Ketamine with midazolam cut procedural pain and desaturation compared with fentanyl in IR sedation

Design

Single-centre randomised clinical trial

Population

260 adults (264 procedures) having image-guided lung or bone biopsy or abscess drainage

Primary outcome

Maximum intraprocedural pain (0–10 numeric rating scale)

Effect

Mean difference −1.4 (95% CI −2.0 to −0.8); desaturation <90% 2.3% vs 9.8%; hallucinations 11.4% vs 3.8%

At one US academic centre, 260 adults having image-guided lung or bone biopsy or abscess drainage (264 procedures) were randomised to sedation with ketamine plus midazolam or fentanyl plus midazolam, given by the interventional radiologists themselves. The primary outcome was the worst pain during the procedure.

Ketamine reduced peak pain by 1.4 points on a 0–10 scale, and pain above 4 fell from 17% to 2.3%. Lowest oxygen saturation was higher and desaturation below 90% less frequent (2.3% vs 9.8%). Patients rated comfort and adequacy of sedation higher. The trade-offs were deeper sedation, higher systolic blood pressure and more hallucinations (11.4% vs 3.8%). Procedure and sedation complications did not differ.

The trial was single-centre, and the patients and staff could likely tell which drug was given from its effects, which may influence pain reports. Ketamine's blood pressure rise and emergence reactions make it a poor choice for some patients, including those with uncontrolled hypertension, significant ischaemic heart disease or psychosis. Ketamine is cheap and widely available in India, but radiologist-led sedation still requires monitoring, trained staff and local sedation policy. It was published in September 2026.

• Consider ketamine with midazolam for moderate sedation during painful image-guided biopsies and drainages.
• Warn patients about possible hallucinations; about 1 in 9 had them with ketamine.
• Avoid ketamine where a rise in blood pressure would be harmful or where there is a history of psychosis.
• Keep continuous oxygen saturation and blood pressure monitoring whatever the regimen.
• Agree the regimen with anaesthesia and write it into local sedation policy before changing practice.

Why it matters

It challenges the default opioid–benzodiazepine regimen used in most IR suites.

Don't overread it

This is one centre, and drug effects may have unblinded patients and staff.

The statistics, in plain English

A mean pain difference of −1.4 points (95% CI −2.0 to −0.8) is clinically noticeable and the interval stays well away from zero. For desaturation, the absolute difference of 7.6 percentage points means about one fewer desaturation for every 13 patients sedated with ketamine. Hallucinations rose by a similar absolute amount, so the benefit comes with a trade-off.

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