Oral Analgesia Before Pediatric Ketamine Sedation is not Associated with an Increased Risk of Emesis and Other Adverse Events

doi:10.1016/j.jemermed.2007.08.076

The Journal of Emergency Medicine

Volume 35, Issue 1, July 2008, Pages 23-28

https://doi.org/10.1016/j.jemermed.2007.08.076 Get rights and content

Abstract

The objective of this study was to determine the association between recent administration of oral analgesics and frequency of adverse events during ketamine sedation in pediatric patients undergoing fracture reduction in the emergency department (ED). This retrospective study was conducted in the ED of a large, urban pediatric teaching hospital. Subjects were patients aged ≤ 18 years seen between November 1, 2004 and October 31, 2005 who received ketamine sedation for fracture reduction. Patients with and without prior oral analgesia within 6 h of ED presentation were compared with respect to emesis and other post-sedation complications. Of 471 evaluable patients who underwent ketamine sedation, 201 received oral analgesia within 6 h. The groups with and without recent oral analgesia were similar in age, weight, and fasting duration for solid foods. Ketamine doses (in mg/kg) were slightly greater in the no prior oral analgesic group (1.40 mg/kg vs. 1.54 mg/kg, respectively, mean difference 0.15 [95% confidence interval (CI) −0.26 to −0.03]). Among patients receiving oral analgesia, 10 of 201(5%) experienced emesis, in contrast to 7 of 270 (2.6%) in the no oral analgesic group, (difference in proportions 2.4% [95% CI −1.1 to 6.5]). Total adverse events were comparable for groups receiving oral analgesia (5%) or no oral analgesia (5.6%, difference in proportions −0.6% [95% CI −4.7% to 3.9%]). No association was found between administration of oral analgesia before procedural sedation and anesthesia and the frequency of emesis or other adverse events.

Introduction

Various influential organizations representing different disciplines, including the American Academy of Pediatrics, the American Pain Society, the Emergency Medical Services for Children Program, and the American College of Emergency Physicians, have written statements encouraging improved treatment of pain (1, 2, 3, 4). However, pain in children remains remarkably under-treated.

Pediatric emergency department (ED) patients receive inadequate or no analgesia for pain due to burns, fractures, or sickle-cell vaso-occlusive crises (5, 6, 7, 8). Children are less likely than adults to receive analgesia for fracture pain (9). Furthermore, children < 24 months of age are less likely than older children to receive analgesia for fractures and burns (9, 10, 11).

An American Academy of Pediatrics committee statement recommends administration of pain medication in ED triage (2). However, clinicians may be concerned about the impact on fasting status. A common practice is to withhold oral medications from patients likely to undergo procedural sedation. A recently published emergency medicine text includes the recommendation that “oral analgesia should never be given until the need for immediate operative repair or conscious sedation is ruled out” (12). Many patients, therefore, may not receive adequate pain management while awaiting procedural sedation and analgesia (PSA).

Numerous publications have reported the safety and efficacy of various pediatric PSA regimens (13, 14, 15, 16, 17, 18, 19, 20). None has studied the relationship between pre-PSA oral analgesia and the incidence of adverse events. Although fasting duration before PSA has no demonstrated association with the incidence of adverse effect, the impact of recent administration of oral analgesia on adverse PSA events has not been previously studied (18, 19). We undertook this study to investigate the association between recent administration of oral analgesic agents and the incidence of adverse effects in children receiving ketamine PSA in the ED.

Section snippets

Study Design

The hospital Institutional Review Board approved this retrospective study of patients receiving ketamine PSA for fracture reduction between November 1, 2004 and October 31, 2005.

The study was conducted in an urban tertiary care children's hospital ED with an annual census of approximately 55,000 visits per year. The ED has a written policy permitting triage administration of oral analgesics including acetaminophen, ibuprofen, or acetaminophen with codeine. Recent administration of oral

Results

There were 506 patients who received ketamine sedation for fracture reduction during the 12-month study period. We excluded 35 patients due to incomplete records (n = 29) and prior anti-emetic (n = 6, most commonly promethazine before interfacility transfer) (Figure 1). The remaining 471 patients were retained for analysis.

The main analysis compared the recent (≤ 6 h) oral analgesia group (n = 201) with the no oral analgesia group (n = 270). The two groups were similar with regard to age,

Discussion

The incidence of emesis in our study associated with ketamine sedation for fracture reduction was low (3–5%) but consistent with previously reported ranges (13, 18, 19, 20, 21).

The use of oral analgesia before PSA does not result in a statistically significant difference in the frequency of emesis or a statistically significant difference in the overall frequency of adverse events. Closer examination reveals that the difference in frequency of emesis between the recent oral analgesia and no

Limitations

The limitations of this study include its dependence on the accuracy and completeness of the medical record for chronologic data and adverse events. ED clinicians may have inaccurately recorded chronologic data or incompletely described adverse events. Chronologic data also are subject to inaccuracy in the calibration of timepieces used in clinical settings and in the documentation of time intervals by clinical personnel (27, 28).

Clinicians may have failed to observe minor transient adverse

Conclusions

This study supports the hypothesis that recent oral analgesia does not impact the incidence of adverse events in patients undergoing ketamine procedural sedation and analgesia. Emergency medicine providers and other primary care providers should consider oral analgesia early in the patient encounter, regardless of the anticipated need for PSA.

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The American College of Emergency Physicians (ACEP) organized a multidisciplinary effort to create a clinical practice guideline specific to unscheduled, time-sensitive procedural sedation, which differs in important ways from scheduled, elective procedural sedation. The purpose of this guideline is to serve as a resource for practitioners who perform unscheduled procedural sedation regardless of location or patient age. This document outlines the underlying background and rationale, and issues relating to staffing, practice, and quality improvement.
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Two systematic reviews23,24 and 2 practice advisories11,25 acknowledge the lack of evidence to support specific preprocedural fasting requirements. Four Class II trials with pediatric patients26-29 and 1 Class II trial with adult and pediatric patients30 examined the effect of fasting time (0 to >8 hours) on emesis and aspiration during ED procedural sedation. None of these studies demonstrated a significant difference in rates of emesis or aspiration when comparing fasting times.
Ketamine and Neurotoxicity: Clinical Perspectives and Implications for Emergency Medicine
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Despite this, no problem is apparent. The existing 42 ED series totaling almost 10,000 children (Table)8-48,73 report no adverse neurologic sequelae from ketamine, although admittedly they had limited or no follow-up. Long-term neurodevelopmental studies of children who have received ketamine have not been conducted and would appear to be the only way to definitively resolve this controversy.49
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The efficacy and safety of ketamine to facilitate painful procedures for children in the emergency department (ED) have been documented in 57 published series totaling nearly 10,000 patients.1-57
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.
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.
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 ≥2.5 mg/kg or total dose ≥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 ≥3), and the choice of intravenous versus intramuscular route.
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.
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Original contributionOral Analgesia Before Pediatric Ketamine Sedation is not Associated with an Increased Risk of Emesis and Other Adverse Events

Abstract

Introduction

Section snippets

Study Design

Results

Discussion

Limitations

Conclusions

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Am J Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Original contribution
Oral Analgesia Before Pediatric Ketamine Sedation is not Associated with an Increased Risk of Emesis and Other Adverse Events