A combination of midazolam and ketamine for procedural sedation and analgesia in adult emergency department patients

Objective: To describe the clinical characteristics of a combination of mid azolam and ketamine for procedural sedation and analgesia in adult emergenc y department (ED) patients. Methods: This was a prospective, observational trial, conducted in the ED of an urban level II trauma center. Patients gre ater than or equal to 18 years of age requiring procedural sedation and ana lgesia were eligible, and enrolled patients received 0.07 mg/kg of intraven ous midazolam followed by 2 mg/kg of intravenous ketamine. Vital signs were recorded at regular intervals. The adequacy of sedation, adverse effects, patient satisfaction, and time to reach discharge alertness were determined . Descriptive statistics were calculated using statistical analysis softwar e. Results: Seventy-seven patients were enrolled. Three were excluded due t o protocol violations, three due to lack of documentation, and one due to s ubcutaneous infiltration of ketamine, leaving 70 patients for analysis. The average age was 31 years, and 41 (59%) were female. Indications for proced ural sedation and analgesia included abscess incision and drainage (66%), f racture/joint reduction (26%), and other (8%). The mean dose of midazolam w as 5.6 +/- 1.4 mg and the mean dose of ketamine was 159 +/- 42 mg. The mean time to achieve discharge criteria was 64 +/- 24 minutes. Five patients ex perienced mild emergence reactions, but there were no episodes of hallucina tions, delirium, or other serious emergence reactions. Eighteen (25%) patie nts recalled dreaming while sedated; twelve (17%) were described as pleasan t, two (3%) unpleasant, three (4%) both pleasant and unpleasant, and one (1 %) neither pleasant nor unpleasant. There were four (6%) cases of respirato ry compromise, two (3%) episodes of emesis, and one (1% )case of myoclonia. All of these were transient and did not result in a change in the patient' s disposition. Only one (1%) patient indicated that she was not satisfied w ith the sedation regimen. Conclusions: The combination of midazolam and ket amine provides effective procedural sedation and analgesia in adult ED pati ents, and appears to be safe.