Ketamine Alone Is Best Sedative for Children's Emergencies

Lara C. Pullen, PhD

August 21, 2017

Ketamine alone was associated with fewer serious adverse events (SAEs) and interventions in children compared with propofol alone or ketamine combined with propofol or fentanyl, a large study of emergency department (ED) procedural sedation has found. 

Maala Bhatt, MD, MSc, director of Pediatric Emergency Research at the University of Ottawa, Ontario, Canada, and colleagues report their results online August 21 in JAMA Pediatrics.

"Ketamine, ketamine plus propofol, and propofol are all effective in providing sedation and are safe in the hands of competent/experienced providers," Dr Bhatt told Medscape Medical News. "However, our results support the fact that ketamine alone has fewer serious adverse events and significant interventions. It should be considered the first-line sedation medication for children undergoing sedation in the ED, especially in settings where recognition and rescue of adverse events in children is not commonly performed."

The researchers used data (n = 9657) from Pediatric Emergency Research Canada, a large collaborative that gathers data on pediatric sedation outside of the operating room.

Although previous ED procedural sedation studies have addressed adverse events, most have been unable to make conclusions about SAEs because of their infrequent occurrence.

The overall incidence of adverse events was 11.7% (95% confidence interval [CI], 6.4% - 16.9%). Oxygen desaturation (5.6%) and vomiting (5.2%) were the most common events. "The low rate of SAEs (1.1%; 95% CI, 0.5% - 1.7%) is consistent with previous reports that procedural sedation is safe in the hands of emergency department physicians," the researchers write.

When the investigators looked more closely at the data and used multivariable models adjusted for all known risk factors, they found that the incidence of SAEs and significant interventions was lowest among patients sedated with ketamine alone.

Specifically, ketamine only was associated with significantly fewer SAEs (0.4%) and interventions than ketamine combined with propofol (2.1%) or fentanyl (3.2%). "Our findings about the combination of ketamine and propofol are important because 'ketofol' use in ED sedation has increased dramatically over the past decade," the authors explain. "Some clinicians believe the sedation experience is improved because combination use offsets each individual agent's limitations."

Of course, when rare serious adverse events occur, providers must perform rescue, and emergency physicians are proficient in recognizing and treating these events. Certain approaches can minimize the occurrence of adverse events. The investigators found that the use of preprocedural antiemetics was associated with a 50% reduction in the odds of vomiting, for example.

Ketamine Dosing

Dr Bhatt also highlighted the surprising finding that higher doses of ketamine resulted in higher rates of vomiting and oxygen desaturation. Her results thus suggest that ketamine exhibits a dose-response relationship.

"Future studies may address how ketamine is dosed," Dr Bhatt told Medscape Medical News. "For example, does a higher initial dose of ketamine (experts recommend an initial dose of 1.5 mg/kg) reduce the need for subsequent additional doses during a sedation, resulting in a lower total dose of medication administered while providing effective sedation?"

The authors have disclosed no relevant financial relationships.

JAMA Pediatr. Published online August 21, 2017. Abstract

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