British Journal of Anaesthesia, Vol 84, Issue 3 335-340, Copyright © 2000 by Oxford University Press
W Funk, W Jakob, T Riedl and K Taeger
Anxiolysis and sedation with oral midazolam are common practice in
paediatric anaesthesia. However, good or excellent results are seen in only
50-80% of cases. For this reason, we investigated if addition of a low dose
of oral ketamine (MIKE: ketamine 3 mg kg-1, midazolam 0.5 mg kg-1) resulted
in better premedication compared with oral midazolam 0.5 mg kg-1 or
ketamine 6 mg kg-1 alone, in a prospective, randomized, double-blind study.
We studied 120 children (mean age 5.7 (range 2-10) yr) undergoing surgery
of more than 30 min duration. After oral premedication in the ward and
transfer, the child's condition in the induction room was evaluated by
assigning 1-4 points to the quality of anxiolysis, sedation, behaviour at
separation from parent and during venepuncture (transfer score). On days 1
and 7 after operation, parents were interviewed for changes in behaviour
(eating, sleep, dreams, toilet training), recollection and satisfaction,
using a standardized questionnaire. The groups were similar in age, sex,
weight, intervention and duration of anaesthesia. The transfer score was
significantly better in the MIKE group (12.5 (95% confidence interval (CI)
11.9-13.1)) than in the ketamine or midazolam groups (10.6 (9.8- 11.4) and
11.5 (10.7-12.3), respectively). Success rates for anxiolysis and behaviour
at separation were greater than 90% with the combination, approximately 70%
with midazolam and only 51% with ketamine alone. The incidence of
salivation, excitation and psychotic symptoms was low in all groups.
Vertigo and emesis before induction were significantly more frequent after
ketamine premedication. During recovery, there were no differences in
sedation or time of possible discharge. After 1 week, parents reported
nightmares (ketamine five, midazolam three, MIKE one), restless sleep
(five/four/four) or negative memories (three/four/one). There were no major
or continuing disturbances in behaviour or development. In summary,
significantly better anxiolysis and separation were observed with a
combination of ketamine and midazolam, even in awake children (sedation was
not successful according to the preset criteria), than with midazolam or
ketamine alone. Duration of action and side effects of the combination were
similar to those of midazolam. The combination of both drugs in strawberry
flavoured glucose syrup (pH 4.5 approximately) is chemically stable for 8
weeks.
ARTICLES
Oral preanaesthetic medication for children: double-blind randomized study of a combination of midazolam and ketamine vs midazolam or ketamine alone
Department of Anaesthesiology, University of Regensburg, Germany.
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