Predictors of emesis and recovery agitation with emergency department ketamine sedation: an individual-patient data meta-analysis of 8,282 children.
OBJECTIVE
Ketamine is widely used in emergency departments (EDs) to facilitate painful procedures; however, existing descriptors of predictors of emesis and recovery agitation are derived from relatively small studies.


METHODS
We pooled individual-patient data from 32 ED studies and performed multiple logistic regression to determine which clinical variables would predict emesis and recovery agitation. The first phase of this study similarly identified predictors of airway and respiratory adverse events.


RESULTS
In 8,282 pediatric ketamine sedations, the overall incidence of emesis, any recovery agitation, and clinically important recovery agitation was 8.4%, 7.6%, and 1.4%, respectively. The most important independent predictors of emesis are unusually high intravenous (IV) dose (initial dose of > or =2.5 mg/kg or a total dose of > or =5.0 mg/kg), intramuscular (IM) route, and increasing age (peak at 12 years). Similar risk factors for any recovery agitation are low IM dose (<3.0 mg/kg) and unusually high IV dose, with no such important risk factors for clinically important recovery agitation.


CONCLUSIONS
Early adolescence is the peak age for ketamine-associated emesis, and its rate is higher with IM administration and with unusually high IV doses. Recovery agitation is not age related to a clinically important degree. When we interpreted it in conjunction with the separate airway adverse event phase of this analysis, we found no apparent clinically important benefit or harm from coadministered anticholinergics and benzodiazepines and no increase in adverse events with either oropharyngeal procedures or the presence of substantial underlying illness. These and other results herein challenge many widely held views about ED ketamine administration.
Green
Steven M
SM
Department of Emergency Medicine, Loma Linda University Medical Center and Children's Hospital, Loma Linda, CA.
Roback
Mark G
MG
Krauss
Baruch
B
Brown
Lance
L
McGlone
Ray G
RG
Agrawal
Dewesh
D
McKee
Michele
M
Weiss
Markus
M
Pitetti
Raymond D
RD
Hostetler
Mark A
MA
Wathen
Joe E
JE
Treston
Greg
G
Garcia Pena
Barbara M
BM
Gerber
Andreas C
AC
Losek
Joseph D
JD
D000367:Age Factors; D000762:Anesthesia Recovery Period; D000778:Anesthetics, Dissociative / Q000008:administration & dosage / Q000009:adverse effects*; D001569:Benzodiazepines / Q000008:administration & dosage; D002648:Child; D002675:Child, Preschool; D018680:Cholinergic Antagonists / Q000008:administration & dosage; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D007223:Infant; D007273:Injections, Intramuscular; D007275:Injections, Intravenous; D007649:Ketamine / Q000008:administration & dosage / Q000009:adverse effects*; D008297:Male; D011595:Psychomotor Agitation / Q000209:etiology*; D012307:Risk Factors; D014839:Vomiting / Q000139:chemically induced*
D000778:Anesthetics, Dissociative; D018680:Cholinergic Antagonists; D001569:Benzodiazepines; D007649:Ketamine