This is completely anecdotal too, but I have had exactly the same experience as Dr. Brown.
I've been using ketamine and versed together since I was a resident in 1998,
and have always had great success (and have never had a significant complication to date; I like to think it's because I start with less than 1 mg/kg of ketamine and slowly titrate upwards to effect).
After reading the paper by Wathen et al. (referenced below), I briefly stopped using versed and literally had my first emergence reaction that very week
(in a teenager to whom I gave ketamine alone without versed).
So I went back to starting with a small dose of versed (usually just under 0.1 mg/kg, rounding down) and have never had another emergence reaction
(and I also use ketamine with versed nearly every shift).
In fact, I have found this combination to be so effective, brief, and uncomplicated that I am not really that excited that we are about to start using propofol.
Peter Auerbach, MD, FAAEM, FAAP
Inova Fairfax Hospital for Children
Falls Church, VA
> Date: Thu, 31 Jan 2008 10:43:18 -0800> From: [log in to unmask]> Subject: Re: pediatric sedation> To: [log in to unmask]> > My anecdotal experience is similar to David Smith's. At our institution,> we routinely use midazolam with Ketamine. We don't use ondansetron. I> perform a Ketamine sedation nearly every shift. Over 10 years, I can> only remember one child who vomited prior to discharge. There may have> been more, but it is certainly rare. This is much lower than what is> reported in the literature, and I'm inclined to believe the midazolam is> making the difference.> > Julie> > Julie Brown, MD, MPH> Assistant Professor, Pediatric Emergency Medicine> Mailstop B5520> Children's Hospital and Regional Medical Center> Seattle, Washington, USA> > I understand the issue of emesis with ketamine but why treat it with benzo and > not a antiemetic like Zofran prior to the procedure? If you premedicate with > zofran you might find you do not have the RN puke scale or the longer stay or > increased risk for desaturation. As for the emergence reaction it tends to be > far less common in younger children and more common in females. Sherwin et al > in Ann Emerg Med. 2000 Wathen et al Ann emerg med 2000 both showed no difference > in emergence reaction with versed. A trick taught to me during my years in KC > was a bit of simple guided imagery prior to sedation. I'm not usually the > touchy feely type but asking kids what they want to dream about and telling them > to start thinking about it just takes seconds and seems to work well. > Additionally letting the parents know that they will have vivid dreams as they > awake and to talk to them about things they like and enjoy helps.
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