Midazolam plus Ketamine

Adding Midazolam to Ketamine for Procedural Sedation Reduces Emergence Reactions in Adults

Coadministration significantly reduced incidence of emergence reactions, and route of ketamine administration had no effect on incidence of adverse events.

Ketamine is associated with untoward emergence reactions after procedural sedation, including nightmares and hallucinations. Coadministration of midazolam to mitigate this reaction is ineffective in children. Researchers assessed the effect of midazolam on incidence of ketamine emergence reactions and the effect of route of ketamine administration on incidence of adverse events in adult patients undergoing procedural sedation. In a prospective, double-blind, placebo-controlled study, 182 patients (age range, 18–50) at an academic emergency department in Turkey were randomized to receive ketamine either intravenously (1.5 mg/kg) or intramuscularly (4.0 mg/kg), either with or without intravenous midazolam (0.03 mg/kg).

Recovery agitation occurred significantly less frequently when midazolam was coadministered with ketamine (8% vs. 25%). Incidence of adverse events (recovery agitation, respiratory events, nausea and vomiting) was similar with the two routes of ketamine administration; no patient had respiratory compromise.

Comment: Coadministration of midazolam with ketamine in adults seems to mitigate emergence reactions with no significant downside.

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Richard D. Zane, MD, FAAEM

Published in Journal Watch Emergency Medicine April 8, 2011

CITATION(S): Sener S et al. Ketamine with and without midazolam for emergency department sedation in adults: A randomized controlled trial. Ann Emerg Med 2011 Feb; 57:109.e2.