J Yeungnam Med Sci.  2024 Jul;41(3):207-212. 10.12701/jyms.2024.00276.

Enhancing ketamine anesthesia with midazolam and fentanyl for children’s ear surgery: a prospective randomized study

• Han SM
• Kwon SY
• In JH
• Joo JD

• KMID: 2558145
• DOI: http://doi.org/10.12701/jyms.2024.00276

Abstract

Background
Myringotomy with tympanostomy tube insertion (MTI) is a superficial surgical procedure used to prevent hearing loss in children with serous otitis media. Intravenous anesthesia, often ketamine, is preferred for this procedure because of its ability to induce sedation without compromising airway reflexes. However, ketamine alone may be insufficient and potentially lead to spontaneous movement during surgery. This study evaluated the effectiveness of midazolam and fentanyl as adjuvants to ketamine in reducing spontaneous movement during MTI and enhancing the quality of recovery.
Methods
This study involved two groups of 30 patients each: one group received intravenous ketamine (1.5 mg/kg) with an equal volume of normal saline (K group), while the other received a combination of midazolam, fentanyl, and ketamine (0.05 mg/kg, 1 μg/kg, and 1.5 mg/kg, respectively; MFK group). We assessed side effects, intraoperative patient movement, surgeon satisfaction, and emergence agitation scores.
Results
The MFK group exhibited significantly lower scores for patient movement (p<0.01) and emergence agitation (p<0.01) and markedly higher surgeon satisfaction scores (p<0.01) than the K group.
Conclusion
Administering a midazolam-fentanyl-ketamine combination effectively reduced spontaneous movement during surgery and emergence agitation during recovery without prolonging discharge times in children undergoing MTI.

Keyword

Fentanyl; Ketamine; Midazolam; Otitis media; Pediatric anesthesia

Figure

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  Fig. 1. Intraoperative characteristics of the midazolam, fentanyl, and ketamine (MFK) group are marked by significantly lower patient movement scores than those of the ketamine (K) group (p<0.01); 0=asleep, calm, and fully flaccid; 1=wiggling of extremities, breathing harshly, or grimacing; 2=slight movement of extremities or body but not head; and 3=thrashing around, including head movement.

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  Fig. 2. Intraoperative characteristics of the midazolam, fentanyl, and ketamine (MFK) group are marked by significantly better surgeon satisfaction scores than those of the ketamine (K) group (p<0.01); 1=excellent surgical conditions, 2=average surgical conditions, overall good but sometimes surgery was interrupted by unexpected movement, and 3=poor surgical conditions.

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  Fig. 3. Emergence agitation scores of the midazolam, fentanyl, and ketamine (MFK) group are significantly better than those of the ketamine (K) group (p<0.01); 1=calm, 2=crying but can be consoled, 3=crying and cannot be consoled, and 4=agitated and thrashing around.

Reference

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