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PEDIATRICS Vol. 102 No. 4 October 1998, pp. 956-963

Comparison of Fentanyl/Midazolam With Ketamine/Midazolam for Pediatric Orthopedic Emergencies

Received Sep 24, 1997; accepted Mar 23, 1998.

Robert M. Kennedy*, Fran L. PorterDagger , J. Philip Miller§, and David M. Jaffe*

From the Department of Pediatrics, Divisions of * Emergency Medicine, Dagger  Newborn Medicine, and § Biostatistics, Washington University School of Medicine, St Louis Children's Hospital, St Louis, Missouri.

Objective.  Emergency management of pediatric fractures and dislocations requires effective analgesia, yet children's pain is often undertreated. We compared the safety and efficacy of fentanyl- versus ketamine- based protocols.

Methodology.  Patients 5 to 15 years of age needing emergency fracture or joint reduction (FR) were randomized to receive intravenous midazolam plus either fentanyl (F/M) or ketamine (K/M). Measures of efficacy were observational distress scores and self- and parental-report. Measures of safety were frequency of abnormalities in and need for support of cardiopulmonary function and other adverse effects.

Results.  During FR, K/M subjects (n = 130) had lower distress scores and parental ratings of pain and anxiety than did F/M subjects (n = 130). Although both regimens equally facilitated reductions, deep sedation, and procedural amnesia, orthopedists favored K/M. Recovery was 14 minutes longer for K/M. Fewer K/M subjects had hypoxia (6% vs 25%), needed breathing cues (1% vs 12%), or required oxygen (10% vs 20%) than did F/M subjects. Two K/M subjects required assisted ventilation briefly. More K/M subjects vomited. Adverse emergence reactions were rare but equivalent between regimens.

Conclusions.  During emergency pediatric orthopedic procedures, K/M is more effective than F/M for pain and anxiety relief. Respiratory complications occurred less frequently with K/M, but respiratory support may be needed with either regimen. Both regimens facilitate reduction, produce amnesia, and rarely cause emergence delirium. Vomiting is more frequent and recovery more prolonged with K/M.  Key words:  ketamine, fentanyl, midazolam, pediatric procedure sedation.




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