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)
20970888Sener/2011182 adult emergency department patients; 18-50 years oldRandomized double blind trial
Key resultsLess 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%).
19029562Dilli/200899 children (59 boys, 40 girls), 2-14 years, all receiving lumbar puncturesRandomized Controlled Trial
Key resultsNightmares and crying episodes occurred more often in the Intravenous ketamine group, as compared to the intravenous ketamine+ midazolam group (P=0.04).
19091264Strayer/2008 Adults receiving ketamine sedationSystematic Review
Key results10-20% 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) 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
None available