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Best evidence topic report
Midazolam and emergence phenomena in children undergoing ketamine sedation
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  1. Simon Carley,
  2. Bruce Martin
  1. Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
  1. Correspondence to: Kevin Mackway-Jones, Consultant (kevin.mackway-jones{at}man.ac.uk)

http://dx.doi.org/10.1136/emj.18.4.273-a

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    Report by Simon Carley,Specialist Registrar Search checked by Bruce Martin, Specialist Registrar

    Clinical scenario

    A 4 year old boy presents to the emergency department with a 4 cm laceration to the thigh. This requires cleaning and layered suture closure. You decide to sedate him using ketamine intramuscularly. You are successful and close the wound. However, while he is recovering he seems to be experiencing unpleasant hallucinations. You wonder whether a small dose of midazolam given with the ketamine would have prevented this.

    Three part question

    [In children undergoing ketamine sedation in the emergency department] is [benzodiazepines plus ketamine better than ketamine alone] at [reducing emergence phenomena and minimising complications and time of sedatrion]?

    Search strategy

    Medline 1966–02/01 using the OVID interface. [(exp ketamine OR ketamine.mp) AND (exp benzodiazepines OR benzodiazepines.mp OR exp midazolam OR midazolam.mp OR exp diazepam OR diazepam.mp OR VERSED.mp OR exp lorazepam OR lorazepam.mp OR hyponotics and sedatives.mp OR hypnovel.mp) AND (child.mp OR children.mp)] LIMIT human, english AND abstracts.

    Search outcome

    Altogether 71 papers found of which only one was relevant. An additional paper has recently been published and was not indexed on Medline at the time of searching. These two papers are shown in table 5.

    View this table:
    Table 5

    Comments

    These two well designed studies investigate the question directly. There seems to be no advantage in the addition of midazolam for IV ketamine sedation. Its use in IM ketamine sedation may be different as the pharmacokinetics of both drugs may be different via the IM route.

    Clinical bottom line

    Midazolam is not needed as an adjunct to ketamine sedation in children.

    Report by Simon Carley,Specialist Registrar Search checked by Bruce Martin, Specialist Registrar

    References

    1. Sherwin TS, Green SM, Khan A, et al. Does adjunctive midazolam reduce recovery agitation after ketamine sedation for pediatric procedures? A randomized double blind placebo controlled trial. Ann Emerg Med2000;35:229–38.
      OpenUrlCrossRefPubMedWeb of Science
    2. Wathen JE, Roback MG, Mackenzie T, et al. Does midazolam alter the clinical effects of intravenous ketamine sedation in children? A double blind randomized controlled emergency department trial. Ann Emerg Med2000;36:579–88.
      OpenUrlCrossRefPubMedWeb of Science