Comparison of fentanyl/midazolam with ketamine/midazolam for pediatric orthopedic emergencies.
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.


METHODS
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.
Department of Pediatrics, Washington University School of Medicine, St Louis Children's Hospital, St Louis, Missouri, USA.
R M
RM
Kennedy
F L
FL
Porter
J P
JP
Miller
D M
DM
Jaffe
D000293:Adolescent; D000701:Analgesics, Opioid / Q000009:adverse effects / Q000627:therapeutic use*; D000778:Anesthetics, Dissociative / Q000009:adverse effects / Q000627:therapeutic use*; D014151:Anti-Anxiety Agents / Q000627:therapeutic use; D001007:Anxiety / Q000188:drug therapy; D002648:Child; D002675:Child, Preschool; D004338:Drug Combinations; D004638:Emergency Treatment; D005260:Female; D005283:Fentanyl / Q000009:adverse effects / Q000627:therapeutic use*; D050723:Fractures, Bone / Q000628:therapy; D006801:Humans; D004204:Joint Dislocations / Q000628:therapy; D007649:Ketamine / Q000009:adverse effects / Q000627:therapeutic use*; D008297:Male; D008874:Midazolam / Q000627:therapeutic use; D010146:Pain / Q000188:drug therapy*; D012119:Respiration / Q000187:drug effects; D016896:Treatment Outcome
D000701:Analgesics, Opioid; D000778:Anesthetics, Dissociative; D014151:Anti-Anxiety Agents; D004338:Drug Combinations; D007649:Ketamine; D008874:Midazolam; D005283:Fentanyl