Advertisement

Rapid Administration Technique of Ketamine for Pediatric Forearm Fracture Reduction: A Dose-Finding Study

      Study objective

      We estimate the minimum dose and total sedation time of rapidly infused ketamine that achieves 3 to 5 minutes of effective sedation in children undergoing forearm fracture reduction in the emergency department.

      Methods

      We used the up-down method to estimate the median dose of intravenous ketamine infused during less than or equal to 5 seconds that provided effective sedation in 50% (ED50) and 95% (ED95) of healthy children aged 2 to 5, 6 to 11, or 12 to 17 years who were undergoing forearm fracture reduction. Most patients were pretreated with opioids. Three investigators blinded to ketamine dose independently graded sedation effectiveness by viewing a video recording of the first 5 minutes of sedation. Recovery was assessed by modified Aldrete score.

      Results

      We enrolled 20 children in each age group. The estimated ED50 was 0.7, 0.5, and 0.6 mg/kg and the estimated ED95 was 0.7, 0.7, and 0.8 mg/kg for the groups aged 2 to 5, 6 to 11, and 12 to 17 years, respectively. For the group aged 2 to 5 years, an empirically derived ED95 was 0.8 mg/kg. All patients who received the empirically derived ED95 in the group aged 2 to 5 years or the estimated ED95 in the groups aged 6 to 11 and 12 to 17 years had effective sedation. The median total sedation time for the 3 age groups, respectively, was 25, 22.5, and 25 minutes if 1 dose of ketamine was administered and 35, 25, and 45 minutes if additional doses were administered. No participant experienced serious adverse events.

      Conclusion

      We estimated ED50 and ED95 for rapidly infused ketamine for 3 age groups undergoing fracture reduction. Total sedation time was shorter than that in most previous studies.
      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

        • Kennedy R.M.
        • Porter F.L.
        • Miller J.P.
        • et al.
        Comparison of fentanyl/midazolam with ketamine/midazolam for pediatric orthopedic emergencies.
        Pediatrics. 1998; 102: 956-963
        • Godambe S.A.
        • Elliot V.
        • Matheny D.
        • et al.
        Comparison of propofol/fentanyl versus ketamine/midazolam for brief orthopedic procedural sedation in a pediatric emergency department.
        Pediatrics. 2003; 112: 116-123
        • Luhmann J.D.
        • Schootman M.
        • Luhmann S.J.
        • et al.
        A randomized comparison of nitrous oxide plus hematoma block versus ketamine plus midazolam for emergency department forearm fracture reduction in children.
        Pediatrics. 2006; 118: e1078-e1086
        • Green S.M.
        • Roback M.G.
        • Kennedy R.M.
        • et al.
        Clinical practice guideline for emergency department ketamine dissociative sedation: 2011 update.
        Ann Emerg Med. 2011; 57: 449-461
        • Green S.M.
        • Rothrock S.G.
        • Harris T.
        • et al.
        Intravenous ketamine for pediatric sedation in the emergency department: safety profile with 156 cases.
        Acad Emerg Med. 1998; 5: 971-976
        • Sherwin T.S.
        • Green S.M.
        • 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: 229-238
        • Shah A.
        • Mosdossy G.
        • McLeod S.
        • et al.
        A blinded, randomized controlled trial to evaluate ketamine/propofol versus ketamine alone for procedural sedation in children.
        Ann Emerg Med. 2011; 57: 425-433.e422
        • Ramaswamy P.
        • Babl F.E.
        • Deasy C.
        • et al.
        Pediatric procedural sedation with ketamine: time to discharge after intramuscular versus intravenous administration.
        Acad Emerg Med. 2009; 16: 101-107
        • Krejcie T.C.
        • Avram M.J.
        What determines anesthetic induction dose? it's the front-end kinetics, doctor!.
        Anesth Analg. 1999; 89: 541-544
        • Ludbrook G.L.
        • Upton R.N.
        A physiological model of induction of anaesthesia with propofol in sheep. 2. Model analysis and implications for dose requirements.
        Br J Anesth. 1997; 79: 505-513
        • Bhatt M.
        • Kennedy R.M.
        • Osmond M.H.
        • et al.
        Consensus-based recommendations for standardizing terminology and reporting adverse events for emergency department procedural sedation and analgesia in children.
        Ann Emerg Med. 2009; 53: 426-435.e424
        • Hoffman G.M.
        • Nowakowski R.
        • Troshynski T.J.
        • et al.
        Risk reduction in pediatric procedural sedation by application of an American Academy of Pediatrics/American Society of Anesthesiologists process model.
        Pediatrics. 2002; 109: 236-243
        • Aldrete J.A.
        The post-anesthesia recovery score revisited.
        J Clin Anesth. 1995; 7: 89-91
        • 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.e1-e4)
        • Green S.M.
        • Roback M.G.
        • Krauss B.
        • et al.
        Predictors of emesis and recovery agitation with emergency department ketamine sedation: an individual-patient data meta-analysis of 8,282 children.
        Ann Emerg Med. 2009; 54 (171-180.e1-e4)
        • Dixon W.
        The up-and-down method for small samples.
        J Am Stat Assoc. 1965; 60: 967-978
        • Herd D.
        • Anderson B.J.
        Ketamine disposition in children presenting for procedural sedation and analgesia in a children's emergency department.
        Paediatr Anesth. 2007; 17: 622-629
        • Pace N.L.
        • Stylianou M.P.
        Advances in and limitations of up-and-down methodology: a precis of clinical use, study design, and dose estimation in anesthesia research.
        Anesthesiology. 2007; 107: 144-152
        • Dixon W.J.
        • Massey F.J.
        Introduction to Statistical Analysis.
        McGraw-Hill Book Co, New York, NY1957
        • Agresti A.
        Categorical Data Analysis.
        3rd ed. Wiley, Hoboken, NJ2013
        • Landis J.R.
        • Koch G.G.
        The measurement of observer agreement for categorical data.
        Biometrics. 1977; 33: 159-174
        • Sharieff G.Q.
        • Trocinski D.R.
        • Kanegaye J.T.
        • et al.
        Ketamine-propofol combination sedation for fracture reduction in the pediatric emergency department.
        Pediatr Emerg Care. 2007; 23: 881-884
        • Wathen J.E.
        • Roback M.G.
        • 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
        • Dallimore D.
        • Herd D.W.
        • Short T.
        • et al.
        Dosing ketamine for pediatric procedural sedation in the emergency department.
        Pediatr Emerg Care. 2008; 24: 529-533
        • Green S.M.
        • Johnson N.E.
        Ketamine sedation for pediatric procedures: part 2, review and implications.
        Ann Emerg Med. 1990; 19: 1033-1046
        • White P.F.
        • Way W.L.
        • Trevor A.J.
        Ketamine—its pharmacology and therapeutic uses.
        Anesthesiology. 1982; 56: 119-136
        • Drummond G.B.
        Comparison of sedation with midazolam and ketamine: effects on airway muscle activity.
        Br J Anesth. 1996; 76: 663-667
        • Hamza J.
        • Ecoffey C.
        • Gross J.B.
        Ventilatory response to CO2 following intravenous ketamine in children.
        Anesthesiology. 1989; 70: 422-425
        • Mankikian B.
        • Cantineau J.P.
        • Sartene R.
        • et al.
        Ventilatory pattern and chest wall mechanics during ketamine anesthesia in humans.
        Anesthesiology. 1986; 65: 492-499
        • Tokics L.
        • Strandberg A.
        • Brismar B.
        • et al.
        Computerized tomography of the chest and gas exchange measurements during ketamine anaesthesia.
        Acta Anaesthesiol Scand. 1987; 31: 684-692
        • Shulman D.L.
        • Bar-Yishay E.
        • Godfrey S.
        Respiratory mechanics and intrinsic PEEP during ketamine and halothane anesthesia in young children.
        Anesth Analg. 1988; 67: 656-662
        • Morel D.R.
        • Forster A.
        • Gemperle M.
        Noninvasive evaluation of breathing pattern and thoraco-abdominal motion following the infusion of ketamine or droperidol in humans.
        Anesthesiology. 1986; 65: 392-398
        • Joly L.M.
        • Benhamou D.
        Ventilation during total intravenous anaesthesia with ketamine.
        Can J Anaesth. 1994; 41: 227-231
        • Connors J.M.
        • Cravero J.P.
        • Kost S.
        • et al.
        Great expectations—defining quality in pediatric sedation: outcomes of a multidisciplinary consensus conference.
        J Healthc Qual. 2013;
        • Crellin D.
        • Sullivan T.P.
        • Babl F.E.
        • et al.
        Analysis of the validation of existing behavioral pain and distress scales for use in the procedural setting.
        Paediatr Anesth. 2007; 17: 720-733
        • 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
        • Roback M.G.
        • Wathen J.E.
        • MacKenzie T.
        • et al.
        A randomized, controlled trial of i.v. versus i.m. ketamine for sedation of pediatric patients receiving emergency department orthopedic procedures.
        Ann Emerg Med. 2006; 48: 605-612
        • Corssen G.
        • Miyasaka M.
        • Domino E.F.
        Changing concepts in pain control during surgery: dissociative anesthesia with CI-581. A progress report.
        Anesth Analg. 1968; 47: 746-759
        • Hollister G.R.
        • Burn J.M.
        Side effects of ketamine in pediatric anesthesia.
        Anesth Analg. 1974; 53: 264-267
        • Young R.A.
        • Epker B.N.
        Ketamine hydrochloride in outpatient oral surgery in children.
        J Oral Surg. 1971; 29: 703-705