Sedation for children requiring wound repair: a randomised controlled double blind comparison of oral midazolam and oral ketamine

Abstract

Objective-To compare the eYcacy of oral ketamine (10 mg/kg) with oral midazolam (0.7 mg/kg) in providing sedation for suturing of lacerations. Method-Prospective, randomised, double blinded trial with consecutive, concealed recruitment of 59 children aged 1 to 7 with wounds requiring local anaesthetic (LA) injection or topical LA with an anxiety score greater than one. Results-Tolerance to LA injection was better with ketamine (p=0.029) and tolerance to procedure after LA injection showed a trend towards being improved with ketamine (p=0.067). There was no diVerence in tolerance to LA application or procedure in children receiving topical LA. Time to reach a sedation score of less than four was faster with ketamine (medians 20 versus 43 minutes, p=0.001) but times from dosing to discharge (medians 105 and 110 minutes) were similar. Inconsolable agitation was reported with midazolam in six cases. Dysphoria was not noted with ketamine. Vomiting was more common with ketamine but not significantly so (six versus two, p = 0.14). Oxygen desaturations were noted in both groups. Ataxia after discharge was seen in four patients, two in each group. Thirty six per cent of children showed new behavioural disturbances in the two weeks after discharge, more commonly in the midazolam group (p=0.048). Conclusions-At these doses tolerance to LA injection was better in children receiving ketamine, with fewer behavioural changes noted in the first two weeks. Midazolam at this dose caused dysphoric reactions, which may have aVected the results. Continuous pulse oximetry monitoring is required when using these drugs. Vomiting and prolonged ataxia occurred in a few patients.

A double-blind, randomised, placebo-controlled trial of oral midazolam plus oral ketamine for sedation of children during laceration repair

“…The level of sedation was documented by using a sedation scale 11. The scale has five levels of sedation ranging from 5 (agitated) to 1 (barely arousable, asleep, needs shaking/shouting to arouse).…”

“…In a few studies, oral ketamine sedation has also been used successfully: for wound care procedures in children with burns,8 for invasive procedures in paediatric oncology patients,9 and for children requiring laceration repair 10. Younge et al 11 compared high oral doses of ketamine (10 mg/kg) with midazolam (0.7 mg/kg) for sedation of children requiring laceration repair. This study showed better tolerance to local anaesthetic injection with oral ketamine, describing only minor, non-significant adverse effects.…”

Oral Diphenhydramine-Midazolam Versus Oral Diphenhydramine for Pediatric Sedation in the Emergency Department

“…Paul and Jason compared the efficiency of oral midazolam and ketamine for inducing sedation in children before suturing their wounds; it was shown that ketamine was superior to midazolam and children who received ketamine tolerated the local anesthesia before the procedure much better than the ones received midazolam (7). In a similar study, Cengiz et al compared the sedative effects of diphenhydramine-midazolam with single midazolam before MRI in children.…”

Discontinuance of Life Sustaining Treatment Utilizing Ketamine for Symptom Management

“…We chose ketamine, as discussed below, as a rescue agent for agitation and as an analgesic adjunct based on its use for sedation in emergency medicine and in the anesthesia literature as well as its differing mechanism of action than the medications she was currently receiving. [7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24] Ketamine is an N-methyl-D aspartase (NMDA) receptor antagonist with known dissociative D. M. Noreika and P. Coyne 39 anesthetic properties. The analgesic and sedative effects that it produces are largely believed to be related to NMDA receptor blockade in the central nervous system and at the spinal cord level, although they additionally may be related to a complex interaction with opioid mu and kappa receptors.…”