title: Ketamine/midazolam versus etomidate/fentanyl: procedural sedation for pediatric orthopedic reductions.
abstract: BACKGROUND
  Orthopedic reductions are commonly performed procedures requiring sedation in the pediatric emergency department (PED). Ketamine is a widely used agent for pediatric procedural sedation, but its use may present difficulties in select populations, such as those with psychiatric diagnoses. In such a case, alternative agents that are safe and effective are needed. Etomidate is a commonly used induction agent for rapid-sequence intubation in the PED. Several retrospective and few prospective studies support etomidate's safety and efficacy in pediatric procedural sedation.
  
  
  OBJECTIVE
  The objective was to compare etomidate/fentanyl (E/F) with ketamine/midazolam (K/M) for procedural sedation during orthopedic reductions in the PED.
  
  
  METHODS
  Prospective, partially blinded, randomized controlled study comparing intravenously administered K/M with intravenously administered E/F. A convenience sample of patients, aged 5 to 18 years, presenting to an urban PED with fracture requiring reduction was enrolled. Outcome measures included guardian and staff completion of visual analog scale and Likert scales for observed pain and satisfaction, blinded OSBD-r (Observational Scale of Behavioral Distress-Revised) scoring of digital recordings of reductions, and sedation and recovery times. Descriptive tracking of adverse effects, adverse events, and interventions were recorded at the sedation.
  
  
  RESULTS
  Twenty-three patients were enrolled, 11 in the K/M group and 12 in the E/F group. The K/M group had significantly lower mean OSBD-r scores compared with the E/F group (0.08 vs 0.89, P = 0.001). Parents rated lower visual analog scale scores with K/M than with E/F (13.7 vs 50.5, P = 0.003) and favored K/M on a 5-point satisfaction scale (P = 0.004). The E/F group had significantly shorter total sedation times (49.6 vs 77.6 minutes, P = 0.003) and recovery times (24.7 vs 61.4 minutes, P = 0.000). There were no significant differences with respect to procedural amnesia and orthopedic practitioner satisfaction. Adverse effects noted in the K/M group included dysphoric emergence reaction and vomiting. Vomiting, injection-site pain, myoclonus, airway readjustment, and supplemental oxygen use were observed in the E/F group.
  
  
  CONCLUSIONS
  This is a small study that strongly suggests that, for pediatric orthopedic reductions, K/M is more effective at reducing observed distress than E/F, although both provide equal procedural amnesia. With its significantly shorter sedation and recovery times, E/F may be more applicable for procedural sedation for shorter, simpler procedures in the PED.
authors.affiliation: Department of Pediatrics, Kapiolani Medical Center for Women and Children, Honolulu, HI, USA. jalee@rchsd.org
authors.forename: Jannet J
authors.initials: JJ
authors.lastname: Lee-Jayaram
authors.forename: Adam
authors.initials: A
authors.lastname: Green
authors.forename: Joshua
authors.initials: J
authors.lastname: Siembieda
authors.forename: Edward J
authors.initials: EJ
authors.lastname: Gracely
authors.forename: Colette C
authors.initials: CC
authors.lastname: Mull
authors.forename: Eileen
authors.initials: E
authors.lastname: Quintana
authors.forename: Terry
authors.initials: T
authors.lastname: Adirim
mesh_terms: D000293:Adolescent; D000778:Anesthetics, Dissociative / Q000008:administration & dosage*; D002648:Child; D002675:Child, Preschool; D016292:Procedural Sedation / Q000379:methods*; D005045:Etomidate / Q000008:administration & dosage*; D005260:Female; D005283:Fentanyl / Q000008:administration & dosage*; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage*; D007649:Ketamine / Q000008:administration & dosage*; D008297:Male; D008874:Midazolam / Q000008:administration & dosage*; D009294:Narcotics / Q000008:administration & dosage*; D019637:Orthopedic Procedures; D010147:Pain Measurement; D011446:Prospective Studies; D018709:Statistics, Nonparametric
chemical_list: D000778:Anesthetics, Dissociative; D006993:Hypnotics and Sedatives; D009294:Narcotics; D007649:Ketamine; D008874:Midazolam; D005283:Fentanyl; D005045:Etomidate