Midazolam, Ketamine or Fentanyl - kids sedation

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2win

2win

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I know that most of us use Midazolam for children sedation. What's your experience with Ketamine and fentanyl?
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1- Procedural Sedation and Analgesia Outcomes in Children After Discharge From the Emergency Department: Ketamine Versus Fentanyl/Midazolam
McQueen A, Wright RO, Kido MM, Kaye E, Krauss B.
Ann Emerg Med. 2009 Aug;54(2):191-97.e1-4. Epub 2009 May 22.
http://www.ncbi.nlm.nih.gov/pubmed/19464072

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.


2- Ketamine and neurotoxicity: clinical perspectives and implications for emergency medicine.
Green SM, Coté CJ.
Ann Emerg Med. 2009 Aug;54(2):181-90. Epub 2008 Nov 6.
http://www.ncbi.nlm.nih.gov/pubmed/18990467

Excerpt:
Effect on anesthesiology
Anesthesiologists have alternatives for the minority of children for whom they currently select ketamine. Nevertheless, ketamine remains the induction/sedative agent of choice for many anesthesiologists in specific patient populations such as those with cyanotic congenital heart disease, hypovolemia, and hemodynamic instability. Should this drug be restricted or withdrawn, anesthesiologists would need to deal with the resultant surge in referrals from the ED.

SUMMARY AND FUTURE RESEARCH
Although it is beyond dispute that ketamine can induce neuronal death in rodents and other animals, there is thus far no evidence that such an effect occurs in humans. Indeed, such a premise is at complete odds with the wealth of human experience with this agent. However, now that this question has been raised, we are obligated to carefully investigate. A first approach might be the effect of ketamine on biomarkers of neurologic injury such as protein S-100B and neuron-specific enolase.119-121 Ultimately, however, it appears that this question can be resolved only through long-term epidemiologic study of children receiving ketamine that also excludes exposure to all other medications that have a similar association in animal models. Such a study should be funded and conducted, but there will be enormous problems with developing adequate controls and sufficient case numbers to arrive at a secure resolution. Until the results of such studies are available, there is insufficient evidence to alter current clinical practice. The ample benefits of ketamine sedation in children substantially outweigh its theoretical risks. Should it ultimately be demonstrated that neuroapoptosis does occur with ketamine or other implicated drugs at clinically relevant doses, then it will be imperative to develop either alternative safer agents or effective mechanisms for blocking the neurotoxic effect.67
 
Ketamine rocks as a peds procedure sedation drug.
 
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Narcotized said:
Ketamine rocks as a peds procedure sedation drug. I loved it as an ER doc.
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Agreed, we use it a LOT with very good effect.

For longer term sedation, I've seen the PICU use ketamine as a drip in a couple of very sick asthmatics, but I don't know how often they do that or for how long. Just something I noted.
 
Had a 3 y/o come in to the ED a couple weeks back. He was involved in a MVC which caused the airbag to deploy causing some scleral lacerations. Opthomologist asked me to sedate him to do an eye exam. When I got to him there were four nurses in the room trying to hold him down to put in his 3rd IV (the other two were quickly yanked out). All you had to do is follow the yelling/crying spells.

Long story short... I stuck him with a ketamine dart in the ED. The optho guy pried open his eye with his tool thingy. The kid didn't even flintch. Remained quiet for the next couple of hours. Great drug!
 
Also... works wonders for chronic pain patients.

If you put a chronic pain patient on a ketamine gtt for a week it seems that their opioid receptors down regulate or reset themselves, requirering much less narcotic to keep the same level of analgesia.

I heard of this during residency. One of the old faculty members had done tons of research in this arena. Interesting.
 
I always use Ketamine/magnesium with my chronic pain patients.
 
Love ketamine darts for peds cases where you want an IV for induction, but kid won't tolerate IV placement awake.

We do a fair number of older children with autism for dental restorations/extractions, and if I have a kid in whom I am worried about aspiration, I do some EMLA cream, ketamine dart, and sometimes po versed and/or nitrous. Works great - smooth IV insertion and you avoid a full mask induction.
 
DreamMachine said:
We do a bunch of pediatric MAC cases (rad onc), using primarily ketamine.
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Some will say that the incidence of nausea is higher after ketamine and also the recovery time is prolonged.
 
Using a little midaz with the ketamine may also be useful. It may improve the side effects dreaming/tough wake up. Propofol is a great drug as well occasionaly will mix that with ketamine which decreases the amount of propofol used and keeps hemodynamic stability.
 
All of our rad onc kids have ports that the nurses access. They get propofol and a facemask for the treatment. Residents don't normally do these cases, so it's usually solo peds attendings.

I remember there being some concern about repeated doses of ketamine and cumulative neurotoxicity. Not sure if it ever made it beyond the rat.
 
If I may ask, working in pediatric ICUs, NICUs, and CT peds ICUs, we use a lot of fentanyl infusions. Is ketamine becoming more of a trend for these settings? If a kid is on a fentanyl gtt for a while, we end up having to put them on methadone.
 
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sevoflurane said:
I always use Ketamine/magnesium with my chronic pain patients.
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👍👍👍
Sevoflurane - read this :
"
Forty patients undergoing total hip replacement arthroplasty under spinal anaesthesia were recruited to the study. After the induction of spinal anaesthesia, the magnesium group (Group M) received magnesium sulphate 50 mg/kg for 15 minutes and then 15 mg/kg/hour by continuous i.v. infusion until the end of surgery. The saline group (Group S) received the same volume of isotonic saline over the same period. After surgery, a patient-controlled analgesia (PCA) device containing morphine and ketorolac was provided for the patients. Postoperative pain scores, PCA consumption, and the incidences of shivering, postoperative nausea and vomiting were evaluated immediately after surgery, and at 30 minutes, and 4, 24, and 48 hours after surgery. Serum magnesium concentrations were checked before the induction of anaesthesia, immediately after surgery, and at 1 and 24 hours after surgery.

Results

Postoperative pain scores were found to be significantly lower in Group M at 4, 24, and 48 hours after surgery (p<0.05). Cumulative postoperative PCA consumptions were also significantly lower in Group M at 4, 24, and 48 hours after surgery (p<0.05). Postoperative magnesium concentrations were higher in Group M (p<0.05 at 4, 24, and 48 hours after surgery), but no side-effects associated with hypermagnesemia were observed. Haemodynamic variables and the incidences of shivering, nausea, and vomiting were similar in the two groups.

Conclusions

The authors conclude that i.v. magnesium sulphate administration during spinal anaesthesia improves postoperative analgesia."
 
sevoflurane said:
Also... works wonders for chronic pain patients.

If you put a chronic pain patient on a ketamine gtt for a week it seems that their opioid receptors down regulate or reset themselves, requirering much less narcotic to keep the same level of analgesia.

I heard of this during residency. One of the old faculty members had done tons of research in this arena. Interesting.
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And you need so little for pain. For boluses even 2-3 4mg boluses in PACU will make a significant difference to the ones who're zonked on fentanyl but still complaining they're in pain. For infusions we run our patients at 4-8mg/hr. I love Ketamine😀
 
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2win said:
👍👍👍
Sevoflurane - read this :
"
Forty patients undergoing total hip replacement arthroplasty under spinal anaesthesia were recruited to the study. After the induction of spinal anaesthesia, the magnesium group (Group M) received magnesium sulphate 50 mg/kg for 15 minutes and then 15 mg/kg/hour by continuous i.v. infusion until the end of surgery. The saline group (Group S) received the same volume of isotonic saline over the same period. After surgery, a patient-controlled analgesia (PCA) device containing morphine and ketorolac was provided for the patients. Postoperative pain scores, PCA consumption, and the incidences of shivering, postoperative nausea and vomiting were evaluated immediately after surgery, and at 30 minutes, and 4, 24, and 48 hours after surgery. Serum magnesium concentrations were checked before the induction of anaesthesia, immediately after surgery, and at 1 and 24 hours after surgery.

Results

Postoperative pain scores were found to be significantly lower in Group M at 4, 24, and 48 hours after surgery (p<0.05). Cumulative postoperative PCA consumptions were also significantly lower in Group M at 4, 24, and 48 hours after surgery (p<0.05). Postoperative magnesium concentrations were higher in Group M (p<0.05 at 4, 24, and 48 hours after surgery), but no side-effects associated with hypermagnesemia were observed. Haemodynamic variables and the incidences of shivering, nausea, and vomiting were similar in the two groups.

Conclusions

The authors conclude that i.v. magnesium sulphate administration during spinal anaesthesia improves postoperative analgesia."
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Nice.

For those doing long back cases and have concerns of propofol syndrome (although I've never seen it in the OR) or just want to cut down on the amount of propofol given, tremendous synergy exists when using propofol, ketamine and magnesium.

Ketamine: increase your amplitude and decreases your latency which is the only drug that does this = neuromonitoring people love it.

Magnesium: bronchodilator, slight muscle relaxation (also good when running motors and don't want to give NMB's), cardiac stable/protective, pain modulator, synergism with other commonly used drugs.

Evolutionarily speaking humans used to eat a lot of berries in their diet. Berries have a lot of mag in them. Now days, our diets are relatively deficient in magnesium. When was the last time you saw a healthy individual with hypermagnesemia? Never.

Magnesium is another great drug in my opinion. 🙂
 
Stitch said:
Agreed, we use it a LOT with very good effect.

For longer term sedation, I've seen the PICU use ketamine as a drip in a couple of very sick asthmatics, but I don't know how often they do that or for how long. Just something I noted.
Click to expand...

I've seen magnesium used quite a bit for bronchodilation in the pedi group.
 
sevoflurane said:
I've seen magnesium used quite a bit for bronchodilation in the pedi group.
Click to expand...

As a longer term med? In general I only use it in the sicker asthmatics (dose 50-75 mg/kg, max of 2 g), and then only once to try and break the bronchospasm. I always give a NS bolus along with it. Some people I've spoken with use it early on (in less sick kids) to try and prevent worsening but I haven't seen it used repeatedly or as a drip.

EDIT: Here's a Cochrane review, but it's a little old. Basically says there's not a lot of good evidence for it, but it may be beneficial in the severe asthmatics in the ED. That's the take our PICU guys have, and they don't use it, at least not in the ICU setting. Personally I think it does work, and is at least worth trying.
 
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Stitch said:
As a longer term med? In general I only use it in the sicker asthmatics (dose 50-75 mg/kg, max of 2 g), and then only once to try and break the bronchospasm. I always give a NS bolus along with it. Some people I've spoken with use it early on (in less sick kids) to try and prevent worsening but I haven't seen it used repeatedly or as a drip.

EDIT: Here's a Cochrane review, but it's a little old. Basically says there's not a lot of good evidence for it, but it may be beneficial in the severe asthmatics in the ED. That's the take our PICU guys have, and they don't use it, at least not in the ICU setting. Personally I think it does work, and is at least worth trying.
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No drip due to commulative affects in this age group. I've seen it used as you stated in the ED. Also have seen it used in moderate to severe asthmatics with post-op bronchospasm. Definitely seen it used in the PICU/NICU on a prn basis for a couple of days. I also think it works. I've seen upsloping of capnograph go away with it in the adult population.
 
All of our peds (generally) get a versed po pedi-prep before most of our general cases. That being said, we've instituted a new sedation algorithm for outpatient procedures and have been having pretty good success with precedex for MRI. For a quick scan, like brain, usually just a bolus suffices. For longer scans, bolus followed by infusion also works well. (As an aside, they are often occasionally EXTRA drowsy in the PACU for longer than one might like). This seems to be the major obstacle to venue. Anybody else using it in this environment with more/less success?
 
I use ketamine for all of my long TIVA neuro monitoring cases. 1mg/kg bolus followed by 0.1 mg/kg/hr. It works great to limit the amount of propofol infused and may be beneficial to the neuro monitoring mentioned above. I don't use it for my short cases, spinal growth rod lengthening etc.
 
Ketamine is an awesome drug and I miss it ))))

I used to be a pediatric anesthesiologist.


However I have to say that PO versed as a routine premedication is absolutely stunning )))) I haven't seen it before using it in the US.
 
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