Melendez Elliot, Bachur Richard
Department of Pediatrics, Division of Critical Care, Massachusetts General Hospital, Boston, MA 02114, USA.
Pediatr Emerg Care. 2009 May;25(5):325-8. doi: 10.1097/PEC.0b013e3181a341e0.
Compare the frequency of respiratory adverse events between patients who received intramuscular (IM) versus intravenous ketamine.
Case control study from 1997 to 2005 at a large urban pediatric emergency department. Adverse events were defined as apnea, hypoxemia (oximetry <93%), hypoventilation, laryngospasm, and other upper airway obstruction. Serious adverse events were defined by the level of intervention and included those cases that required positive pressure ventilation, insertion of oral or nasal airway, or endotracheal intubation. Minor adverse events were respiratory events requiring minimal intervention (stimulation, supplemental O2, airway repositioning). Controls (2:1) were selected by the next chronological patient in the data set who received ketamine but had no respiratory adverse event.
Four thousand two hundred fifty-two patients received ketamine; 102 cases (2.4%) had respiratory adverse events, including 38 patients with severe adverse events (0.9%). Interventions for the cases included supplemental O2 (59/102, 58%), airway repositioning (36/102, 35%), continuous positive airway pressure (7/102, 7%), positive pressure ventilation (33/102, 32%), nasal airway (2/102, 2%), oral airway (1/102, 1%), stimulation (11/102, 11%), and intubation (1/102, 1%). Overall, 33% of all subjects received IM ketamine including 47% of cases and 27% of controls. Intramuscular IM ketamine was associated with increased likelihood of adverse events (odds ratio [OR] 2.1, 95% CI, 1.3-3). Twenty (69%) of the 29 patients with laryngospasm received IM ketamine (OR, 5.2; 95% CI, 2.3-11.9) and 20 (53%) of the 38 patients who had severe events were administered IM (OR, 2.4; 95% CI, 1.2-4.9). Use of pre-sedation morphine or combined administration with midazolam and/or atropine was not associated with adverse events. Specific procedures were not associated with increased adverse events.
Respiratory adverse events with ketamine are uncommon. Serious events, like laryngospasm, are rare but occur more commonly with IM administration. This increased risk associated with IM administration should be considered in the sedation plan.
比较接受肌内注射（IM）与静脉注射氯胺酮的患者发生呼吸不良事件的频率。
1997年至2005年在一家大型城市儿科急诊科进行的病例对照研究。不良事件定义为呼吸暂停、低氧血症（血氧饱和度<93%）、通气不足、喉痉挛和其他上呼吸道梗阻。严重不良事件根据干预水平定义，包括那些需要正压通气、插入口腔或鼻腔气道或气管插管的病例。轻微不良事件是需要最少干预（刺激、补充氧气、气道重新定位）的呼吸事件。对照组（2:1）由数据集中按时间顺序排列的下一位接受氯胺酮但无呼吸不良事件的患者选择。
4252例患者接受了氯胺酮治疗；102例（2.4%）发生呼吸不良事件，其中38例（0.9%）为严重不良事件。对这些病例的干预措施包括补充氧气（59/102，58%）、气道重新定位（36/102，35%）、持续气道正压通气（7/102，7%）、正压通气（33/102，32%）、鼻腔气道（2/102，2%）、口腔气道（1/102，1%）、刺激（11/102，11%）和插管（1/102，1%）。总体而言，所有受试者中有33%接受了肌内注射氯胺酮，其中病例组为47%，对照组为27%。肌内注射氯胺酮与不良事件发生的可能性增加相关（比值比[OR]2.1，95%可信区间，1.3 - 3）。29例喉痉挛患者中有20例（69%）接受了肌内注射氯胺酮（OR，5.2；95%可信区间，2.3 - 11.9），38例严重事件患者中有20例（53%）接受了肌内注射（OR，2.4；95%可信区间，1.2 - 4.9）。使用镇静前吗啡或与咪达唑仑和/或阿托品联合给药与不良事件无关。特定操作与不良事件增加无关。
氯胺酮引起的呼吸不良事件并不常见。严重事件，如喉痉挛，很少见，但在肌内注射时更常发生。在镇静计划中应考虑与肌内注射相关的这种增加的风险。
