Journal of Clinical Oncology, Vol 15, 94-102, Copyright © 1997 by American Society of Clinical Oncology
Ketamine-midazolam versus meperidine-midazolam for painful procedures in pediatric oncology patients
CM Marx, J Stein, MK Tyler, ML Nieder, SB Shurin and JL Blumer
Department of Pediatrics, Case Western Reserve University, School of Medicine, Cleveland, OH, USA.
PURPOSE: To compare the efficacy, characteristics of onset/recovery, and
safety of ketamine/atropine/midazolam with meperidine/midazolam used as
premedication for painful procedures in children with cancer. METHODS: A
randomized, double-blind crossover trial for two successive painful
procedures (bone marrow aspiration or biopsy, lumbar puncture, or combined
procedures) was performed at a referral-based pediatric hematology-oncology
clinic and associated inpatient service of a university teaching hospital.
Twenty-two children, aged 24 to 178 months, were enrolled and 18 (81.8%)
completed the double-blind, crossover trial. Each child received
intravenous premedication with either meperidine 2 mg/kg and midazolam 0.1
mg/kg (MM) or atropine 0.01 mg/kg, midazolam 0.05 mg/kg, and ketamine 1.5
mg/kg (KM) on one occasion followed by the alternative regimen on a second
occasion. The initial premedication regimen was chosen by random
assignment. RESULTS: Efficacy was assessed by a trained observer using the
Observational Scale of Behavioral Distress-Revised (OSBD-R). Operator,
nurse, parent, and patient opinions of efficacy were recorded on a visual
analog scale (VAS). Side effects were monitored by pulse oximetry, nasal
end-tidal capnography, and serial blood pressure measurements. Use of KM
resulted in significantly less procedural distress than MM (1.37 +/- 2.20 v
7.04 +/- 8.06 OSBD-R units; P < .05). Both operators and nurses rated KM
more effective than MM. KM use was associated with earlier readiness for
the procedure (19.2 v 24.0 minutes) and more rapid recovery (39.3 v 74.6
minutes for removal of monitoring devices and 58.5 v 87.1 minutes for
discharge). Procedures undertaken after ketamine sedation were associated
with fewer side effects than observed with MM sedation (hypoxia, 17.7% v
82.4%; hypotension, 16.6% v 55.6%; reduced respiratory rate, 0% v 38.9%).
The incidence of emergence reactions or behavioral abnormalities within 24
hours postprocedure was similar in both treatment groups. At 7 days
postprocedure, no child had persistent behavioral abnormalities and all
children had amnesia for the procedure. Parents and children expressed a
preference for KM over MM in 12 of 18 cases (P < .05). CONCLUSION: A
premedication regimen of KM produced superior sedation with a faster onset
and recovery and fewer side effects than a MM combination.
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