Midazolam or ketamine for procedural sedation of children in the emergency department

Midazolam or ketamine for procedural sedation of children in the emergency department

Report by Andrew Munro, Specialist in Emergency Medicine FACEM

Checked by Ian Machonochie, Consultant in Paediatric Emergency Medicine

Coffs Harbour Base Hospital, NSW, Australia

Abstract

A short cut review was carried out to establish whether ketamine or midazolam is superior at providing safe and effective conscious sedation in children in the emergency department. A total of 203 papers were found using the reported searches, of which four presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are summarised in table 1. It is concluded that midazolam and ketamine have similar efficacy and safety profiles but that ketamine is preferred by parents and physicians.

Table 1.

Author, date, country	Patient group	Study type	Outcomes	Key results	Study weaknesses
McGlone et al, 1998, UK	102 children (1–7 years). Divided into either midazolam (0.5 mg/kg nasal) or ketamine (2.5 mg/kg IM)	Prospective “allocation”	Behaviour before, during and after procedure. Vomiting before and after discharge. Time to discharge. Parental and nursing satisfaction	Significantly less restraint required in ketamine group (p<0.01). Ketamine caused more vomiting during recovery (p = 0.012). Midazolam children discharge 7 min earlier. Ketamine significantly preferred (p = 0.018)	? randomised. Two different routes of administration, uncertain final bioavailability of intranasal route. Small numbers. Atropine added to ketamine group
Everitt et al, 2002, Australasia	54 Australasian EDs. Ketamine 12%, midazolam 77%	Survey of agents used and ED physicians. 45 of 54 surveyed departments responded	Linear analogue depiction of perceived efficacy of sedation	IV ketamine 14% better sedation than midazolam	One respondent per ED. Open to responder bias. Not patient focused. No standard doses. Not limited to ketamine and midazolam alone
Roback et al, 2005, USA	2500 consecutive children (median age 6.7 years) receiving IV or IM procedural sedation. Ketamine 59%, midazolam/ketamine 12%, midazolam 10.4%	Prospective database. Retrospectively analysed	Respiratory complications.Apnoea/ larygospasm/ desaturation	Ketamine 6.1%, ketamine/midazolam 10%, midazolam 5.8%	Not randomised, not blinded. Multiple drug combinations. ?standardised doses. Glycopyrolate was given to all who had ketamine. ?mandatory reporting
			Vomiting	Ketamine 10.1%, ketamine/midazolam 5.4%, midazolam 0.8%
Sacchetti et al 2007, USA	226 children aged <13 years. Ketamine 60%, midazolam 28%. Across 14 community EDs	Prospective database	Adverse events	Nil recorded for both drugs	Database “self‐reported”, ?reliability. Low rate of respiratory events reported

ED, emergency department; IM, intramuscular; IV, intravenous.

Three‐part question

In [children needing painful procedures in the emergency department] is [midazolam or ketamine] [safer and more effective at achieving conscious sedation]?

Clinical scenario

A mother brings her 5‐year‐old son to the emergency department with a deep scalp laceration, having fallen onto the corner of a coffee table. The wound requires sutures. For various reasons the option for procedural sedation in this department is limited to midazolam. Due to your past experience, you are more comfortable using ketamine. Although there is a large amount of data in the emergency literature to show efficacy and safety for both agents, you are not aware of direct comparisons to back your preference for ketamine in children in the emergency department setting.

Search strategies

Medline 1960–April 2007 using the OVID interface: (exp ketamine/or ketamine.mp.) AND (exp midazolam/or midazolam.mp.) AND (exp child/ or “children”.mp. or exp pediatrics/ or “pediatric”. mp.). LIMIT to human AND English language.

The Cochrane Library Issue 2, 2007: MeSH descriptor Ketamine explode all trees AND MeSH descriptor Midazolam explode all trees AND (emergency department):ti,ab,kw 7 papers none relevant

Outcome

Of the 203 papers found in Medline, 199 were found to be irrelevant or of insufficient quality for inclusion. Of seven papers found in Cochrane none were relevant. The remaining four papers are summarised in table 1.

Comments

The available comparative studies involved multiple agents and combinations, routes of administration and doses. No head to head trials of intravenous ketamine versus intravenous midazolam for procedural sedation in children in the emergency setting could be found. Secondary findings show that satisfaction of parents and physicians was greater with ketamine and that physicians felt it was safer.

Clinical bottom line

Ketamine and midazolam have similar safety profiles in the emergency setting for children. Ketamine causes more vomiting but appears to be the preferred agent for most parents and many emergency department physicians.