I use midazolam with iv ketamine in adults (have seen awful dysphoric
reactions without) - not just good sedation for procedures but fantastic
analgesia in trauma.
I don't use midazolam with ketamine in kids though. I haven't seen the same
evidence of dysphoria or emergence reactions, and it's supported by the
evidence below. Ketamine is a fantastic drug, and I'm more familiar with it
than most of my anaesthetic colleagues. Anyone using oral midazolam in kids?
Cliff Reid
Does midazolam alter the clinical effects of intravenous ketamine sedation
in children? A double-blind, randomized, controlled, emergency department
trial
Joe E. Wathen, MD
Mark G. Roback, MD
Todd Mackenzie, PhD
Joan P. Bothner, MD
Ann Emerg Med 2000 Dec;36(6):579-88.
Study Objective: This study was conducted to investigate the frequency and
severity of adverse effects, specifically emergence phenomena, experienced
by patients receiving intravenous ketamine with or without midazolam for
sedation in a pediatric emergency department.
Methods: Patients aged 4.5 months to 16 years receiving ketamine sedation
were prospectively enrolled in a double-blind, randomized, controlled study
at a university-affiliated children’s hospital–pediatric ED. All patients
received ketamine (1 mg/kg) and glycopyrrolate (5 µg/kg) intravenously.
Patients were randomly assigned to receive midazolam (0.1 mg/kg)
intravenously or no midazolam. Total time of sedation, sedation efficacy,
and adverse effects were recorded. Adverse effects were compared between
patients receiving ketamine versus those who received ketamine and
midazolam. Additional comparisons were made based on age and number of
ketamine doses administered.
Results: Two hundred sixty-six patients were studied; 129 received ketamine
and 137 patients received ketamine and midazolam. Time of sedation and
efficacy of sedation were equivalent between groups. Overall, adverse
effects with ketamine sedation included respiratory events (12 [4.5%]),
vomiting (50 [18.7%]), emergence phenomena in the pediatric ED (71 [26.7%]),
and emergence phenomena at home (60 [22.4%]). Significant emergence
phenomena in the pediatric ED (ie, nightmares, hallucinations, and severe
agitation) occurred in 7.1% of the ketamine group and in 6.2% of the
ketamine-midazolam group, a rate difference of 0.8 (95% confidence interval
[CI] –5.3 to 7.0). The addition of midazolam led to an increased incidence
of oxygen desaturation events (ketamine 1.6% versus ketamine-midazolam 7.3%;
rate difference –5.7, 95% CI –10.6 to –0.9) but a decreased incidence of
vomiting (ketamine 19.4%, ketamine-midazolam 9.6%, rate difference 9.8, 95%
CI 1.4 to 18.2). The incidence of emergence phenomena and significant
emergence phenomena was not affected by the addition of midazolam. However,
the addition of midazolam was associated with more agitation in the
pediatric ED in children 10 years or older (ketamine 5.7% versus
ketamine-midazolam 35.7%; rate difference –30.0, 95% CI –10.7 to –49.3). Age
breakdown further showed 6.3% (95% CI 0.9 to 11.6) more episodes of oxygen
desaturation in the ketamine-midazolam group in children younger than 10
years, and 12.1% (95% CI 1.5 to 22.6) more vomiting episodes in the ketamine
group in children younger than 10 years.
Conclusion: Ketamine and combined ketamine and midazolam provided equally
effective sedation. The addition of midazolam did not alter the incidence of
emergence phenomena. Vomiting occurred more frequently in the ketamine only
group, whereas oxygen desaturation occurred more frequently in the
ketamine-midazolam group. These findings were more pronounced in patients
younger than 10 years. Parental and physician satisfaction remained high for
all patients receiving intravenous ketamine sedation. [Wathen JE, Roback MG,
Mackenzie T, Bothner JP. Does midazolam alter the clinical effects of
intravenous ketamine sedation in children? A double-blind, randomized,
controlled, emergency department trial. Ann Emerg Med. December
2000;36:579-588.]
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