Efficacy and Safety of Low-Dose Midazolam and Ketamine for Sedation

Procedural sedoanalgesia is given to Children undergoing invasive procedures to reduce anxiety and fear. Cost-effective sedation will help Non-anesthesiologists (trained in pediatric advanced life support) provide care outside the operating room. A recent study assessed the efficacy and safety of administering a low dose of the midazolam-ketamine combination during invasive procedures conducted outside the operating room.

The study enrolled 165 children aged 1 to 17 years scheduled for diagnostic lumbar puncture, intrathecal chemotherapy, and bone marrow procedures to receive ketamine (0.5 mg/kg) and midazolam (0.05 mg/kg). It used the Modified Ramsay score to evaluate Sedation levels. A score of 5 or 6 directed starting the procedure, while a score of 1 or 2 after 3 min demanded a second dose of both drugs and a score of 3 or 4 demanded administration of either of one drug. No sedation after three aliquots of both drugs indicated treatment failure.

The study observed-

• The mean time to sedation= 2.3 ± 1.8 min
• The recovery time = 1.6 ± 0.53 hours. 
• The success rate was 99.4%, with 66.1% requiring one aliquot, 32.15% requiring two aliquots, and 1.2% needing a third. 
• Success rate with 1st aliquot= 44.4% in undernourished children, as compared to 72.1% in other children.
• Adverse effects were minimal, with 84.8% having no issues. 
• Only 12% had Vomiting, 3% had headaches, and  3% had fever.
• Oxygen support was required in one child.

Therefore, administering low-dose midazolam and ketamine for sedoanalgesia in critical care settings beyond the operating room is both safe and effective. Opting for repeated aliquots tailored to individual responses, rather than a single dose, serves to mitigate potential adverse effects.

Sethupathy A, Gunasekaran V, Chelliah S. et al. Efficacy and Safety of Low Dose Midazolam and Ketamine for Sedation During Invasive Procedures in Pediatric Hemato-Oncology. Indian J Pediatr. 2024. https://doi.org/10.1007/s12098-024-05128-8