title: Ketamine-midazolam versus meperidine-midazolam for painful procedures in pediatric oncology patients.
abstract: OBJECTIVE
  To compare the efficacy, characteristics of onset/recovery, and safety of ketamine/atropine/midazolam with meperidine/midazolam used as premedication for painful procedures in children with cancer.
  
  
  METHODS
  A randomized, double-blind crossover trial for two successive painful procedures (bone marrow aspiration or biopsy, lumbar puncture, or combined procedures) was performed at a referral-based pediatric hematology-oncology clinic and associated inpatient service of a university teaching hospital. Twenty-two children, aged 24 to 178 months, were enrolled and 18 (81.8%) completed the double-blind, crossover trial. Each child received intravenous premedication with either meperidine 2 mg/kg and midazolam 0.1 mg/kg (MM) or atropine 0.01 mg/kg, midazolam 0.05 mg/kg, and ketamine 1.5 mg/kg (KM) on one occasion followed by the alternative regimen on a second occasion. The initial premedication regimen was chosen by random assignment.
  
  
  RESULTS
  Efficacy was assessed by a trained observer using the Observational Scale of Behavioral Distress-Revised (OSBD-R). Operator, nurse, parent, and patient opinions of efficacy were recorded on a visual analog scale (VAS). Side effects were monitored by pulse oximetry, nasal end-tidal capnography, and serial blood pressure measurements. Use of KM resulted in significantly less procedural distress than MM (1.37 +/- 2.20 v 7.04 +/- 8.06 OSBD-R units; P < .05). Both operators and nurses rated KM more effective than MM. KM use was associated with earlier readiness for the procedure (19.2 v 24.0 minutes) and more rapid recovery (39.3 v 74.6 minutes for removal of monitoring devices and 58.5 v 87.1 minutes for discharge). Procedures undertaken after ketamine sedation were associated with fewer side effects than observed with MM sedation (hypoxia, 17.7% v 82.4%; hypotension, 16.6% v 55.6%; reduced respiratory rate, 0% v 38.9%). The incidence of emergence reactions or behavioral abnormalities within 24 hours postprocedure was similar in both treatment groups. At 7 days postprocedure, no child had persistent behavioral abnormalities and all children had amnesia for the procedure. Parents and children expressed a preference for KM over MM in 12 of 18 cases (P < .05).
  
  
  CONCLUSIONS
  A premedication regimen of KM produced superior sedation with a faster onset and recovery and fewer side effects than a MM combination.
authors.affiliation: Department of Pediatrics, Case Western Reserve University, School of Medicine, Cleveland, OH, USA.
authors.forename: C M
authors.initials: CM
authors.lastname: Marx
authors.forename: J
authors.initials: J
authors.lastname: Stein
authors.forename: M K
authors.initials: MK
authors.lastname: Tyler
authors.forename: M L
authors.initials: ML
authors.lastname: Nieder
authors.forename: S B
authors.initials: SB
authors.lastname: Shurin
authors.forename: J L
authors.initials: JL
authors.lastname: Blumer
mesh_terms: D000777:Anesthetics; D001706:Biopsy; D001856:Bone Marrow Examination; D002648:Child; D002652:Child Behavior / Q000187:drug effects; D002675:Child, Preschool; D018592:Cross-Over Studies; D004311:Double-Blind Method; D005260:Female; D006801:Humans; D006993:Hypnotics and Sedatives; D007649:Ketamine; D008297:Male; D008614:Meperidine; D008874:Midazolam; D013129:Spinal Puncture
chemical_list: D000777:Anesthetics; D006993:Hypnotics and Sedatives; D007649:Ketamine; D008614:Meperidine; D008874:Midazolam