Procedural Sedation and Analgesia Outcomes in Children After Discharge From the Emergency Department: Ketamine Versus Fentanyl/Midazolam
Received 5 July 2008; received in revised form 30 November 2008 and 19 April 2009; accepted 22 April 2009. published online 25 May 2009.
Study objective
Although the safety and efficacy of procedural sedation and analgesia in the pediatric emergency department (ED) has been established, the prevalence of adverse events after discharge has not been well studied. We compare the postdischarge incidence of adverse behavioral events and vomiting and hypothesize that ketamine would be associated with increased adverse behaviors.
Methods
We conducted a prospective observational study of postdischarge behavioral changes and vomiting after sedation with ketamine, ketamine/midazolam, or fentanyl/midazolam. Families were administered a Post Hospital Behavior Questionnaire (PHBQ), with higher scores indicating more adverse behaviors (anxiety, sleep disturbances). We used linear and logistic regression to model PHBQ scores and logistic regression to model vomiting risk adjusting for age, sex, procedure, length of procedure, and parental presence as potential confounders.
Results
Seven hundred eighty-six children were enrolled and 554 children (61% boys; mean age 7.5±4.5 years) were contacted. The prevalence of postdischarge vomiting was 18%, but the prevalence of adverse behavioral changes was low. When adjusted for potential confounders, the odds of a higher PHBQ score increased among patients receiving fentanyl/midazolam (fentanyl/midazolam odds ratio [OR] 2.6, 95% confidence interval [CI] 1.08 to 6.03, P=.03; ketamine OR 1.7, 95% CI 0.84 to 3.57; ketamine/midazolam OR 0.5, 95% CI 0.26 to 1.07).
Conclusion
Procedural sedation and analgesia in the ED is well tolerated. Though postdischarge vomiting occurs with some frequency, there is a low prevalence of adverse behavioral events after discharge. The use of fentanyl/midazolam was associated with higher adverse behavioral scores.
aSection of Pediatric Emergency Medicine, The University of Chicago, Chicago, IL
bDepartment of Environmental Health, Harvard School of Public Health, Boston, MA
cDivision of Emergency Medicine, Children's Hospital and Harvard Medical School, Boston, MA
Author contributions: AM and BK conceived and designed the study. AM, MMK, EK, and BK recruited patients, conducted the follow-up interviews, and managed the data. ROW assisted with study design and analyzed the data. AM drafted the article, and all authors contributed substantially to its revision. AM takes responsibility for the paper as a whole.
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ABSTRACT