Optimal Dosing of Ketamine for Procedural Sedation and Analgesia in Children

Study Overview
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Brief Summary
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There is a wide variation of published IV ketamine dosing regimens used for procedural sedation in children in the Emergency Department (ED). The purpose of the study was to compare the efficacy, duration of sedation and adverse events between the three commonly administered doses of IV ketamine (1 mg/kg, 1.5 mg/kg and 2 mg/kg) using the traditional administration method of 30-60 second infusion for ED sedation in children.

Detailed Description
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This was a prospective, double-blind, randomized controlled trial of children aged 3 to 18 years who received IV ketamine for procedural sedation and analgesia (PSA) for orthopedic procedures, incision and drainage (I & D) of skin abscess and laceration repair in an inner city, tertiary care pediatric ED. Random sequence allocation was performed using a computer-generated, random number table by the study research pharmacist. The study participants were grouped according to their age as follows (1) 3-6 years (2) 7-12 years (3) 13-18 years. Children from each age group were assigned in equal numbers to all three ketamine dosing (1 mg/kg, 1.5 mg/kg and 2 mg/kg) groups using random permuted blocks stratified by the pharmacist. All ED staff including the physician and the nurse in charge of sedation, the study research assistant, the parents/guardians and the study subjects were blinded to the randomization and the group assignments. The dosage and administration of additional doses of ketamine were left to the discretion of the ED physician in charge of the sedation. The research team did not participate in the clinical care including sedation of the patient. Children were monitored per ED policy for the entire duration of sedation. Three 1 ml blood samples for the ketamine assay was collected from the existing intravenous access at three time intervals: 3-5 minutes after ketamine administration, at midpoint during the procedure and prior to discharge of the patient from the ED. In the event a second dose of ketamine was administered, a 4th 1 ml sample was collected 3-5 minutes after the 2nd dose in children weighing >20 kilograms. Patient demographics, procedure type, NPO status , ASA classification, pain medication administered prior to sedation (timing, dosage and type), number and total doses of ketamine administered after the initial study dose, sedation efficacy and duration, length of procedure, adverse events related to sedation, interventions performed to address the adverse events and patient disposition were collected. The study research assistant also performed a follow up phone call to the parents/caregivers of the children 48 hours after ED discharge to collect information on adverse events that happened at home . A total of 3 attempts were made to contact the parent/caregiver after which the participant was considered as lost to followup.

Official Title
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Optimal Dosing of Ketamine for Procedural Sedation and Analgesia in Children

Conditions
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Moderate, Deep Sedation

Intervention / Treatment
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* Drug: Ketamine IV 1mg/kg
* Drug: Ketamine IV 1.5mg/kg
* Drug: Ketamine IV 2mg/kg


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Children 3 -18 years of age Belonging to American Society of Anesthesiologists (ASA) classification 1 or 2 Receiving IV ketamine for procedural sedation for orthopedic procedures, Incision and Drainage of skin abscess and laceration repair Exclusion Criteria: Contraindications to use of Ketamine Parents or legal guardian not available or declined to provide informed consent Child declined to provide assent, Patients that received intramuscular ketamine, Patient that received benzodiazepines in addition to ketamine Children weighing >100 kilogram Children with developmental disabilities.

Ages Eligible for Study
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Minimum Age: 3 Years
Maximum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Quadruple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: ketamine IV 1 mg/kg<br>Intervention: A blinded dose of 1mg/kg IV ketamine is administered to patients | Drug: Ketamine IV 1mg/kg<br>* Intervention: Ketamine IV 1mg/kg<br>|
| Experimental: Ketamine IV 1.5 mg/kg<br>Intervention: A blinded dose of 1.5mg/kg IV ketamine is administered to patients | Drug: Ketamine IV 1.5mg/kg<br>* Intervention: Ketamine IV 1.5 mg/kg<br>|
| Experimental: Ketamine IV 2 mg/kg<br>Intervention: A blinded dose of 2 mg/kg IV ketamine is administered to patients | Drug: Ketamine IV 2mg/kg<br>* Intervention: Ketamine IV 2 mg/kg<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Sedation Efficacy | Measure sedation depth using Ramsay Sedation Scale. Varies from 1-6 with 1: anxious, agitated, restless 2: Cooperative, oriented, tranquil 3: responsive to commands 4: Brisk response to light glabellar tap or auditory stimulus 5: Sluggish response to light glabellar tap or loud auditory stimulus 6 being no response to light glabellar tap or loud auditory stimulus. Higher the score, greater is the depth of sedation. Use of ketamine usually provides a depth of sedation of 5 or 6. | Participants will be assessed after study drug adminsitration and the maximum depth of sedation achieved recorded. Approximately 2 hours | 
| Pain | Measure pain using self reported Wong Baker faces pain rating scale prior to sedation, during sedation and prior to discharge.The scale shows a series of faces ranging from a happy face at 0, No hurt to a crying face at 10 Hurts worst. The patient must choose the face that best describes how they are feeling. The score has values of 0(no hurt), 2(hurts little bit), 4(hurts little more), 6(hurts even more), 8(hurts whole lot),10 (hurts worst). The patient chooses one number that describes the pain best (eg. Either a 2 or 4). | Patients will be assessed during the procedure after administration of sedation medicaiton. Approximately 30 minutes | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Sedation Duration | Length of sedation was defined as the time duration from the administration of study medication until ready for discharge using standardized discharge criteria (Aldrete scoring >9) followed at our institution. | Patients will be assessed during the length of time from administration of sedation medication until ready for discharge, Approximately 3 hours | 
| Additional Dose | Number of participants to whom additional doses of ketamine administered apart from the study dose | Patients will be assessed during procedure . Approximately 1 hours | 
| Adverse Events | Adverse events secondary to sedation experienced by the patient and interventions performed to overcome them | Patients will be assessed after administration of medication until discharge and will have a follow up phone call 48 hours after discharge for 3 attempts. 5 days., | 
| Sedation Satisfaction | Consultants will be asked to rate their level of satisfaction with sedation on a Likert Scale of 1-3 | At the end of the procedure. Approximately 1 hour | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Procedural sedation, ketamine, children