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PEDIATRICS Vol. 112 No. 1 July 2003, pp. 116-123

Comparison of Propofol/Fentanyl Versus Ketamine/Midazolam for Brief Orthopedic Procedural Sedation in a Pediatric Emergency Department

Sandip A. Godambe, MD, PhD*,§, Vanessa Elliot, PhD{ddagger}, Dana Matheny, RN* and Jay Pershad, MD*

* Division of Pediatric Emergency Medicine, LeBonheur Children’s Medical Center, Memphis, Tennessee
{ddagger} Child Development Center, Vanderbilt University, Nashville, Tennessee
§ Division of Pediatric Emergency Medicine, Kosair Children’s Hospital, Louisville, Kentucky

Purpose. To compare the effectiveness of 2 medication regimens, propofol/fentanyl (P/F) and ketamine/midazolam (K/M), for brief orthopedic emergency department procedural sedation. This study was powered to compare recovery times (RT) and procedural distress as measured by the Observational Score of Behavioral Distress-revised (OSBD-r; range: 0–23.5 with 23.5 representing maximal distress).

Methods. We conducted a prospective, partially-blinded controlled comparative trial comparing intravenous P/F with K/M in a convenience sample of 113 patients aged 3 to 18 years old undergoing orthopedic procedural sedation. All medications were administered by the intermittent intravenous bolus method. An independent sedation nurse recorded total sedation time and RT. Effectiveness was measured using 6 parameters: 1) patient distress as assessed by independent blinded observers after videotape review using the OSBD-r; 2) orthopedic satisfaction score (Likert scale 1–5); 3) sedation nurse satisfaction score (Likert 1–5); 4) parental perception of procedural pain using a 0 to 100 mm Visual Analog Scale with the upper limit being "most pain"; 5) patient recall of the procedure; and 6) 1 to 3 week follow-up.

Results. RT and total sedation time were significantly less in the P/F group than in the K/M group (33.4 minutes vs 23.2 minutes). The mean OSBD-r scores during manipulation were 0.084 and 0.278 for the K/M and P/F groups, respectively. Although this difference was statistically significant (95% confidence interval for the mean difference –0.34 to –0.048), both regimens were successful in keeping the scores low. There was no statistical difference between the groups in the other measures of effectiveness. There was a statistically significant difference between the groups in the occurrence of desaturation and late side effects.

Conclusions. RT with P/F is shorter than with K/M. P/F is comparable to K/M in reducing procedural distress associated with painful orthopedic procedures in the pediatric emergency department. Although propofol has a greater potential of respiratory depression and airway obstruction as compared with ketamine, it offers some unique advantages including a quicker offset and smoother recovery profile.

Key Words: propofol • fentanyl • ketamine • midazolam • procedural sedation

Abbreviations: PSA, procedural sedation and analgesia • P/F, propofol/fentanyl • K/M, ketamine/midazolam • RT, recovery time • OSBD-r, Observational Score of Behavioral Distress-revised • PED, pediatric emergency department • ED, emergency department • ASA, American Society of Anesthesia • TST, total sedation time • IV, intravenous • VAS, Visual Analog Scale • NPO, nil per os

Received for publication Jul 15, 2002; Accepted Feb 24, 2003.




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