Advertisement

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

      Study objective

      Ketamine is widely used in emergency departments (EDs) to facilitate painful procedures; however, existing descriptors of predictors of emesis and recovery agitation are derived from relatively small studies.

      Methods

      We pooled individual-patient data from 32 ED studies and performed multiple logistic regression to determine which clinical variables would predict emesis and recovery agitation. The first phase of this study similarly identified predictors of airway and respiratory adverse events.

      Results

      In 8,282 pediatric ketamine sedations, the overall incidence of emesis, any recovery agitation, and clinically important recovery agitation was 8.4%, 7.6%, and 1.4%, respectively. The most important independent predictors of emesis are unusually high intravenous (IV) dose (initial dose of ≥2.5 mg/kg or a total dose of ≥5.0 mg/kg), intramuscular (IM) route, and increasing age (peak at 12 years). Similar risk factors for any recovery agitation are low IM dose (<3.0 mg/kg) and unusually high IV dose, with no such important risk factors for clinically important recovery agitation.

      Conclusion

      Early adolescence is the peak age for ketamine-associated emesis, and its rate is higher with IM administration and with unusually high IV doses. Recovery agitation is not age related to a clinically important degree. When we interpreted it in conjunction with the separate airway adverse event phase of this analysis, we found no apparent clinically important benefit or harm from coadministered anticholinergics and benzodiazepines and no increase in adverse events with either oropharyngeal procedures or the presence of substantial underlying illness. These and other results herein challenge many widely held views about ED ketamine administration.
      To read this article in full you will need to make a payment
      ACEP Member Login
      ACEP Members, full access to the journal is a member benefit. Use your society credentials to access all journal content and features.

      Purchase one-time access:

      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Green S.M.
        • Cote C.J.
        Ketamine and neurotoxicity: clinical perspectives and implications for emergency medicine.
        Ann Emerg Med. 2009; 54: 181-190
        • Green S.M.
        • Roback M.G.
        • 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
        • Green S.M.
        • Rothrock S.G.
        • Lynch E.L.
        • et al.
        Intramuscular ketamine for pediatric sedation in the emergency department: safety profile with 1,022 cases.
        Ann Emerg Med. 1998; 31: 688-697
        • Roback M.G.
        • Bajaj L.
        • Wathen J.E.
        • 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
        • Roback M.G.
        • Wathen J.E.
        • 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
        • Heinz P.
        • Geelhoed G.C.
        • Wee C.
        • et al.
        Is atropine needed with ketamine sedation?.
        Emerg Med J. 2006; 23: 206-209
        • Green S.M.
        • Krauss B.
        Clinical practice guideline for emergency department ketamine dissociative sedation in children.
        Ann Emerg Med. 2004; 44: 460-471
        • Green S.M.
        • Kuppermann N.
        • Rothrock S.G.
        • et al.
        Predictors of adverse events with ketamine sedation in children.
        Ann Emerg Med. 2000; 35: 35-42
        • Hostetler M.A.
        • Barnard J.A.
        Removal of esophageal foreign bodies in the pediatric ED: is ketamine an option?.
        Am J Emerg Med. 2002; 20: 96-98
        • Krauss B.
        • Green S.M.
        Procedural sedation and analgesia in children.
        Lancet. 2006; 367: 766-780
        • Sherwin T.S.
        • Green S.M.
        • Khan A.
        • et al.
        Does adjunctive midazolam reduce recovery agitation after ketamine sedation for pediatric procedures?.
        Ann Emerg Med. 2000; 35: 239-244
        • Langston W.T.
        • Wathen J.E.
        • Roback M.G.
        • 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
        • Green S.M.
        • Sherwin T.
        Incidence and severity of recovery agitation following ketamine sedation in young adults.
        Am J Emerg Med. 2005; 23: 142-144
        • McGlone R.G.
        • 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
        • McGlone R.G.
        • Howes M.C.
        • 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
        • Szappanyos G.G.
        • Gemperle M.
        • Rifat K.
        Selective indications for ketamine anaesthesia.
        Proc R Soc Med. 1971; 64: 1156-1159
        • Faithfull N.S.
        • Haider R.
        Ketamine for cardiac catheterisation.
        Anaesthesia. 1971; 26: 318-323
        • Phillips L.A.
        • Seruvatu S.G.
        • Rika P.N.
        Anaesthesia for the surgeon-anaesthetist in difficult situations.
        Anaesthesia. 1970; 25: 36-45
        • Green S.M.
        • Klooster M.
        • Harris T.
        • et al.
        Ketamine sedation for pediatric gastroenterology procedures.
        J Pediatr Gastroent Nutr. 2001; 32: 26-33
        • Green S.M.
        • Denmark T.K.
        • Cline J.
        • et al.
        Ketamine sedation for pediatric critical care procedures.
        Pediatr Emerg Care. 2001; 17: 244-248
        • Green S.M.
        • Krauss B.
        Should I give ketamine IV or IM [editorial]?.
        Ann Emerg Med. 2006; 48: 613-614
        • Brown L.
        • Christian-Kopp S.
        • Sherwin T.S.
        • et al.
        Adjunctive atropine is unnecessary during ketamine sedation in children.
        Acad Emerg Med. 2008; 15: 314-318
        • Wathen J.E.
        • Roback M.G.
        • Mackenzie T.
        • et al.
        Does midazolam alter the clinical effects of intravenous ketamine sedation in children?.
        Ann Emerg Med. 2000; 36: 579-588
        • Kennedy R.M.
        • McAllister J.D.
        Midazolam with ketamine: who benefits [editorial]?.
        Ann Emerg Med. 2000; 35: 297-299