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Three Part Question

[In children requiring procedural sedation with ketamine] does [the coadministration of atropine] alter [salivation, safety, vomiting, recovery time and/or effectiveness]

Clinical Scenario

A 4 year old patient presents to the ED with a lip laceration, you decide to repair it under ketamine sedation and prepare an appropriate dose of ketamine and atropine. However, before administration your colleague (who has recently returned from Australia) tells you that it is a waste of time and that the Antipodeans never use it. You wonder if this is true.

Search Strategy

MEDLINE(R) In-Process & Other Non-Indexed Citations and MEDLINE(R) 1950 to 2008 February Week 3
EMBASE 1980 - 2007 Week 8
CINAHL 1982 - 2007 February Week 3
Cochrane Database of Systematic Reviews (CDSR) <1st Quarter 2008>
ACP Journal Club <1991 to January/February 2008>
Database of Abstract and Reviews of Effects (DARE) <1st Quarter 2008>
Cochrane Central Register of Controlled Trials (CCRCT) <1st Quarter 2007>
(All via the Ovid Interface)
Medline: [exp Ketamine/ OR ketamine.mp OR ketalar.mp.] AND [exp Atropine/ OR atropine.mp] LIMIT to humans and English language
EMBASE: [exp Ketamine/ OR ketamine.mp. OR ketalar.mp.] AND [exp Atropine/ OR atropine.mp.] LIMIT to humans and English and Child
CINAHL: [exp Ketamine/ OR ketamine.mp. OR ketalar.mp.] AND [exp Atropine/ OR atropine.mp.]
All EBM Reviews (CDSR, ACP Journal Club, DARE, CCRCT): atropine.mp. AND ketamine.mp

Search Outcome

109 papers were found in Medline, 58 in EMBASE, 12 in CINAHL, 6 in CDSR, 0 in ACP Journal Club, 1 in DARE and 54 in CCRCT. One paper was relevant to the 3 part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Heinz P et al 2006 England	83 patients aged 13 months to 14.5 years (median age 3.4 years) enrolled 16 month period at a University teaching hospital. Patients were given 4mg/Kg of IM ketamine. They were randomised to either 0.01mg/Kg atropine or placebo.	PRCT.	Incidence of hypersalivation	11.4% in atropine group vs. 30.8% in placebo group. OR 0.29, CIs 0.09 - 0.91.	Small numbers. Differences suggest possible real effect but too small to detect them. Much larger dose of ketamine than many other centres. This may lead to a much greater incidence of side effects... for which you then may well need atropine. A number of qualititive outcomes with no defined measure e.g. hypersalivation.
			Transient rash	22.7% in atropine group vs. 5.1% in placebo group. OR 5.44, CIs 1.11 - 26.6
			Vomiting	9.1% in atropine group vs. 25.6% in placebo group. OR 0.29, CIs 0.09 - 1.02
			Stridor/layngospasm	9.1% in atropine group vs.15.4% in placebo group. OR 0.61, NS
			Muscle rigidity	13.6% in atropine group vs. 20.5% in placebo group. OR 0.86, NS
			Need for intervention	27.3% in atropine group vs. 20.5% in placebo group. OR 1.45, NS

Comment(s)

Ketamine is increasingly used in the UK for paediatric sedation. One of the many controversies in its use is the routine co-administration of atropine. Some argue that it is unnecessary, others that it reduces the incidence of complications. In this BET we only found one study to support the use of atropine. However, its findings are, in our opinion, limited owing to the large ketamine dose used and the IM route. If you use 4mg/Kg IM then give atropine. If, like us, you titrate IV doses to the required effect then the question remains to be answered.

Clinical Bottom Line

Atropine should be routinely given if high dose IM ketamine is used. There is insufficient evidence to determine its effectiveness at lower doses, or if given by the IV route.

References

1. Heinz P, Geelhoed GC, Pascoe EM. Is atropine needed with ketamine sedation? A prospective randomised, double blind study. EMJ 205;23:206-209