Annals of Emergency Medicine
Volume 54, Issue 2 , Pages 171-180.e4 , August 2009

Predictors of Emesis and Recovery Agitation With Emergency Department Ketamine Sedation: An Individual-Patient Data Meta-Analysis of 8,282 Children

  • Steven M. Green, MD

      Affiliations

    • Department of Emergency Medicine, Loma Linda University Medical Center and Children's Hospital, Loma Linda, CA
    • Corresponding Author InformationAddress for correspondence: Steven M. Green, MD, Department of Emergency Medicine, Loma Linda University Medical Center, 11234 Anderson St, Loma Linda, CA 92354; 805-969-2144, fax 775-307-4121
    • ,
  • Mark G. Roback, MD

      Affiliations

    • Department of Pediatrics, University of Minnesota, Minneapolis, MN
    • ,
  • Baruch Krauss, MD, EdM

      Affiliations

    • Division of Emergency Medicine, Children's Hospital and Harvard Medical School, Boston, MA
    • ,
  • Lance Brown, MD, MPH

      Affiliations

    • Department of Emergency Medicine, Loma Linda University Medical Center and Children's Hospital, Loma Linda, CA
    • ,
  • Ray G. McGlone, FCEM

      Affiliations

    • Royal Lancaster Infirmary, Lancaster, UK
    • ,
  • Dewesh Agrawal, MD

      Affiliations

    • Division of Emergency Medicine, Children's National Medical Center, Washington, DC
    • ,
  • Michele McKee, MD, MS

      Affiliations

    • Division of Emergency Medicine, Boston Medical Center, Boston, MA
    • ,
  • Markus Weiss, MD

      Affiliations

    • Department of Anaesthesia, University Children's Hospital, Zurich, Switzerland
    • ,
  • Raymond D. Pitetti, MD, MPH

      Affiliations

    • Division of Pediatric Emergency Medicine, Children's Hospital of Pittsburgh, PA
    • ,
  • Mark A. Hostetler, MD, MPH

      Affiliations

    • Department of Pediatrics, University of Chicago, Chicago, IL
    • ,
  • Joe E. Wathen, MD

      Affiliations

    • Department of Pediatrics, University of Colorado Health Sciences Center, Denver, CO
    • ,
  • Greg Treston, MBBS

      Affiliations

    • Emergency Department, Royal Darwin Hospital, Darwin, Northern Territory, Australia
    • ,
  • Barbara M. Garcia Pena, MD

      Affiliations

    • Division of Emergency Medicine, Miami Children's Hospital, Miami, FL
    • ,
  • Andreas C. Gerber, MD

      Affiliations

    • Department of Anaesthesia, University Children's Hospital, Zurich, Switzerland
    • ,
  • Joseph D. Losek, MD

      Affiliations

    • Department of Pediatrics, Medical University of South Carolina, Charleston, SC
    • ,
  • Emergency Department Ketamine Meta-Analysis Study Group

      Affiliations

    • All members are listed in the Appendix.

Received 27 January 2009 ,Revised 13 March 2009 ,Accepted 1 April 2009.

References 

  1. Green SM, Cote CJ. Ketamine and neurotoxicity: clinical perspectives and implications for emergency medicine. Ann Emerg Med. 2009;54:181–190
  2. Green SM, Roback MG, Krauss B, et al. Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children. Ann Emerg Med. 2009;54:158–168
  3. Green SM, Rothrock SG, Lynch EL, et al. Intramuscular ketamine for pediatric sedation in the emergency department: safety profile with 1,022 cases. Ann Emerg Med. 1998;31:688–697
  4. Roback MG, Bajaj L, Wathen JE, et al. Preprocedural fasting and adverse events in procedural sedation and analgesia in a pediatric emergency department: are they related?. Ann Emerg Med. 2004;44:454–459
  5. Roback MG, Wathen JE, MacKenzie T, et al. A randomized, controlled trial of IV versus IM ketamine for sedation of pediatric patients receiving emergency department orthopedic procedures. Ann Emerg Med. 2006;48:605–612
  6. Heinz P, Geelhoed GC, Wee C, et al. Is atropine needed with ketamine sedation? (a prospective, randomized, double blind study). Emerg Med J. 2006;23:206–209
  7. Green SM, Krauss B. Clinical practice guideline for emergency department ketamine dissociative sedation in children. Ann Emerg Med. 2004;44:460–471
  8. Green SM, Kuppermann N, Rothrock SG, et al. Predictors of adverse events with ketamine sedation in children. Ann Emerg Med. 2000;35:35–42
  9. Hostetler MA, Barnard JA. Removal of esophageal foreign bodies in the pediatric ED: is ketamine an option?. Am J Emerg Med. 2002;20:96–98
  10. Krauss B, Green SM. Procedural sedation and analgesia in children. Lancet. 2006;367:766–780
  11. Sherwin TS, Green SM, Khan A, et al. Does adjunctive midazolam reduce recovery agitation after ketamine sedation for pediatric procedures? (a randomized, double-blind, placebo-controlled trial). Ann Emerg Med. 2000;35:239–244
  12. Langston WT, Wathen JE, Roback MG, et al. Effect of ondansetron on the incidence of vomiting associated with ketamine sedation in children: a double-blind, randomized, placebo-controlled trial. Ann Emerg Med. 2008;52:30–34
  13. Green SM, Sherwin T. Incidence and severity of recovery agitation following ketamine sedation in young adults. Am J Emerg Med. 2005;23:142–144
  14. McGlone RG, Fleet T, Durham S, et al. A comparison of intramuscular ketamine with high dose intramuscular midazolam with and without intranasal flumazenil in children before suturing. Emerg Med J. 2001;18:34–38
  15. McGlone RG, Howes MC, Joshi M. The Lancaster experience of 2.0 to 2.5 mg/kg intramuscular ketamine for paediatric sedation: 501 cases and analysis. Emerg Med J. 2004;21:290–295
  16. Szappanyos GG, Gemperle M, Rifat K. Selective indications for ketamine anaesthesia. Proc R Soc Med. 1971;64:1156–1159
  17. Faithfull NS, Haider R. Ketamine for cardiac catheterisation. Anaesthesia. 1971;26:318–323
  18. Phillips LA, Seruvatu SG, Rika PN. Anaesthesia for the surgeon-anaesthetist in difficult situations. Anaesthesia. 1970;25:36–45
  19. Green SM, Klooster M, Harris T, et al. Ketamine sedation for pediatric gastroenterology procedures. J Pediatr Gastroent Nutr. 2001;32:26–33
  20. Green SM, Denmark TK, Cline J, et al. Ketamine sedation for pediatric critical care procedures. Pediatr Emerg Care. 2001;17:244–248
  21. Green SM, Krauss B. Should I give ketamine IV or IM [editorial]?. Ann Emerg Med. 2006;48:613–614
  22. Brown L, Christian-Kopp S, Sherwin TS, et al. Adjunctive atropine is unnecessary during ketamine sedation in children. Acad Emerg Med. 2008;15:314–318
  23. Wathen JE, Roback MG, Mackenzie T, et al. Does midazolam alter the clinical effects of intravenous ketamine sedation in children? (a double-blind, randomized, controlled emergency department trial). Ann Emerg Med. 2000;36:579–588
  24. Kennedy RM, McAllister JD. Midazolam with ketamine: who benefits [editorial]?. Ann Emerg Med. 2000;35:297–299

 Provide feedback for this article at the journal's Web site, www.annemergmed.com.

 Supervising editors: Kathy N. Shaw, MD, MSCE; Michael L. Callaham, MD

 Dr. Shaw and Dr. 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.

 Publication date: Available online June 6, 2009.

 Reprints not available from the authors.

PII: S0196-0644(09)00372-2

doi: 10.1016/j.annemergmed.2009.04.004

Annals of Emergency Medicine
Volume 54, Issue 2 , Pages 171-180.e4 , August 2009

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