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Study objectiveAlthough 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. MethodsWe 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. ResultsIn 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. ConclusionRisk 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. a Department of Emergency Medicine, Loma Linda University Medical Center and Children's Hospital, Loma Linda, CA b Department of Pediatrics, University of Minnesota, Minneapolis, MN c Division of Emergency Medicine, Children's Hospital and Harvard Medical School, Boston, MA d Royal Lancaster Infirmary, Lancaster, UK e Division of Emergency Medicine, Children's National Medical Center, Washington, DC f Division of Emergency Medicine, Boston Medical Center, Boston, MA g Department of Anaesthesia, University Children's Hospital, Zurich, Switzerland h Division of Pediatric Emergency Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA i Department of Pediatrics, University of Chicago, Chicago, IL j Department of Pediatrics, University of Colorado Health Sciences Center, Denver, CO k Emergency Department, Royal Darwin Hospital, Darwin, Northern Territory, Australia l Division of Emergency Medicine, Miami Children's Hospital, Miami, FL m Department of Pediatrics, Medical University of South Carolina, Charleston, SC
Provide feedback on this article at the journal's Web site, www.annemergmed.com. Supervising editors: Kathy N. Shaw, MD, MSCE; Michael L. Callaham, MD. Drs. Shaw and Callaham were the supervising editors on this article. Dr. Green did not participate in the editorial review or decision to publish this article. Author contributions: SMG conceived and designed the study. The methodology was critiqued and revised with extensive input from MGR, BK, LB, DA, RDP, JEW, and GT. All authors reviewed and recoded their data to comply with study definitions, and before data analysis the study protocol was critiqued and refined by all authors. SMG performed the data analysis, and a writing committee composed of SMG, MGR, and BK then created the article. All authors critiqued the draft, and there were substantial revisions. SMG takes responsibility for the paper as a whole. Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Earn CME Credit: Continuing Medical Education is available for this article at: www.ACEP-EMedHome.com. Publication date: Available online February 7, 2009. Reprints not available from the authors. PII: S0196-0644(08)02084-2 doi:10.1016/j.annemergmed.2008.12.011 © 2008 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
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ABSTRACT
Predictors of Airway and Respiratory Adverse Events With Ketamine Sedation in the Emergency Department: An Individual-Patient Data Meta-analysis of 8,282 Children