Intravenous ketamine plus midazolam is superior to intranasal midazolam for emergency paediatric procedural sedation

Comparative evaluation of intranasal midazolam-ketamine, dexmedetomidine-ketamine, midazolam-fentanyl, and dexmedetomidine-fentanyl combinations for procedural sedation and analgesia in pediatric dental patients: a randomized controlled trial

Background

In order to assess the effectiveness of various analgesio-sedative combinations for pain relief and sedation in pediatric dental patients, a thorough evaluation of clinical studies and patient outcomes is necessary.

Methods

A total of 128 healthy, uncooperative pediatric dental patients were randomly allocated to receive one of the four combinations of drugs via the intranasal (IN) route: Group I received midazolam-ketamine (MK), Group II received dexmedetomidine-ketamine (DK), Group III received midazolam-fentanyl (MF), and Group IV received dexmedetomidine-fentanyl (DF) in a parallel-arm study design. The efficacy and safety of the combinations were evaluated using different parameters.

Results

The onset of sedation was significantly faster in the DF group than in the DK, MF, and MK groups (P < 0.001). The depth of sedation was significantly higher in the DK and DF groups than in the MK and MF groups (P < 0.01). DK and DF produced significant intra- and postoperative analgesia when compared with combinations of MK and MF. No significant adverse events were observed for any of the combinations.

Conclusions

The DK and DF groups showed potential as analgesio-sedatives in view of their anxiolytic and analgesic effects.

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.

Evaluation of Intranasal Midazolam for Pediatric Sedation during the Suturing of Traumatic Lacerations: A Systematic Review

Objective: The objective of this study was to evaluate the efficacy and safety of intranasal midazolam as part of a paediatric sedation and analgesic procedure during the suturing of traumatic lacerations in paediatric emergency departments. Methodology: A systematic review of clinical trials was completed in July 2021. The databases consulted were PUBMED, SCOPUS, WEB OF SCIENCE, NICE and Virtual Health Library. Eligibility criteria: randomised and nonrandomised clinical trials. Two independent, blinded reviewers performed the selection and data extraction. The participants were 746 children, of whom, 377 received intranasal midazolam. All of the children were admitted to an emergency department for traumatic lacerations that required suturing. The quality of the articles was evaluated with the Jadad scale. This systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Results: Nine studies were included in the review. The intranasal administration of midazolam in healthy children produces anxiolysis and minimal/moderate sedation without serious side effects. Although there are combinations of parenteral drugs that produce deeper sedation, they also have greater adverse effects. No significant differences in the initiation of sedation and the suture procedure were found between the intranasal route and the parenteral route. Conclusions: The use of intranasal midazolam in healthy children produces sufficiently intense and long-lasting sedation to allow for the suturing of traumatic lacerations that do not present other complications; therefore, this drug can be used effectively in paediatric emergency departments.

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.

Intranasal Fentanyl and Midazolam for Procedural Analgesia and Anxiolysis in Pediatric Urgent Care Centers

OBJECTIVES

Intranasal fentanyl and midazolam use is increasing in the acute care setting for analgesia and anxiolysis, but there is a lack of literature demonstrating their use, alone or in combination, at pediatric urgent care centers.

METHODS

This retrospective study investigated intranasal fentanyl and midazolam use at an urgent care center located within Le Bonheur Children's Hospital and 2 affiliated off-site centers from September 22, 2011, to December 30, 2015. Data collected included patient demographics, initial fentanyl dose, initial midazolam dose, type of procedure, and serious adverse drug reactions.

RESULTS

Of the 490 patients who met the inclusion criteria, 143 patients received intranasal fentanyl alone, 92 received intranasal midazolam alone, and 255 received fentanyl in combination with midazolam. The overall patient population was 50% male with a median (range) age of 4.5 (0.2-17.9) years, and most patients were black at 57.1%. The median (range) initial intranasal fentanyl dose was 2.02 (0.99-4.22) μg/kg, and the median initial (range) intranasal midazolam dose was 0.19 (0.07-0.42) mg/kg. In cases where fentanyl and midazolam were administered in combination, the median (range) initial fentanyl dose was 2.23 (0.6-4.98) μg/kg and median (range) initial midazolam dose was 0.2 (0.03-0.45) mg/kg. There were no serious adverse drug reactions reported.

CONCLUSIONS

Intranasal fentanyl and midazolam when administrated alone and in combination can provide analgesia and anxiolysis for minor procedures in pediatric patients treated in the urgent care setting.

Incidence and predictors of respiratory adverse events in children undergoing procedural sedation with intramuscular ketamine in a paediatric emergency department

INTRODUCTION

Although ketamine is one of the commonest medications used in procedural sedation of children, to our knowledge, there is currently no published report on predictors of respiratory adverse events during ketamine sedation in Asian children. We aimed to determine the incidence of and factors associated with respiratory adverse events in children undergoing procedural sedation with intramuscular (IM) ketamine in a paediatric emergency department (ED) in Singapore.

METHODS

A retrospective analysis was done of all children who underwent procedural sedation with IM ketamine in the paediatric ED between 1 April 2013 and 31 October 2017. Demographics and epidemiological data, including any adverse events and interventions, were extracted electronically from the prospective paediatric sedation database. The site of procedure was determined through reviewing medical records. Descriptive statistics were used for incidence and baseline characteristics. Univariate and multivariate logistic regression analyses were performed to determine significant predictors.

RESULTS

Among 5,476 children, 102 (1.9%) developed respiratory adverse events. None required intubation or cardiopulmonary resuscitation. Only one required bag-valve-mask ventilation. The incidence rate was higher in children aged < 3 years, at 3.6% compared to 1.0% in older children (odds ratio [OR] 3.524, 95% confidence interval [CI] 2.354-5.276; p < 0.001). Higher initial ketamine dose (adjusted OR 2.061, 95% CI 1.371-3.100; p = 0.001) and type of procedure (adjusted OR 0.190 (95% CI 0.038-0.953; p = 0.044) were significant independent predictors.

CONCLUSION

The overall incidence of respiratory adverse events was 1.9%. Age, initial dose of IM ketamine and type of procedure were significant predictors.

When to Pick the Nose: Out-of-Hospital and Emergency Department Intranasal Administration of Medications

The intranasal route for medication administration is increasingly popular in the emergency department and out-of-hospital setting because such administration is simple and fast, and can be used for patients without intravenous access and in situations in which obtaining an intravenous line is difficult or time intensive (eg, for patients who are seizing or combative). Several small studies (mostly pediatric) have shown midazolam to be effective for procedural sedation, anxiolysis, and seizures. Intranasal fentanyl demonstrates both safety and efficacy for the management of acute pain. The intranasal route appears to be an effective alternative for naloxone in opioid overdose. The literature is less clear on roles for intranasal ketamine and dexmedetomidine.

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.

Paediatric procedural sedation using ketamine in a UK emergency department: a 7 year review of practice

BACKGROUND

Ketamine is growing in popularity for procedural sedation in the paediatric population, yet safety concerns remain. We performed a retrospective review of practice and outcomes of paediatric ketamine sedation using the World SIVA International Sedation Task Force reporting tool.

METHODS

A retrospective inspection of the dedicated emergency department electronic sedation database and subsequent note and sedation chart review was performed for all paediatric sedations throughout a 7 yr period from September 2006. All adverse events were stratified.

RESULTS

During the study period, procedural sedation was provided for a total of 243 children, of whom 215 were sedated with ketamine, most commonly for wound management (n=131). The median patient age was 4 yr (14 months to 15 yr), and 63.7% were male. Of the total, 76.7% were discharged home either directly (n=101) or after brief observation (n=64). One patient required subsequent general anaesthesia after a failed sedation with paradoxical agitation. Of the total, 9.8% of patients had an adverse event, the most severe risk stratification being 'minor risk'. All interventions were 'minimal risk'. There were no 'sentinel risk' outcomes.

CONCLUSIONS

These data support the ongoing use of ketamine for paediatric procedural sedation in the emergency department by emergency physicians. Relatively high resource requirements mean that ensuring adequate numbers of procedures may prove challenging.

Procedural sedation and analgesia in the emergency department

Procedural sedation and analgesia (PSA) is a core part of modern emergency department (ED) care allowing the rapid provision of important procedures. The safe delivery of a PSA service requires an appropriately staffed and equipped environment backed up by an ongoing system of training, audit and review. Topics covered in this review include: the evidence relating to the agents used; patient care before, during and after the procedure; the outcomes of ED PSA; and, the special considerations relating to PSA in children.

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.

A Randomized Clinical Trial of Intravenous and Intramuscular Ketamine for Pediatric Procedural Sedation and Analgesia

INTRODUCTION

Ketamine is an agent broadly used for pediatric procedural sedation and analgesia in emergency departments. It has been found to be safe and with a low risk of complications. Choosing between intravenous (IV) and intramuscular (IM) injections is a matter of concern, so we did a comparison between the two methods in terms of their efficacy and rate of complications.

METHODS

This single-blind clinical trial recruited 240 children (age: three months to 15 years, weight > 5 kg), who underwent short and painful procedures at the emergency departments. They were randomly allocated to two groups of 120 patients to receive either IV or IM ketamine with of 1.5 and 4 mg/kg doses, respectively. Indications for use, dose, side effects, and efficacy of the medications as well as duration of the procedure and time to recovery were compared between the two groups.

RESULTS

The mean age of the IV and IM groups were 6.5 ± 3.6 and 3.05 ± 2.6 years, respectively (p < 0.001). The onset of action of ketamine was 1.7 ± 1.1 minutes in the IV group and 8.6 ± 3.1 in the IM ones (p < 0.001). Patients of the IV and IM groups remained in optimal sedation for 20.6±12.0 and 37.2±11.8 minutes, respectively (P < 0.001). Time until emergency department discharge was 65.3 ± 36.9 minutes in the IV group and 72.2 ± 14.5 in the IM group (P = 0.40). Ketamine had excellent and moderate efficacy in 66.7% and 32.5% of the IV group and 70.0% and 25.0% in the IM group, respectively (p = 0.02). Totally, 60.0% of IV group patients and 40.0% of IM group experienced drug side effects (p = 0.21). Need for rescue dose was significantly higher in IV group (26.7% vs. 10.0%; p < 0.001). Finally, recovery was tranquil and comfortable in 88 patients (73.3%) of the IV group and 108 patients (90.0%) of the IM group (p = 0.06).

CONCLUSION

We found that although the sedative and analgesic effects of IM and IV ketamine are not significantly different, duration of effect and onset of action are more desirable in the IV group for suturing, fracture reduction, and foreign body removal. Meanwhile, the IM method can lead to lesser need of rescue doses.

Procedural sedation for pediatric patients in the emergency department at King Khalid University Hospital, Riyadh, K.S.A

Procedural sedation and analgesia (PSA) has become the standard of care for diagnostic and therapeutic procedures undertaken in the Emergency Department (ED). In the Pediatric Emergency Department (PED) of King Khalid University Hospital (KKUH), which is a major teaching hospital in Riyadh Kingdom of Saudi Arabia we developed a standard protocol for PSA since 2005. The aim of this article is to report the experience at KKUH in pediatric PSA.

OBJECTIVES

To report the experience at KKUH in pediatric PSA.

OBJECTIVES

To report the experience at KKUH in pediatric PSA.

MATERIALS AND METHODS

Retrospective cross-sectional study of all cases who underwent PSA for painful procedures in Pediatric Emergency at KKUH from December 2005 to July 2008.

RESULTS

A total of 183 patients were reviewed. 179 patients were analyzed. Age ranges from 4 months to 13 years (mean 6 years). Nearly 66% were male. Ketamine was the most commonly used drug. Reduction of fracture/dislocation was the most common indication for sedation. Adverse events were identified in only 5.6% of patients. Vomiting was the most common recorded side-effect. The length of stay in the ED was ranging from 28 to 320 min (mean 111 min).

CONCLUSION

Intravenous Ketamine is a consistently effective method of producing a rapid, brief period of adequate sedation and analgesia in children in the ED with no major side-effects noted in our experience.

Deep sedation in pediatric imaging: efficacy and safety of intravenous chlorpromazine

BACKGROUND

The quality of MRI and CT depends largely on immobility of the patient during the procedure, which is often difficult to achieve without sedation in children below the age of 6 years.

OBJECTIVE

To assess the efficacy and safety of intravenous chlorpromazine sedation for repeated imaging in young children treated for cancer.

MATERIALS AND METHODS

From July 2003 to January 2007, information on children younger than 6 years of age having MRI or CT was prospectively collected. Forty-five minutes before the scan, a 10-min infusion of chlorpromazine 0.5 mg/kg was administered and managed by non-anesthetic staff. Patient monitoring included continuous measurement of pulse, respiration, oxygen saturation and arterial blood pressure. Procedure-related parameters and adverse events were documented. Sedation was considered successful when the procedure was completed and at least 95% of images were usable.

RESULTS

One-hundred-one procedures (82 MRI, 19 CT) were evaluated in 62 children, 3-74 months old. Adequate sedation was achieved in 96% of cases, with mean induction time, 22 min; mean duration of sleep, 72 min, and mean duration of procedure, 33 min. Mean time spent in the radiology unit was 104 min. Ninety-six percent of imaging procedures were successfully completed. No cardiac, respiratory, neurological or allergic complication occurred.

CONCLUSION

Intravenous chlorpromazine is safe and effective for procedural sedation in young children with cancer undergoing MRI and CT.

Pediatric procedural sedation and analgesia

Procedural sedation and analgesia (PSA) is an evolving field in pediatric emergency medicine. As new drugs breach the boundaries of anesthesia in the Pediatric Emergency Department, parents, patients, and physicians are finding new and more satisfactory methods of sedation. Short acting, rapid onset agents with little or no lingering effects and improved safety profiles are replacing archaic regimens. This article discusses the warning signs and areas of a patient's medical history that are particularly pertinent to procedural sedation and the drugs used. The necessary equipment is detailed to provide the groundwork for implementing safe sedation in children. It is important for practitioners to familiarize themselves with a select few of the PSA drugs, rather than the entire list of sedatives. Those agents most relevant to PSA in the pediatric emergency department are presented.

Intravenous vs intramuscular ketamine for pediatric procedural sedation by emergency medicine specialists: a review

Ketamine is a general anesthetic agent widely used for pediatric procedural sedation outside the operating theater by nonanesthesiologists. In a setting where efficacy and safety of the agent are paramount, there are conflicting recommendations in terms of optimal mode of parenteral administration, as well as optimal dosage and need for the coadministration of adjunctive agents to decrease side effects. We investigated existing evidence to determine whether ketamine should be best administered intravenously or intramuscularly. This analysis was made difficult by limited direct comparisons of both modes of parenteral administration and a lack of consistent definitions for key outcomes such as 'effectiveness,''adverse events,''hypoxia,''ease of completion of the procedure,' and 'satisfaction' across studies that have evaluated ketamine. Based on large data sets, the safety and efficacy of both modes of administration are broadly similar. Although data on head to head comparisons of intravenous and intramuscular ketamine is limited, based on our analysis, we conclude that the trends indicate ketamine is ideally administered intravenously.

Anticholinergics and ketamine sedation in children: a secondary analysis of atropine versus glycopyrrolate

OBJECTIVES

Adjunctive anticholinergics are commonly administered during emergency department (ED) ketamine sedation in children under the presumption that drying oral secretions should decrease the likelihood of airway and respiratory adverse events. Pharmacologic considerations suggest that glycopyrrolate might exhibit a superior adverse effect profile to atropine. The authors contrasted the adverse events noted with use of each of these anticholinergics in a large multicenter observational database of ketamine sedations.

METHODS

This was a secondary analysis of an observational database of 8,282 ED ketamine sedations assembled from 32 prior series. The authors compared the relative incidence of six adverse events (airway and respiratory adverse events, laryngospasm, apnea, emesis, recovery agitation, and clinically important recovery agitation) between children who received coadministered atropine, glycopyrrolate, or no anticholinergic. Multivariable analysis using the specific anticholinergic as a covariate was performed, while controlling for other known predictors.

RESULTS

Atropine was associated with less vomiting (5.3%) than either glycopyrrolate (10.7%) or no anticholinergic (11.4%) in both unadjusted and multivariable analyses. Glycopyrrolate was associated with significantly more airway and respiratory adverse events (6.4%) than either atropine (3.3%) or no anticholinergic (3.0%) and similarly more clinically important recovery agitation (2.1% vs. 1.2 and 1.3%). There were, however, no differences noted in odds of laryngospasm and apnea.

CONCLUSIONS

This secondary analysis unexpectedly found that the coadministered anticholinergic atropine exhibited a superior adverse event profile to glycopyrrolate during ketamine sedation. Any such advantage requires confirmation in a separate trial; however, our data cast doubt on the traditional premise that glycopyrrolate might be superior. Further, neither anticholinergic showed efficacy in decreasing airway and respiratory adverse events.

Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children

STUDY OBJECTIVE

Although ketamine is one of the most commonly used sedatives to facilitate painful procedures for children in the emergency department (ED), existing studies have not been large enough to identify clinical factors that are predictive of uncommon airway and respiratory adverse events.

METHODS

We pooled individual-patient data from 32 ED studies and performed multiple logistic regressions to determine which clinical variables would predict airway and respiratory adverse events.

RESULTS

In 8,282 pediatric ketamine sedations, the overall incidence of airway and respiratory adverse events was 3.9%, with the following significant independent predictors: younger than 2 years (odds ratio [OR] 2.00; 95% confidence interval [CI] 1.47 to 2.72), aged 13 years or older (OR 2.72; 95% CI 1.97 to 3.75), high intravenous dosing (initial dose > or =2.5 mg/kg or total dose > or =5.0 mg/kg; OR 2.18; 95% CI 1.59 to 2.99), coadministered anticholinergic (OR 1.82; 95% CI 1.36 to 2.42), and coadministered benzodiazepine (OR 1.39; 95% CI 1.08 to 1.78). Variables without independent association included oropharyngeal procedures, underlying physical illness (American Society of Anesthesiologists class >or = 3), and the choice of intravenous versus intramuscular route.

CONCLUSION

Risk factors that predict ketamine-associated airway and respiratory adverse events are high intravenous doses, administration to children younger than 2 years or aged 13 years or older, and the use of coadministered anticholinergics or benzodiazepines.

Pediatric procedural sedation with ketamine: time to discharge after intramuscular versus intravenous administration

OBJECTIVES

Ketamine is an attractive agent for pediatric procedural sedation. There are limited data on time to discharge comparing intramuscular (IM) vs. intravenous (IV) ketamine. The authors set out to determine whether IM or IV ketamine leads to quicker discharge from the emergency department (ED) and how side effect profiles compare.

METHODS

All patients who had received ketamine IM or IV at a tertiary children's hospital ED during the 3-year study period (2004-2007) were identified. Prospective sedation registry data, retrospective medical records, and administrative data were reviewed for drug dosages, use of additional agents, time of drug administration to discharge, total ED time (triage to discharge), and adverse events. A subgroup analysis for patients requiring five or fewer sutures (short suture group) was performed.

RESULTS

A total of 229 patients were enrolled (60% male) with median age of 2.8 years (IQR =1.8-4.3 years) and median weight of 15.7 kg (range = 8.7-74 kg). Ketamine was most frequently employed for laceration repair (80%) and foreign body removal (9%). Overall, 48% received ketamine IM and 52% received it IV. In the short-suture subgroup, 52% received ketamine IM, while 48% received it IV. Multivariate linear regression analysis determined time from drug administration to patient discharge as 21 minutes shorter for IV compared with IM administration, adjusted for age and number of additional doses (R(2) = -0.35; 95% CI = -0.5 to -0.19; p < 0.001). Total time in the ED (triage to discharge) comparing IV versus IM administration, adjusting for age and gender and number of additional doses, was not significantly different (p = 0.16). In the short-suture subgroup, time to discharge from administration was also shorter in the IV ketamine group (R(2) = -0.454; 95%CI = -0.66 to -0.25; p < 0.001) but similar for total time in ED (p = 0.16). Overall, adverse events occurred in 35% (95% CI = 27% to 45%) of the IM group and 20% (95% CI = 13% to 28%) of the IV group (p = 0.01). Only one patient required brief bag-mask ventilation.

CONCLUSIONS

In this institution, time from drug injection to discharge was shorter in the IV compared to IM ketamine group, both overall and for the short-suture group. However, time from triage to discharge was similar.

Atomized intranasal midazolam use for minor procedures in the pediatric emergency department

BACKGROUND

Procedural sedation is increasingly more common in pediatric emergency departments. We report our experience with intranasal midazolam (INM) using a unique atomization delivery device, specifically the efficacy and safety of this method of sedation.

METHODS

We performed a retrospective chart review of children who received INM sedation in the emergency department from April 1, 2005, through June 30, 2005. All children aged 1 to 60 months who received INM as the initial means of sedation were eligible for the study. Patients were excluded if they were older than 60 months.

RESULTS

There were 205 patients who received INM for sedation and who met the study criteria. The mean age was 31.3 +/- 13.2 months (range, 1.5-60 months). The mean and median initial INM dose was 0.4 mg/kg (range, 0.3-0.8 mg/kg). Laceration repair was the most common procedure necessitating sedation (89%). The median degree-of-sedation score achieved was 2.0 (anxiolysis). Eleven patients (5.4%; 95% CI, 3%-9%) required an additional sedative to complete the procedure. Ten of the 11 patients received ketamine as the adjunctive sedative, and 1 patient required additional INM. The average time of last oral intake to start of sedation was 3.5 hours (range, 0.5-10.0 hours). Thirty six patients (18%) were NPO for 2 hours or less. There was 1 adverse event (0.5%; 95% CI, 0%-3%). This was a minor desaturation episode following ketamine administration requiring brief blow by oxygen. There were no adverse events (0%; 95% CI, 0%-2%) in patients who received INM alone.

CONCLUSION

We conclude that atomized INM is effective in providing anxiolysis to children undergoing minor procedures in the pediatric emergency department. We are encouraged that no adverse events occurred with the use of INM alone despite relatively short fasting times.

Blinded trials taken to the test: an analysis of randomized clinical trials that report tests for the success of blinding

BACKGROUND

Blinding can reduce bias in randomized clinical trials, but blinding procedures may be unsuccessful. Our aim was to assess how often randomized clinical trials test the success of blinding, the methods involved and how often blinding is reported as being successful.

METHODS

We analysed a random sample of blinded randomized clinical trials indexed in the The Cochrane Central Register of Controlled Trials and published in 2001. We identified 1599 blinded trials, and noted if they had conducted any test for the success of blinding. We also selected 200 trials randomly that did not report any such test, and sent a questionnaire to the corresponding authors asking them if they had conducted any tests.

RESULTS

Thirty-one out of 1599 trials (2%) reported tests for the success of blinding. Test methods varied, and reporting was generally incomplete. Blinding was considered successful in 14 out of the 31 trials (45%) and unclear in 10 (32%). Of the seven trials (23%) reporting unsuccessful blinding the risk of a biased trial result was either not addressed or was discounted in six cases. We received 130 questionnaires from trial authors (65%) of which 15 (12%) informed that they had conducted, but not published, tests.

CONCLUSIONS

Blinding is rarely tested. Test methods vary, and the reporting of tests, and test results, is incomplete. There is a considerable methodological uncertainty how best to assess blinding, and an urgent need for improved methodology and improved reporting.

Procedural sedation and analgesia in children

Procedural sedation and analgesia for children--the use of sedative, analgesic, or dissociative drugs to relieve anxiety and pain associated with diagnostic and therapeutic procedures--is now widely practised by a diverse group of specialists outside the operating theatre. We review the principles underlying safe and effective procedural sedation and analgesia and the spectrum of procedures for which it is currently done. We discuss the decision-making process used to determine appropriate drug selection, dosing, and sedation endpoint. We detail the pharmacopoeia for procedural sedation and analgesia, reviewing the pharmacology and adverse effects of these drugs. International differences in practice are described along with current areas of controversy and future directions.

Potential of ketamine and midazolam, individually or in combination, to induce apoptotic neurodegeneration in the infant mouse brain

Recently, it was reported that anesthetizing infant rats for 6 h with a combination of anesthetic drugs (midazolam, nitrous oxide, isoflurane) caused widespread apoptotic neurodegeneration in the developing brain, followed by lifelong cognitive deficits. It has also been reported that ketamine triggers neuroapoptosis in the infant rat brain if administered repeatedly over a period of 9 h. The question arises whether less extreme exposure to anesthetic drugs can also trigger neuroapoptosis in the developing brain. To address this question we administered ketamine, midazolam or ketamine plus midazolam subcutaneously at various doses to infant mice and evaluated the rate of neuroapoptosis in various brain regions following either saline or these various drug treatments. Each drug was administered as a single one-time injection in a dose range that would be considered subanesthetic, and the brains were evaluated by unbiased stereology methods 5 h following drug treatment. Neuroapoptosis was detected by immunohistochemical staining for activated caspase-3. It was found that either ketamine or midazolam caused a dose-dependent, statistically significant increase in the rate of neuroapoptosis, and the two drugs combined caused a greater increase than either drug alone. The apoptotic nature of the neurodegenerative reaction was confirmed by electron microscopy. We conclude that relatively mild exposure to ketamine, midazolam or a combination of these drugs can trigger apoptotic neurodegeneration in the developing mouse brain.

Ketamine for Conscious Sedation in Pediatric Emergency Care

The literature concerning the efficacy and safety of ketamine for conscious sedation during procedures in pediatric emergency departments was reviewed. Data were obtained from the Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures developed by the American Academy of Pediatrics Committee on Drugs, and from a MEDLINE search (January 1966-July 2004). Search terms were conscious sedation, ketamine, and emergency department; articles relevant to pediatric age group were selected. Clinical end points were efficacy and adverse effects associated with ketamine. Ketamine was effective for conscious sedation in 89-100% of patients in various studies using intravenous, intramuscular, or oral routes of administration. The efficacy of ketamine was similar to or greater than that of other drugs, such as midazolam and the combination of meperidine, promethazine, and chlorpromazine. The main adverse effects of ketamine were emesis, recovery agitation, and emergence phenomena. Ketamine appears to be an effective and well-tolerated agent for conscious sedation in pediatric patients. Overall physician and parent satisfaction with the administration of this agent for conscious sedation was high.

Use of midazolam and ketamine as sedation for children undergoing minor operative procedures

OBJECTIVES

We used intravenous midazolam and ketamine for children undergoing minor operative procedures with satisfactory results. We aimed to further evaluate its efficacy and adverse effects in pediatric ward setting.

METHODS

This was a prospective study of all children undergoing minor operations with sedation in our pediatric general and oncology wards from July 1998 to June 1999. The procedures included lumber puncture+/-intrathecal chemotherapy, bone marrow aspiration+/-trephine biopsy, central venous catheter removal, skin biopsy, or their combination. All sedation procedures were started with midazolam 0.1 mg/kg and ketamine 1 mg/kg; they were increased gradually to 0.4 and 4 mg/kg, respectively, if necessary. Heart rate and SaO2 were continuously monitored.

RESULTS

Altogether, 369 minor operations were performed in 112 patients (male:female=2:1, median age 6 years, range 5 months-17 years). All achieved adequate sedation, with 96% within 30 s and 75% required just the starting dose. Younger children required a higher dosage (p=0.003 for midazolam, p<0.001 for ketamine). The median recovery time was 87 min, with no association with age, sex, or dosage of sedation, but was longer in patients having hallucination (p=0.001). Adverse effects included tachycardia (27.9%), increased secretion (17.6%), agitation (13.6%), nausea and vomiting (9.2%), hallucination (8.7%), desaturation (8.4%), and cataleptic reaction (0.8%). All desaturation episodes were transient and responded to oxygen supplement alone. None developed bronchospasm or convulsion. Some adverse effects were dose-related. Half of the children who received 0.3 mg/kg midazolam developed desaturation.

CONCLUSIONS

Intravenous midazolam-ketamine can provide rapid, effective, and safe sedation for children undergoing minor operations in ward setting. Adverse effects are mild. Midazolam above 0.3 mg/kg should be used with caution.

Clinical practice guideline for emergency department ketamine dissociative sedation in children

We present an evidence-based clinical practice guideline for the administration of the dissociative agent ketamine for emergency department pediatric procedural sedation and analgesia. Substantial research in recent years has necessitated updates and revisions to the widely disseminated 1990 recommendations. We critically discuss indications, contraindications, personnel requirements, monitoring, dosing, coadministered medications, recovery issues, and future research questions for dissociative sedation.

Ketamine for paediatric sedation/analgesia in the emergency department

This review investigates the use of ketamine for paediatric sedation and analgesia in the emergency department.

The Lancaster experience of 2.0 to 2.5 mg/kg intramuscular ketamine for paediatric sedation: 501 cases and analysis

OBJECTIVES

To report the experience of using intramuscular ketamine 2.0 or 2.5 mg/kg for minor painful procedures in children in a medium sized district general hospital accident and emergency department. To demonstrate the safety and acceptability of ketamine and determine if the incidence of adverse effects is related to dose or other variables.

METHODS

Prospective data collection and analysis using Statsdirect and SPSS software.

RESULTS

501 consecutive cases were collected from August 1996 to April 2002. A total of 310 children received 2.0 mg/kg and 191 received 2.5 mg/kg. Twenty six received a second dose. In seven cases oxygen saturation fell below 93%, three of these fell below 90%. There was one case of laryngospasm. Eight cases received airway suctioning, five of these were mouth or lip wounds. Seventeen per cent vomited in recovery or at home for which one child required admission. Muscle hypertonicity was observed in 6.8%, disturbed sleep or nightmares in 2%. The median time to discharge was 85 minutes. Ninety seven per cent of parents' experiences were "the same as" or "better than" expected. No children suffered any lasting or troublesome complications.

CONCLUSIONS

2.0 - 2.5 mg/kg intramuscular ketamine sedation is a safe and acceptable technique when used within a defined protocol. Lower dose ketamine (2 mg/kg) warrants further study in view of potentially less airway complications and quicker discharge times than previously reported.

Prolonged pre-procedure fasting time is unnecessary when using titrated intravenous ketamine for paediatric procedural sedation

BACKGROUND

Paediatric procedural sedation (PPS) is a common procedure in most general EDs. Many departmental guidelines suggest mandatory fasting times for children undergoing PPS, in an attempt to decrease the incidence of postoperative vomiting and (theoretically) aspiration pneumonitis, despite there being little or no evidence in the literature to support these mandatory fasting times.

OBJECTIVES

To prospectively address the relationship between preprocedure fasting time and intraprocedure or postprocedure vomiting in children aged 1-12 years undergoing procedural sedation with intravenous ketamine in the ED.

METHODS

From January 1999 to May 2000 all children presenting to the Royal Darwin Hospital Emergency Department with a condition requiring ketamine PPS were enrolled for data collection after parental consent was obtained. Titrated intravenous ketamine was administered via protocol. Prospective ED procedural sedation data collection forms of 272 consecutive cases of titrated intravenous ketamine sedation were reviewed.

RESULTS

Fasting time was accurately recorded on 257 (95%) data collection forms. There was no intraprocedure vomiting. Overall rate of postprocedure vomiting was 13.9%. No statistically significant association between decreased fasting time and increased incidence of vomiting was found. In fact, there was a trend towards increased incidence of vomiting with increased fasting time (P = 0.08). The rate of vomiting of those children fasted 3 h or greater preprocedure (20/127 or 15.8%) was over twice the rate of those fasted less than 1 hour (2/30 or 6.6%). Incidence of vomiting was significantly associated with increasing age (P = 0.0007). No clinically evident aspiration pneumonitis occurred.

CONCLUSION

Prolonged preprocedure fasting time did not reduce the incidence of postprocedure vomiting in this case series; to the contrary there was a increased incidence of vomiting with longer fasting times (P = 0.08). There was an increase in postprocedure vomiting with increasing age of the patients.

Pain and stress management in the Neonatal Intensive Care Unit — A national survey in Austria

Neonates are sensitive to pain and vulnerable to both its short-term and long-term effects. Management of analgesia is thought to be hampered by lack of awareness that newborns are capable of experiencing pain and by fears about adverse effects associated with analgesics. The purpose of this study was to assess current medical practice in preventive analgesia and sedation in the neonate throughout Austria. This report details the results of a survey in 28 neonatal intensive care units (NICUs) in Austria. Data collection took place from October to December 2001. All NICUs reported the capability of newborns to experience and express pain and nearly all stated the possibility of pain affecting morbidity. Validated scores for pain assessment were used by 11% of NICUs, standardized protocols for analgesia existed in 75%, and 100% practiced non-pharmacological treatment strategies. The use of preventive measures in routinely performed painful procedures ranged from 8% to 96%. For example, only 8% of NICUs prevent distress and pain prior to umbilical vessel catheterization, 29% prior to subcutaneous injections and 46% prior to heel lancing. Nearly all NICUs apply analgesia before lumbar puncture and thoracic-drain placement, and all use analgesic and/or sedative medication in elective intubation.

CONCLUSION

There is widespread awareness among neonatologists of the importance and effects of distress caused by pain in newborns. However, the necessity of providing sufficient analgesia is underestimated. Further information on the safety of analgesic drugs in neonatology is imperative.

Paediatric sedation in emergency department: what is our practice?

OBJECTIVES

The aim of the present study was to document the use of sedation in paediatric patients in emergency departments within Australia and New Zealand.

METHODS

A questionnaire was sent to 54 emergency departments throughout Australia and New Zealand.

RESULTS

A total of 45 departments (83%) responded to the survey. Because the adult departments (n 5) reported few paediatric attendances, they were not included in the analysis. Thirty-nine of 40 departments (97.50%) reported using sedation in children. Midazolam was used most frequently (77%) for sedation. There was marked variation in the route of delivery and the dose of midazolam used. Ketamine was reported as the most efficacious agent used, but it was used only in 12% of cases. Formal guidelines existed in all paediatric departments but only in 58% of mixed departments, and formal discharge criteria were used in only 52% of all departments. The use of topical anaesthesia in wound closure was reported in only 3,000 of departments.

CONCLUSIONS

There exists wide variation in practice regarding the use of sedation in children in emergency departments throughout Australia and New Zealand. Thus, the development of adequate guidelines, including discharge instructions and the use of topical agents, will improve sedation for children.