Title	The Reduction Of The Adverse Effects Of Ketamine When Combined With Midazolam During Anesthesia
Clinical Question	In the anesthetized patient, does the combination of ketamine (Ketalar) with midazolam (Versed) reduce the adverse effects (hallucinations) produced by ketamine when it is used alone?
Clinical Bottom Line	The combination of ketamine and midazolam reduces the adverse effects produced by ketamine when it is used alone.
Best Evidence
PubMed ID Author / Year Patient Group Study type (level of evidence) 20970888 Sener/2011 182 adult emergency department patients; 18-50 years old Randomized double blind trial Key results Less recovery agitation was shown in patients receiving midazolam (8% versus 25%; difference 17%; 95% confidence interval. When a comparison of IV versus IM routes was done, the occurrence of adverse events was comparable (recovery agitation 13% versus 17%, difference 4%, 95% CI -8% to 16%; respiratory events 0% versus 0%, difference 0%, 95% CI -2% to 2%; nausea/vomiting 28% versus 34%, difference 6%, 95% CI -8% to 20%). 19029562 Dilli/2008 99 children (59 boys, 40 girls), 2-14 years, all receiving lumbar punctures Randomized Controlled Trial Key results Nightmares and crying episodes occurred more often in the Intravenous ketamine group, as compared to the intravenous ketamine+ midazolam group (P=0.04). 19091264 Strayer/2008 Adults receiving ketamine sedation Systematic Review Key results 10-20% of the studies done showed emergence phenomena as an effect of ketamine sedation.
Evidence Search	"Ketamine"[Mesh] AND "Midazolam"[Mesh]
Comments on The Evidence	For the article by Sener, the study design was a randomized, double-blind trial, where the groups were similar at the start, and the groups were treated the same. The article does not mention whether there was a greater than 80 percent completion rate, or whether there was adequate follow-up. Compliance was adequate, recall bias is unlikely, and there were no competing interests. For the article by Dilli, the study design was a randomized controlled trial and the groups were similar at the start. The article does not mention whether there was a greater than 80 percent completion rate or not, whether there was adequate follow-up, or whether there was adequate compliance. The groups were treated the same, and it was not a double-blind trial. There were no competing interests, and recall bias is unlikely. The article by Strayer was a systematic review. A comprehensive search was done for appropriate trials. The article does not mention whether each research study was evaluated for validity, or whether a meta-analysis was completed.
Applicability	In general, patients (similar to the ones in these studies) present to dental offices (including the those of the oral surgeon or pediatric dentist) with special anesthetic needs. Knowledge of the adverse effects of ketamine as an anesthetic, as compared to its effects when combined with midazolam would be beneficial when considering anesthetic agents for patients during dental treatment.
Specialty	(General Dentistry) (Oral Surgery) (Pediatric Dentistry)
Keywords	Ketamine, Midazolam, Ketalar, Versed, adverse effects
ID#	2287
Date of submission	04/19/2012
E-mail	Shariff@livemail.uthscsa.edu
Author	Salimah Shariff
Co-author(s)
Co-author(s) e-mail
Faculty mentor	Jack Vizuete, DDS
Faculty mentor e-mail	VizueteJ@uthscsa.edu
Basic Science Rationale (Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?) None available
Comments and Evidence-Based Updates on the CAT (FOR PRACTICING DENTISTS', FACULTY, RESIDENTS and/or STUDENTS COMMENTS ON PUBLISHED CATs) None available