketamine : Current trends in emergency and intensive care medicine

S(+)-ketamine, the pure dextrorotatory enantiomer of ketamine has been available for clinical use in analgesia and anesthesia for more than 25 years. The main effects are mediated by non-competitive inhibition of the N-methyl-D-aspartate (NMDA) receptor but S(+)-ketamine also interacts with opioid receptors, monoamine receptors, adenosine receptors and other purinergic receptors. Effects on α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptors, metabotropic glutamate receptors (mGluR) and L‑type calcium chanels have also been described. S(+)-ketamine stimulates the sympathetic nerve system, making it an ideal drug for analgosedation or induction of anesthesia in instable patients. In addition, the neuroprotective properties, bronchodilatory, antihyperalgesic or antiepileptic effects provide interesting therapeutic options. In this article we discuss the numerous effects of S(+)-ketamine under pharmacological and clinical aspects especially for typical indications in emergency medicine as well as intensive care.

Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease: A Scientific Statement From the American Heart Association

Cardiac arrest occurs at a higher rate in children with heart disease than in healthy children. Pediatric basic life support and advanced life support guidelines focus on delivering high-quality resuscitation in children with normal hearts. The complexity and variability in pediatric heart disease pose unique challenges during resuscitation. A writing group appointed by the American Heart Association reviewed the literature addressing resuscitation in children with heart disease. MEDLINE and Google Scholar databases were searched from 1966 to 2015, cross-referencing pediatric heart disease with pertinent resuscitation search terms. The American College of Cardiology/American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. The recommendations in this statement concur with the critical components of the 2015 American Heart Association pediatric basic life support and pediatric advanced life support guidelines and are meant to serve as a resuscitation supplement. This statement is meant for caregivers of children with heart disease in the prehospital and in-hospital settings. Understanding the anatomy and physiology of the high-risk pediatric cardiac population will promote early recognition and treatment of decompensation to prevent cardiac arrest, increase survival from cardiac arrest by providing high-quality resuscitations, and improve outcomes with postresuscitation care.

[Efficacy, safety and satisfaction of sedation-analgesia in Spanish emergency departments]

OBJECTIVES

To offer analgesia and sedation should be a priority in paediatric emergency departments. The aim of this study was to determine the effectiveness and safety of the sedation-analgesia procedure, as well as the satisfaction of the doctors, patients and parents.

METHODS

A multicentre, observational, and prospective analytical study was conducted on the sedation-analgesia procedure performed on children younger than 18 years old in 18 paediatric emergency departments in Spain from February 2015 until January 2016.

RESULTS

A total of 658 procedures were recorded. The effectiveness was good in 483 cases (76.1%; 95%CI: 72.7-79.4%), partial in 138 (21.7%; 95%CI: 18.5-24.9%), and poor in 14 (2.2%; 95%CI: 1.1-3.4). The effectiveness was better when the doctor in charge was an emergency paediatrician (OR: 3.14; 95%CI: 1.10-8.95), and when a deeper level of sedation was achieved (OR: 2.37; 95%CI: 1.68-3.35). Fifty two children (8.4%) developed adverse drug reactions, more usually gastrointestinal, neurological or respiratory ones (89.9% were resolved in <2h). One patient was intubated. The older child and a deeper level of sedation were found to be independent risk factors for adverse reactions (OR: 1.18; 95%CI: 1.09-1.28 and OR: 1.86; 95%CI: 1.22-2.83, respectively). Thirteen children (5%) developed late adverse drug reactions, more commonly, dizziness and nauseas. A combination of midazolam/ketamine had been used in all the cases (RR: 24.46; 95%CI: 11.78-50.76). The perceived satisfaction level (0-10) was obtained from 604 doctors (mean: 8.54; SD: 1.95), 526 parents (mean: 8.86; SD: 1.49), and 402 children (mean: 8.78; SD: 1.70).

CONCLUSIONS

The sedation-analgesia procedure performed in paediatric emergency departments by trained paediatricians seems to be useful, effective and safe, as well as satisfactory for all participants.

Behavioral Changes in Children After Emergency Department Procedural Sedation

OBJECTIVE

The purpose of this study was to determine the proportion of children undergoing procedural sedation for fracture reduction in the emergency department (ED) observed to experience negative postdischarge behaviors. Predictors of negative behaviors were evaluated, including anxiety.

METHODS

This was a prospective cohort study of children receiving intravenous ketamine sedation for ED fracture reduction. The child's anxiety prior to sedation was measured with the Modified Yale Preoperative Anxiety Scale. Negative behavioral changes were measured with the Post-Hospitalization Behavior Questionnaire 1 to 2 weeks after discharge. Descriptive statistics and odds ratios (ORs) were calculated. Chi-square test was used for comparisons between groups. Multivariable logistic regression models evaluated predictors of negative behavioral change after discharge.

RESULTS

Ninety-seven patients were enrolled; 82 (85%) completed follow-up. Overall, 33 (40%) children were observed to be highly anxious presedation and 18 (22%) had significant negative behavior changes after ED discharge. Independent predictors for negative behaviors were high anxiety (OR = 9.0, 95% confidence interval [CI] = 2.3-35.7) and nonwhite race (OR = 6.5, 95% CI = 1.7-25.0).

CONCLUSION

For children undergoing procedural sedation in the ED, two in five children have high preprocedure anxiety and almost one in four have significant negative behaviors 1 to 2 weeks after discharge. Highly anxious and nonwhite children have increased risk of negative behavioral changes that have not been previously recognized in the ED setting.

Shortened preprocedural fasting in the pediatric emergency department

BACKGROUND

There is no evidence of an association between fasting time and the incidence of adverse events during procedural sedation and analgesia. Pediatric and adult emergency medicine guidelines support avoiding delaying procedures based on fasting time. General pediatric guidelines outside emergent care settings continue to be vague and do not support a set fasting period for urgent and emergent procedures.

OBJECTIVE

To describe shortened preprocedural fasting and vomiting event rates during the implementation of a shortened fasting protocol.

METHODS

This was a prospective study of patients undergoing procedural sedation and analgesia (PSA) in an urban, tertiary care children's hospital emergency center from March 2010-February 2012. All consecutive patients had documentation of preprocedural fasting time and adverse events recorded on a standardized data collection form.

RESULTS

PSA occurred in 2426 patients with fasting data available for 2188 (90.2%); 1472 were fasted ≥6 h for solids and 716 patients were in the shortened fasting group (<6 h). There is no evidence of an association between emesis at any time and shortened fasting time unadjusted (OR = 1.18 (95% CI 0.75-1.84) or adjusted for known risk factors including age >12 years, initial ketamine dose >2.5 mg/kg or total dose >5.0 mg/kg (OR = 1.14 (95% CI 0.74-1.75).

CONCLUSION

Analysis of a large prospective cohort study failed to find evidence of an association between emesis and shortened fasting time upon implementation of a shortened fasting protocol for procedural sedation and analgesia.

Comparison of Ketamine with Midazolam versus Ketamine with Fentanyl for Pediatric Extracorporeal Shock Wave Lithotripsy Procedure: A Randomized Controlled Study

Objectives

To compare the effects of ketamine-fentanyl (KF) and ketamine-midazolam (KM) combinations on hemodynamic parameters, recovery properties, pain, and side effects in pediatric patients undergoing extracorporeal shock wave lithotripsy (ESWL) procedure.

Methodology

In this double-blinded, randomized trial, 60 pediatric patients aged between 1 and 13 years with American Society of Anesthesiologists physical status Classes I and II, who scheduled for ESWL procedure, were included in the study. Patients were randomly divided into two groups: Group KM received 0.1 mg/kg of midazolam +1-1.5 mg/kg of ketamine and Group KF received 1 μg/kg of fentanyl +1-1.5 mg/kg of ketamine intravenously.

Results

There were similar demographic properties, recovery, and discharge times between groups. No statistically significant difference was found in peripheral oxygen saturation, mean and diastolic blood pressure, Ramsey sedation scores, modified Aldrete recovery scores, side effects, and recovery times (Group KM, 16.067 ± 1.2 min; Group KF, 19.46 ± 0.86 min) between groups (P > 0.05).

Conclusion

KF combination offers better hemodynamic properties, less side effects with lower visual analog scores, and face, legs, activity, cry, and consolability scores than KM in the pediatric ESWL procedure.

Sedation and analgesia for procedures in the pediatric emergency room

OBJECTIVE

Children and adolescents often require sedation and analgesia in emergency situations. With the emergence of new therapeutic options, the obsolescence of others, and recent discoveries regarding already known drugs, it became necessary to review the literature in this area.

DATA SOURCES

Non-systematic review in the PubMed database of studies published up to December 2016, including original articles, review articles, systematic reviews, and meta-analyses. References from textbooks, publications from regulatory agencies, and articles cited in reviews and meta-analyses through active search were also included.

DATA SYNTHESIS

Based on current literature, the concepts of sedation and analgesia, the necessary care with the patient before, during, and after sedoanalgesia, and indications related to the appropriate choice of drugs according to the procedure to be performed and their safety profiles are presented.

CONCLUSIONS

The use of sedoanalgesia protocols in procedures in the pediatric emergency room should guide the professional in the choice of medication, the appropriate material, and in the evaluation of discharge criteria, thus assuring quality in care.

Pediatric Procedural Sedation Using the Combination of Ketamine and Propofol Outside of the Emergency Department: A Report From the Pediatric Sedation Research Consortium

OBJECTIVES

Outcomes associated with a sedative regimen comprised ketamine + propofol for pediatric procedural sedation outside of both the pediatric emergency department and operating room are underreported. We used the Pediatric Sedation Research Consortium database to describe a multicenter experience with ketamine + propofol by pediatric sedation providers.

DESIGN

Prospective observational study of children receiving IV ketamine + propofol for procedural sedation outside of the operating room and emergency department using data abstracted from the Pediatric Sedation Research Consortium during 2007-2015.

SETTING

Procedural sedation services from academic, community, free-standing children's hospitals, and pediatric wards within general hospitals.

PATIENTS

Children from birth to less than or equal to 21 years old.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 7,313 pediatric procedural sedations were performed using IV ketamine + propofol as the primary sedative regimen. Median age was 84 months (range, < 1 mo to ≤ 21 yr; interquartile range, 36-144); 80.6% were American Society of Anesthesiologists-Physical Status less than III. The majority of sedation was performed in dedicated sedation or radiology units (76.1%). Procedures were successfully completed in 99.8% of patients. Anticholinergics (glycopyrrolate and atropine) or benzodiazepines (midazolam and lorazepam) were used in 14.2% and 41.3%, respectively. The overall adverse event and serious adverse event rates were 9.79% (95% CI, 9.12-10.49%) and 3.47% (95% CI, 3.07-3.92%), respectively. No deaths occurred. Risk factors associated with an increase in odds of adverse event included ASA status greater than or equal to III, dental suite, cardiac catheterization laboratory or radiology/sedation suite location, a primary diagnosis of having a gastrointestinal illness, and the coadministration of an anticholinergic.

CONCLUSIONS

Using Pediatric Sedation Research Consortium data, we describe the diverse use of IV ketamine + propofol for procedural sedation in the largest reported cohort of children to date. Data from this study may be used to design sufficiently powered prospective randomized, double-blind studies comparing outcomes of sedation between commonly administered sedative and analgesic medication regimens.

Investigation of Efficacy of Lidocaine Spray for Sedated Esophagogastroduodenoscopy in Children

PURPOSE

Our aim in this study is to investigate efficacy of topical lidocaine spray for sedated esophagogastroduodenoscopy (EGD) in children.

METHODS

The endoscopy of children aged between 3-18 years who underwent EGD in our endoscopy unit. Intravenous (IV) midazolam and ketamine were used for sedation. Prior to sedation, endoscopy nurse applied topical lidocaine 10% with pump spray at 1 mg/kg dose in group 1, and distilled water via identically scaled pump spray in group 2, in a double blinded fashion.

RESULTS

Sedation was not applied in 24.1% of the cases in topical lidocaine spray group (LS group) and in 5.7% of the cases in distilled water spray group (DS group). Gag reflex was observed in 6.5% of cases in LS group and 33.3% of cases in DS group (p=0.024), increased oral secretion was observed in 9.3% of cases in LS group and 51.7% of cases in DS group (p=0.038), sore throat was observed in 3.7% of cases in LS group and 35.6% of cases in DS group (p=0.019) and the difference was statistically significant.

CONCLUSION

The study showed that topical pharyngeal lidocaine reduces both requirement and amount of IV sedation before EGD in children and sore throat, gag reflex and decreased oral secretion increase.

Efficacy and safety of midazolam and ketamine in paediatric upper endoscopy

BACKGROUND AND STUDY AIM

Upper endoscopy can be successfully carried out in children under deep sedation and anaesthesia. However, the best method of upper endoscopy for children who require gastrointestinal intervention has yet to be defined. The aim of this study is to investigate the efficacy and safety of the sedation induced by intravenous midazolam and ketamine during upper endoscopy in children.

PATIENTS AND METHODS

This study included patients ages 3-18years who had undergone upper endoscopy. All subjects received IV midazolam and ketamine. During the intervention, hypoxia, tachycardia, bradycardia, hypertension, and hypotension were recorded. After the intervention, euphoria, dysphoria, vertigo, visual problems (such as diplopia and nystagmus), and emergencies (such as arrhythmia, convulsion, and hallucination), among other findings, were recorded. Older children who were capable of expressing themselves were questioned to help determine these conditions.

RESULTS

The mean age of the study group was was 11.9±3.42years; 54% of the patients were females, and 46% were males. During the upper endoscopy, hypoxia occurred in 9% of patients, mild hypertension in 14%, hypotension in 5%, tachycardia in 23%, bradycardia in 8%, and flushing-urticaria in 2%. After the upper endoscopy, one of the most common complications was sore throat, which occurred in 24% of patients. Vomiting was observed in 14% of patients, dizziness in 24%, diplopia in 27%, euphoria in 3% (5 patients), dysphoria in 4%, and hallucination in 4%. Of the total patients, 4% required oxygen supply with a face mask.

CONCLUSION

The results of our study showed that the use of IV midazolam and ketamine during upper endoscopy in children was safe and effective.

A rectally administered combination of midazolam and ketamine was easy, effective and feasible for procedural pain in children with cerebral palsy

AIM

The aim of this study was to investigate how effective a combination of rectally administered midazolam and racemic ketamine was for reducing pain in paediatric cerebral palsy patients receiving intramuscular injections of botulinum neurotoxin A. The feasibility and safety of the pain relief were also explored.

METHOD

Children with cerebral palsy, aged one to 18 years, were recruited from a regional paediatric rehabilitation unit between April 2012 and May 2014. Pain intensity, feasibility, total time spent in the clinic and side effects were registered. Pain scores were recorded by parents and healthcare professionals using different pain scales.

RESULTS

We recorded 128 procedures in 61 children. The median scores were two (range: 0-10) for pain intensity and nine (range: 0-10) for feasibility. The median treatment time in the outpatient unit was 3.25 hours, and the most common side effects were nausea, pain and sleep disturbance. Gross motor function levels showed a negative correlation with the pain scores. This method could be an alternative to nitrous oxide/oxygen mixture for patients who do not tolerate inhalation analgesia.

CONCLUSION

Rectally administered midazolam and racemic ketamine provided effective pain relief for paediatric cerebral palsy outpatients receiving painful injections and was a viable alternative to inhalation analgesia.

Etomidate Versus Ketamine: Effective Use in Emergency Procedural Sedation for Pediatric Orthopedic Injuries

OBJECTIVES

The aim of this study was to compare the induction and recovery times, postsedation observation durations, and adverse effects of etomidate and ketamine in pediatric patients with fractures and/or dislocations requiring closed reduction in the emergency department.

METHODS

Forty-four healthy children aged 7 to 18 years were included. The patients were randomly divided into 2 groups. Group 1 (24 patients) received etomidate and fentanyl, and group 2 (20 patients) received ketamine intravenously. The Ramsay Sedation Scale and American Pediatric Association discharge criteria were used to evaluate the patients.

RESULTS

There were 70 fractured bones and 3 joint dislocations. Except in 1 case (2.3%), all of the injuries were reducted successfully. The mean amount of drugs used to provide adequate sedation and analgesia were 0.25 mg/kg of etomidate and 1.30 μg/kg of fentanyl in group 1 and 1.25 mg/kg of ketamine in group 2. Fourteen patients (31.8%) reported adverse effects, and none required hospitalization. There was no difference between the groups in the recovery times, occurrence of adverse effects, and postsedation observation durations (P > 0.05). The mean (SD) induction time for the patients in group 1 was 4.3 (1.0) minutes, whereas it was 2.2 (1.6) minutes in group 2 (P < 0.001).

CONCLUSIONS

Etomidate induces effective and adequate sedation in the pediatric emergency department for painful orthopedic procedures. Ketamine, which has longer action times, might be preferred for reductions because orthopedic procedures could be lengthy.

Procedural Sedation Outside of the Operating Room Using Ketamine in 22,645 Children: A Report From the Pediatric Sedation Research Consortium

OBJECTIVE

Most studies of ketamine administered to children for procedural sedation are limited to emergency department use. The objective of this study was to describe the practice of ketamine procedural sedation outside of the operating room and identify risk factors for adverse events.

DESIGN

Observational cohort review of data prospectively collected from 2007 to 2015 from the multicenter Pediatric Sedation Research Consortium.

SETTING

Sedation services from academic, community, free-standing children's hospitals and pediatric wards within general hospitals.

PATIENTS

Children from birth to 21 years old or younger.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Describe patient characteristics, procedure type, and location of administration of ketamine procedural sedation. Analyze sedation-related adverse events and severe adverse events. Identify risk factors for adverse events using multivariable logistic regression. A total of 22,645 sedations performed using ketamine were analyzed. Median age was 60 months (range, < 1 mo to < 22 yr); 72.0% were American Society of Anesthesiologists-Physical Status less than III. The majority of sedations were performed in dedicated sedation or radiology units (64.6%). Anticholinergics, benzodiazepines, or propofol were coadministered in 19.8%, 57.9%, and 35.4%, respectively. The overall adverse event occurrence rate was 7.26% (95% CI, 6.92-7.60%), and the frequency of severe adverse events was 1.77% (95% CI, 1.60-1.94%). Procedures were not completed in 39 of 19,747 patients (0.2%). Three patients experienced cardiac arrest without death, all associated with laryngospasm.

CONCLUSIONS

This is a description of a large prospectively collected dataset of pediatric ketamine administration predominantly outside of the operating room. The overall incidence of severe adverse events was low. Risk factors associated with increased odds of adverse events were as follows: cardiac and gastrointestinal disease, lower respiratory tract infection, and the coadministration of propofol and anticholinergics.

Optimal dosing of intravenous ketamine for procedural sedation in children in the ED-a randomized controlled trial

OBJECTIVE

The objective of the study is to compare need for redosing, sedation efficacy, duration, and adverse events between 3 commonly administered doses of parenteral ketamine in the emergency department (ED).

METHODS

We conducted a prospective, double-blind, randomized controlled trial on a convenience sample of children 3 to 18years who received intravenous ketamine for procedural sedation. Children from each age group (3-6, 7-12, and 13-18years) were assigned in equal numbers to 3 dosing groups (1, 1.5, and 2mg/kg) using random permuted blocks. The primary outcome measure was need for ketamine redosing to ensure adequate sedation. Secondary outcome measures were sedation efficacy, sedation duration, and sedation-related adverse events.

RESULTS

A total of 171 children were enrolled of whom 125 (1mg/kg, 50; 1.5mg/kg, 35; 2mg/kg, 40) received the randomized dose and were analyzed. The need for ketamine redosing was higher in the 1mg/kg group (8/50; 16.0% vs 1/35; 2.9% vs 2/40; 5.0%). There was no significant difference in the median Ramsay sedation scores (5.5 [interquartile range {IQR}, 4-6] vs 6 [IQR, 4-6] vs 6 [IQR, 5-6]), FACES-R score (0 [IQR, 0-4] vs 0 [IQR, 0-0] vs 0 [IQR, 0-0]), sedation duration in minutes (23 [IQR, 19-38] vs 24.5 [IQR, 17.5-34.5] vs 23 [IQR, 19-29]), and adverse events (10.0% vs 14.3% vs 10.0%) between the 3 dosing groups. Physician satisfaction was lower in the 1mg/kg group (79.6% vs 94.1% vs 97.3%).

CONCLUSIONS

Adequate sedation was achieved with all 3 doses of ketamine. Higher doses did not increase the risk of adverse events or prolong sedation. Ketamine administered at 1.5 or 2.0mg/kg intravenous required less redosing and resulted in greater physician satisfaction.

Ketamine-based procedural sedation and analgesia for botulinum toxin A injections in children with cerebral palsy

INTRODUCTION

Adequate procedural sedation and analgesia (PSA) is essential to reduce pain and distress for children undergoing intramuscular botulinum toxin (BoNT-A) injections. This study describes our institution's experience with ketamine-based PSA in terms of safety and efficacy in children with cerebral palsy receiving BoNT-A injections.

MATERIAL AND METHODS

This is an analysis of ketamine-based PSA for children undergoing BoNT-A injections between January 2000 and October 2014. All patients received PSA according to our institution's sedation protocol. From 2000 to 2012, intravenous ketamine and midazolam PSA was administered. From 2013 onwards, intravenous ketamine was used as a sole agent for PSA.

RESULTS

A total of 152 BoNT-A procedures were performed successfully on 87 children. The median age of the children was 5 years 5 months with 9 children younger than 36 months. Ten procedures (6.6%) were associated with acute transient self-limiting side effects: Four developed rashes, three had nausea and vomiting, one child had limb tremors and another child complained of mild headache. One child reported nightmares on the evening of the procedure during the two-week post-procedure review. No child experienced serious adverse events.

CONCLUSION

Administration of ketamine-based PSA for intramuscular BoNT-A procedures in children can be both safe and efficacious.

Is ketamine a lifesaving agent in childhood acute severe asthma?

Children with acute severe asthma exacerbation are at risk of developing respiratory failure. Moreover, conventional aggressive management might be futile in acute severe asthma requiring intubation and invasive ventilation. The aim of this review is to detail evidence on the use of ketamine in childhood asthma exacerbations. A search of the MEDLINE, EMBASE, and Cochrane databases was performed, using different combinations of the following terms: ketamine, asthma, use, exacerbation, and childhood. In addition, we searched the references of the identified articles for additional articles. We then reviewed titles and included studies that were relevant to the topic of interest. Finally, the search was limited to studies published in English and Spanish from 1918 to June 2015. Due to the scarcity in the literature, we included all published articles. The literature reports conflicting results of ketamine use for acute severe asthma in children. Taking into consideration the relatively good safety profile of the drug, ketamine might be a reasonable option in the management of acute severe asthma in children who fail to respond to standard therapy. Furthermore, pediatricians and pediatric emergency clinicians administering ketamine should be knowledgeable about the unique actions of this drug and its potential side effects.

Ketamine Sedation After Administration of Oral Contrast: A Retrospective Cohort Study

BACKGROUND

The American Academy of Pediatrics and American Society of Anesthesiologists have published consensus-based fasting guidelines intended to reduce the risk of pulmonary aspiration. The purpose of our study was to compare the rate of adverse events in patients sedated with ketamine within 2 hours of oral contrast intake to those who were nil per os (NPO).

METHODS

A retrospective cohort review of a database of children between July 2008 and May 2011. The rate of adverse events in children sedated with ketamine after intake of oral contrast for an abdominal computed tomography were compared with those sedated without taking oral contrast.

RESULTS

One hundred and four patients sedated for a computed tomography scan; 22 patients were sedated within 2 hours of taking oral contrast, and 82 were NPO. The 2 groups were comparable with regard to gender, race, and American Society of Anesthesiologists status. The mean (SD) time between the second dose of oral contrast and induction of sedation was 58 (24) minutes. Vomiting occurred in 4 of 22 patients in the oral contrast group (18%; 95% confidence interval 2%-34%) and 1 of 82 patients in the NPO group (1%; 95% confidence interval, 0%, 4%; P < .001). There was no difference in oxygen desaturation between the groups (P = .6).

CONCLUSIONS

Children who received oral contrast up to 58 minutes before ketamine sedation had a higher rate of vomiting than those who did not receive oral contrast. We did not identify cases of clinical aspiration, and the incidence of hypoxia between the 2 groups was not statistically significant.

Options and Considerations for Procedural Sedation in Pediatric Imaging

As pediatric imaging capabilities have increased in scope, so have the complexities of providing procedural sedation in this environment. While efforts by many organizations have dramatically increased the safety of pediatric procedural sedation in general, radiology sedation creates several special challenges for the sedation provider. These challenges require implementation of additional safeguards to promote safety during sedation while maintaining effective and efficient care. Multiple agent options are available, and decisions regarding which agent(s) to use should be determined by both patient needs (i.e., developmental capacities, underlying health status, and previous experiences) and procedural needs (i.e., duration, need for immobility, and invasiveness). Increasingly, combinations of agents to either achieve the conditions required or mitigate/counterbalance adverse effects of single agents are being utilized with success. To continue to provide effective imaging sedation, it is incumbent on sedation providers to maintain familiarity with continuing evolutions within radiology environments, as well as comfort and competence with multiple sedation agents/regimens. This review discusses the challenges associated with radiology sedation and outlines various available agent options and combinations, with the intent of facilitating appropriate matching of agent(s) with patient and procedural needs.

Comparison of two analgesia protocols for the treatment of pediatric orthopedic emergencies

SummaryObjective:to compare the efficacy of two analgesia protocols (ketamine versus morphine) associated with midazolam for the reduction of dislocations or closed fractures in children.Methods:randomized clinical trial comparing morphine (0.1mg/kg; max 5mg) and ketamine (2.0mg/kg, max 70mg) associated with midazolam (0.2mg/kg; max 10mg) in the reduction of dislocations or closed fractures in children treated at the pediatrics emergency room (October 2010 and September 2011). The groups were compared in terms of the times to perform the procedures, analgesia, parent satisfaction and orthopedic team.Results:13 patients were allocated to ketamine and 12 to morphine, without differences in relation to age, weight, gender, type of injury, and pain scale before the intervention. There was no failure in any of the groups, no differences in time to start the intervention and overall procedure time. The average hospital stay time was similar (ketamine = 10.8+5.1h versus morphine = 12.3+4.4hs; p=0.447). The median pain (faces pain scale) scores after the procedure was 2 in both groups. Amnesia was noted in 92.3% (ketamine) and 83.3% (morphine) (p=0.904). Parents said they were very satisfied in relation to the analgesic intervention (84.6% in the ketamine group and 66.6% in the morphine group; p=0.296). The satisfaction of the orthopedist regarding the intervention was 92.3% in the ketamine group and 75% in the morphine group (p=0.222).Conclusion:by producing results similar to morphine, ketamine can be considered as an excellent option in pain management and helps in the reduction of dislocations and closed fractures in pediatric emergency rooms.

The design of a multicentre Canadian surveillance study of sedation safety in the paediatric emergency department

INTRODUCTION

Procedural sedation and analgesia have become standard practice in paediatric emergency departments worldwide. Although generally regarded as safe, serious adverse events such as bradycardia, asystole, pulmonary aspiration, permanent neurological injury and death have been reported, but their incidence is unknown due to the infrequency of their occurrence and lack of surveillance of sedation safety. To improve our understanding of the safety, comparative effectiveness and variation in care in paediatric procedural sedation, we are establishing a multicentre patient registry with the goal of conducting regular and ongoing surveillance for adverse events in procedural sedation.

METHODS

This multicentre, prospective cohort study is enrolling patients under 18 years of age from six paediatric emergency departments across Canada. Data collection is fully integrated into clinical care and is performed electronically in real time by the healthcare professionals caring for the patient. The primary outcome is the proportion of patients who experience a serious adverse event as a result of their sedation. Secondary outcomes include the proportion of patients who experience an adverse event that could lead to a serious adverse event, proportion of patients who receive a significant intervention in response to an adverse event, proportion of patients who experience a successful sedation, and proportion of patients who experience a paradoxical reaction to sedation. There is no predetermined end date for data collection.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from participating sites. Results will be disseminated using a multifaceted knowledge translation strategy by presenting at international conferences, publication in peer-reviewed journals, and through established networks.

The Efficacy and Safety of Procedural Sedoanalgesia with Midazolam and Ketamine in Pediatric Hematology

OBJECTIVE

The aim of this study is to investigate the efficacy and safety of sedoanalgesia performed outside the operating room by pediatricians trained in advanced airway management and life support.

MATERIALS AND METHODS

Midazolam and ketamine were administered consecutively by intravenous route under cardiorespiratory monitoring for painful procedures of pediatric hematology.

RESULTS

A total of 115 patients had 237 sedoanalgesia sessions. Sedation time was 24.02±23.37 s and sedation success was 92.5% (Ramsay scores of ≥5). Patient satisfaction was high. The recovery time was 28.81±14.4 min. Although statistically significant (p<0.01) increases in systolic and diastolic blood pressure, heart rate, and respiratory rate were observed without clinical importance, they improved without any intervention. No severe adverse events were observed.

CONCLUSION

Sedoanalgesia with intravenous midazolam and ketamine for pediatric hematology and oncology patients' painful minor invasive procedures performed in an optimally equipped setting outside the operating room by pediatricians trained and certificated in advanced airway management and life support is effective and safe.

Rapid administration technique of ketamine for pediatric forearm fracture reduction: a dose-finding study

STUDY OBJECTIVE

We estimate the minimum dose and total sedation time of rapidly infused ketamine that achieves 3 to 5 minutes of effective sedation in children undergoing forearm fracture reduction in the emergency department.

METHODS

We used the up-down method to estimate the median dose of intravenous ketamine infused during less than or equal to 5 seconds that provided effective sedation in 50% (ED50) and 95% (ED95) of healthy children aged 2 to 5, 6 to 11, or 12 to 17 years who were undergoing forearm fracture reduction. Most patients were pretreated with opioids. Three investigators blinded to ketamine dose independently graded sedation effectiveness by viewing a video recording of the first 5 minutes of sedation. Recovery was assessed by modified Aldrete score.

RESULTS

We enrolled 20 children in each age group. The estimated ED50 was 0.7, 0.5, and 0.6 mg/kg and the estimated ED95 was 0.7, 0.7, and 0.8 mg/kg for the groups aged 2 to 5, 6 to 11, and 12 to 17 years, respectively. For the group aged 2 to 5 years, an empirically derived ED95 was 0.8 mg/kg. All patients who received the empirically derived ED95 in the group aged 2 to 5 years or the estimated ED95 in the groups aged 6 to 11 and 12 to 17 years had effective sedation. The median total sedation time for the 3 age groups, respectively, was 25, 22.5, and 25 minutes if 1 dose of ketamine was administered and 35, 25, and 45 minutes if additional doses were administered. No participant experienced serious adverse events.

CONCLUSION

We estimated ED50 and ED95 for rapidly infused ketamine for 3 age groups undergoing fracture reduction. Total sedation time was shorter than that in most previous studies.

Evaluating the hematoma block as an adjunct to procedural sedation for closed reduction of distal forearm fractures

OBJECTIVES

Although procedural sedation using intravenous agents is highly effective for forearm fracture reduction, the process is both resource and time intensive. Our objective was to determine whether the use of a hematoma block as an adjunct to procedural sedation with ketamine and midazolam reduces (1) pain during the procedure (scored using the Observational Score for Behavioral Distress-Revised score) or (2) the excess sedation time, defined by the time between procedure completion and discharge from sedation. Our secondary outcome measure was total ketamine dose administered during the procedure.

METHODS

A randomized, double-blind, placebo-controlled clinical trial was conducted. Before fracture reduction, children 3 to 17 years of age randomly received 2% lidocaine (L) or normal saline (NS) into the hematoma of their fracture site during sedation with intravenous ketamine and midazolam.

RESULTS

Ninety patients were randomized: 50 to L and 40 to NS. The groups were similar with regard to age, sex, type of fracture, and prior administration of pain medication. Median Observational Score for Behavioral Distress-Revised scores were 1.11 and 1.69 for the L and NS groups, respectively (P = 0.23). Excess sedation time was not significantly different between the groups (P = 0.36), with a median excess sedation time of 33.0 and 36.0 minutes for the L and NS groups, respectively. Mean ketamine dose administered was not different between the groups (P = 0.42). The mean total dose administered was 1.00 mg/kg and 1.07 mg/kg in the L and NS groups, respectively. Mean midazolam dose was 0.05 mg/kg for both groups.

CONCLUSIONS

The use of a hematoma block as an adjunct to procedural sedation with ketamine and midazolam for forearm fracture reduction conferred no additional benefit and did not decrease observed pain scores, excess sedation time, or total ketamine dose administered.