Oral Midazolam with Ketamine for Pediatric Laceration Repairs

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Published in Emerg Med J 2014 Aug 15; 31:649

Authors: Barkan S et al.

Compared with oral midazolam alone, midazolam and ketamine achieved a deeper level of sedation and a higher success rate but led to longer emergency department stays.

To compare the efficacy of oral midazolam alone and in combination with oral ketamine for pediatric laceration repairs, researchers in Israel randomized 60 healthy children (age range, 1–10 years) who required sedation for laceration repairs to receive either regimen. All patients received topical lidocaine, epinephrine, and tetracaine at triage, and premedication with oral midazolam (0.5 mg/kg) followed by oral ketamine (5 mg/kg) or placebo, as well as 1% intradermal lidocaine, prior to suturing.

Most patients (80%) had facial lacerations. Fewer patients in the midazolam-ketamine group than in the midazolam-placebo group required intravenous sedation (2 vs. 8 patients), and these patients were excluded from the analysis. Pain (rated by parents on a visual analog scale) was similar between groups. Time to discharge was longer in the midazolam-ketamine group (187 vs. 122 minutes). Adverse events occurred at similar rates in the two groups; all were mild and resolved spontaneously.

Comment
Although numerous sedation regimens are used to achieve analgesia and anxiolysis for pediatric patients undergoing painful procedures, oral ketamine is not common. Based on this study, adding oral ketamine to oral midazolam should be considered, with particular attention paid to the longer emergency department stays.