Safety and Depth of Sedation With Ketamine Alone Versus Ketamine With Midazolam in Pediatric Fracture Reduction

ObjectivesPediatric patients with extremity fractures often require sedation for fracture reduction in the pediatric emergency department (PED). Although orthopedic literature suggests combination sedation regimens may be more effective for fracture reduction, some pediatric literature suggests adverse events are more frequent. The primary objective of this study is to determine the comparable depth of sedation and incidence of adverse events when intravenous ketamine is used alone versus with midazolam for pediatric procedural sedation and orthopedic fracture reduction.MethodsThis is a retrospective cohort study of pediatric patients 2-18 years old who underwent sedation for fracture reduction in the PED at a single level 1 trauma center over a 2-year period. Medical records were reviewed, and occurrence of adverse events, depth of sedation (Ramsey score), midazolam dose, total ketamine administration, opiate administration, total sedation time, and time to PED discharge were compared in patients who received ketamine alone versus those who received ketamine with midazolam. Logistic regression models were adjusted to evaluate for potential confounders.ResultsThere was a statistically significant increase in the occurrence of hypoxia with coadministration of midazolam (5% vs 0%). When hypoxia occurred, it was mild and resolved with repositioning or administration of supplemental oxygen. Length of sedation was increased in sedations with coadministration of benzodiazepines by approximately 3.5 minutes. Time to PED discharge was not significantly different. There was no significant difference in depth of sedation, ketamine dose administered, end-tidal CO2 measurements, administration of positive pressure ventilation, vomiting, agitation, or overall occurrence of adverse events. No patients developed apnea or laryngospasm.ConclusionsThis study showed a low rate of adverse events in pediatric sedation for orthopedic reduction with ketamine alone or ketamine with midazolam. There was an increased occurrence of hypoxia with coadministration of midazolam and an increase in the length of sedation. This study showed no difference in depth of sedation based on Ramsay scores when midazolam was coadministered. Information on the orthopedic reduction and provider satisfaction was not collected.