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

Abstract

Study Objective To estimate the minimum dose and total sedation time of rapidly infused ketamine that achieves 3-5 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 over ≤ 5 sec that provided effective sedation in 50% (ED50) and 95% (ED95) of healthy children aged 2-5, 6-11 or 12-17 years undergoing forearm fracture reduction. Most 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 2-5, 6-11 and 12-17 years age groups, respectively. For the 2-5 years age group, an empirically derived ED95 was 0.8 mg/kg. All who received the empirically derived ED95 in the 2-5 years group or the estimated ED95 in the 6-11 and 12-17 years group had effective sedation. The median total sedation time for the three age groups respectively, was 25, 22.5 and 25 minutes if one dose of ketamine was administered and 35, 25 and 45 minutes if additional doses were administered. No participant experienced serious adverse events. Conclusions We estimated ED50 and ED95 for rapidly infused ketamine for three age groups undergoing fracture reduction. Total sedation time was shorter than most previous studies.

Procedural Sedation for Orthopedic Fracture Reductions in the Pediatric Emergency Department

“…[29][30][31] The initial ketamine dose is 1-2 mg/kg administered over 30 to 60 seconds. 27,30,32,33 Chinta et al 34 reported in a prospective small trial for fracture reduction that smaller ketamine doses (0.7-0.8 mg/kg) with a rapid infusion (5 sec) technique achieved effective brief sedation and rapid recovery.…”

Hot Off the Press: Subdissociative-dose Ketamine for Acute Pain in the Emergency Department

“…Future investigations should use consistent ketamine 9 and comparator dosing, use a single pain scale to assess efficacy, stratify outcomes by pain etiology, 10 and adhere to Consolidated Standards of Reporting Trials (CONSORT) guidelines for monitoring and reporting of adverse events across studies.…”

Intravenous Ketamine Bolus: Not So Fast!

“…4 However, the trial's criterion for discharge readiness was an Aldrete score of greater than 8, a lower threshold than the score of greater than 10 used by Cinta et al 1 The heterogeneity of discharge readiness criteria, ranging from physician determination to use of the Vancouver Sedation Recovery Scale and Aldrete scores, limits robust comparison with previous literature. 7,8 So what are the implications of this study for the practicing emergency physician?…”