Optimal dosing of intravenous ketamine for procedural sedation in children in the ED-a randomized controlled trial
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Published on: June 2, 2022
Nirupama Kannikeswaran1, Mary Lieh-Lai2, Monica Malian3
1Carman and Ann Adams Department of Pediatrics, Division of Emergency Medicine, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit, MI 48201.
Insights
Higher intravenous ketamine doses (1.5 and 2.0 mg/kg) in children provided adequate sedation with less need for redosing and greater physician satisfaction compared to 1.0 mg/kg, without increasing adverse events.
Area of Science:
- Pediatric Emergency Medicine
- Pharmacology
- Anesthesiology
Background:
- Procedural sedation in children is crucial in the emergency department.
- Parenteral ketamine is commonly used for procedural sedation in pediatric patients.
- Optimizing ketamine dosing is essential for balancing efficacy and safety.
Purpose of the Study:
- To compare the need for redosing, sedation efficacy, duration, and adverse events of three common parenteral ketamine doses in the emergency department.
- To evaluate the optimal intravenous ketamine dosage for procedural sedation in children.
Main Methods:
- Prospective, double-blind, randomized controlled trial involving children aged 3-18 years.
- Intravenous ketamine administered at 1, 1.5, or 2 mg/kg for procedural sedation.
- Primary outcome: need for ketamine redosing; Secondary outcomes: sedation efficacy, duration, and adverse events.
Main Results:
- 125 children were analyzed across the three dosing groups (1, 1.5, and 2 mg/kg).
- The 1 mg/kg group required significantly more redosing (16.0%) compared to 1.5 mg/kg (2.9%) and 2 mg/kg (5.0%).
- No significant differences were observed in sedation efficacy, duration, or adverse events; physician satisfaction was higher with 1.5 and 2 mg/kg doses.
Conclusions:
- All three intravenous ketamine doses (1, 1.5, and 2 mg/kg) achieved adequate sedation in children.
- Higher ketamine doses (1.5 and 2.0 mg/kg) reduced the need for redosing and improved physician satisfaction without increasing adverse events.
- Intravenous ketamine at 1.5 or 2.0 mg/kg is a safe and effective option for procedural sedation in pediatric emergency departments.
Objective:
The objective of the study is to compare need for redosing, sedation efficacy, duration, and adverse events between 3 commonly administered doses of parenteral ketamine in the emergency department (ED).
Methods:
We conducted a prospective, double-blind, randomized controlled trial on a convenience sample of children 3 to 18years who received intravenous ketamine for procedural sedation. Children from each age group (3-6, 7-12, and 13-18years) were assigned in equal numbers to 3 dosing groups (1, 1.5, and 2mg/kg) using random permuted blocks. The primary outcome measure was need for ketamine redosing to ensure adequate sedation. Secondary outcome measures were sedation efficacy, sedation duration, and sedation-related adverse events.
Results:
A total of 171 children were enrolled of whom 125 (1mg/kg, 50; 1.5mg/kg, 35; 2mg/kg, 40) received the randomized dose and were analyzed. The need for ketamine redosing was higher in the 1mg/kg group (8/50; 16.0% vs 1/35; 2.9% vs 2/40; 5.0%). There was no significant difference in the median Ramsay sedation scores (5.5 [interquartile range {IQR}, 4-6] vs 6 [IQR, 4-6] vs 6 [IQR, 5-6]), FACES-R score (0 [IQR, 0-4] vs 0 [IQR, 0-0] vs 0 [IQR, 0-0]), sedation duration in minutes (23 [IQR, 19-38] vs 24.5 [IQR, 17.5-34.5] vs 23 [IQR, 19-29]), and adverse events (10.0% vs 14.3% vs 10.0%) between the 3 dosing groups. Physician satisfaction was lower in the 1mg/kg group (79.6% vs 94.1% vs 97.3%).
Conclusions:
Adequate sedation was achieved with all 3 doses of ketamine. Higher doses did not increase the risk of adverse events or prolong sedation. Ketamine administered at 1.5 or 2.0mg/kg intravenous required less redosing and resulted in greater physician satisfaction.
