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Sedation for pediatric procedures, using ketamine and midazolam, in a primarily adult intensive care unit: A retrospective evaluation

Slonim, Anthony D. MD; Ognibene, Frederick P. MD, FCCM

Pediatric Critical Care

Objective To evaluate the effectiveness and safety of pediatric procedures performed by adult critical care practitioners, using the combination of ketamine and midazolam for anesthesia and sedation.

Design A retrospective case series.

Setting The intensive care unit (ICU) of a 325-bed tertiary research hospital.

Patients Individuals from 1 to 18 yrs of age who had intravenous midazolam sedation and ketamine anesthesia administered while undergoing lumbar puncture, bone biopsy, central venous catheter placement, liver biopsy, thoracentesis, or bone marrow aspirate/biopsy.

Interventions None.

Measurements and Main Results A retrospective chart review was performed. The dosages of medications used were tabulated, and milligram per kilogram dosages were calculated. The procedures performed, their durations, and any complications of the anesthesia and sedation were noted. These complications included: oxygen desaturations <90%, vital sign alterations requiring intervention, rashes, subjective complaints of dizziness by the patient, and emergence reactions to ketamine.

A total of 127 pediatric patients were admitted to the ICU sedation area for a total of 295 procedures.All patients received ketamine and midazolam intravenously in divided doses and titrated to effect. A total of nine complications were observed. These complications included oxygen desaturation <90% (n = 1), vital sign alterations requiring treatment (n = 3), rash (n = 2), dizziness (n = 1), wheezing (n = 1), and emergence reaction (n = 1). No patient required admission to the ICU because of a complication. There were no episodes of bradycardia or other cardiopulmonary compromise.

Conclusions Pediatric anesthesia and sedation, using ketamine and midazolam, can be performed in a designated monitored setting, outside of the operating room, by experienced personnel, including nonpediatricians. This therapeutic combination allows painful procedures to be performed with less anxiety and discomfort. In experienced hands, a limited number of side effects occur. (Crit Care Med 1998; 26:1900-1904)

From the Critical Care Medicine Department, Warren G. Magnuson Clinical Center, National Institutes of Health, Bethesda, MD.

Address requests for reprints to: Frederick P. Ognibene, MD, National Institutes of Health, Warren G. Magnuson Clinical Center, Critical Care Medicine Department, Building 10, Room 7D43, 10 Center Drive MSC 1662, Bethesda, MD 20892-1662. E-mail:

© Williams & Wilkins 1998. All Rights Reserved.