title: Procedural sedation and analgesia outcomes in children after discharge from the emergency department: ketamine versus fentanyl/midazolam.
abstract: OBJECTIVE
  Although the safety and efficacy of procedural sedation and analgesia in the pediatric emergency department (ED) has been established, the prevalence of adverse events after discharge has not been well studied. We compare the postdischarge incidence of adverse behavioral events and vomiting and hypothesize that ketamine would be associated with increased adverse behaviors.
  
  
  METHODS
  We conducted a prospective observational study of postdischarge behavioral changes and vomiting after sedation with ketamine, ketamine/midazolam, or fentanyl/midazolam. Families were administered a Post Hospital Behavior Questionnaire (PHBQ), with higher scores indicating more adverse behaviors (anxiety, sleep disturbances). We used linear and logistic regression to model PHBQ scores and logistic regression to model vomiting risk adjusting for age, sex, procedure, length of procedure, and parental presence as potential confounders.
  
  
  RESULTS
  Seven hundred eighty-six children were enrolled and 554 children (61% boys; mean age 7.5+/-4.5 years) were contacted. The prevalence of postdischarge vomiting was 18%, but the prevalence of adverse behavioral changes was low. When adjusted for potential confounders, the odds of a higher PHBQ score increased among patients receiving fentanyl/midazolam (fentanyl/midazolam odds ratio [OR] 2.6, 95% confidence interval [CI] 1.08 to 6.03, P=.03; ketamine OR 1.7, 95% CI 0.84 to 3.57; ketamine/midazolam OR 0.5, 95% CI 0.26 to 1.07).
  
  
  CONCLUSIONS
  Procedural sedation and analgesia in the ED is well tolerated. Though postdischarge vomiting occurs with some frequency, there is a low prevalence of adverse behavioral events after discharge. The use of fentanyl/midazolam was associated with higher adverse behavioral scores.
authors.affiliation: Section of Pediatric Emergency Medicine, The University of Chicago, Chicago, IL, USA. lisa.mcqueen@gmail.com
authors.forename: Alisa
authors.initials: A
authors.lastname: McQueen
authors.forename: Robert O
authors.initials: RO
authors.lastname: Wright
authors.forename: Maya M
authors.initials: MM
authors.lastname: Kido
authors.forename: Erica
authors.initials: E
authors.lastname: Kaye
authors.forename: Baruch
authors.initials: B
authors.lastname: Krauss
mesh_terms: D000759:Adjuvants, Anesthesia / Q000008:administration & dosage* / Q000009:adverse effects; D000778:Anesthetics, Dissociative / Q000008:administration & dosage* / Q000009:adverse effects; D002648:Child; D002653:Child Behavior Disorders / Q000139:chemically induced*; D004636:Emergency Service, Hospital; D005260:Female; D005283:Fentanyl / Q000008:administration & dosage* / Q000009:adverse effects; D006801:Humans; D007649:Ketamine / Q000008:administration & dosage* / Q000009:adverse effects; D016015:Logistic Models; D008297:Male; D008874:Midazolam / Q000008:administration & dosage* / Q000009:adverse effects; D019370:Observation; D017063:Outcome Assessment, Health Care; D015995:Prevalence; D011446:Prospective Studies; D012044:Regression Analysis; D011795:Surveys and Questionnaires; D014839:Vomiting / Q000139:chemically induced* / Q000453:epidemiology
chemical_list: D000759:Adjuvants, Anesthesia; D000778:Anesthetics, Dissociative; D007649:Ketamine; D008874:Midazolam; D005283:Fentanyl