What is the role of ketamine in pediatric sedation?

Updated: May 08, 2018
  • Author: Wan-Tsu Wendy Chang, MD; Chief Editor: Ted Rosenkrantz, MD  more...
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Ketamine is a dissociative agent that induces catalepsy. It exhibits sedative, analgesic, and amnestic properties. This agent is related to phencyclidine (PCP) and has shown a history of efficacy. It preserves the airway reflexes and has minimal effect on the respiratory drive. Ketamine has bronchodilatory effects and is especially effective with bronchospasms. In addition, it has a good safety profile in children.

After IV administration of ketamine, peak onset of action occurs within 1 minute, and the duration of action is about 10-15 minutes. After IM administration, the peak onset of action occurs in about 5-10 minutes, and the duration of action is 15-30 minutes.

Because of the risk of hypertension, dysphoria, and agitation, ketamine is rarely used in adults. In pediatric patients, ketamine may (rarely) cause laryngospasm. The reaction appears to be idiosyncratic and not to be a function of age, dose, coadministration of anticholinergics, or other clinical variables. [17]

Dosing is 1-1.5 mg/kg by slow IV push (not to exceed 0.5 mg/kg/min). Additional doses may be administered at 0.5 mg/kg IV every 10-15 minutes, depending on the patient’s response and the duration of the procedure. Alternatively, ketamine may be given as 4 mg/kg IM, and additional doses of 2-4 mg/kg may be administered—again, depending on the patient’s response and the duration of the procedure.

A 2013 study demonstrated the benefit of performing sedation with a newly available combination of ketamine and propofol, known as ketofol, rather than with ketamine plus fentanyl for sedation. Switching to the newer combination resulted in a 14% decrease in adverse events overall, a 7% decrease in oxygen desaturation, and a 9% decrease in nausea and vomiting. The decrease in desaturation requiring positive pressure ventilation was 35%. [18]

A retrospective study examined the data that suggested an advantage of sedation with the combination of ketamine and propofol over ketamine alone or propofol alone. The study found that sedation with the combination of ketamine and propofol can be safely performed by a skilled emergency physician. [19]  However, a prospective, multicenter, observational cohort study from 6 pediatric emergency departments that examined 6295 cases of pediatric sedation reported that the use of ketamine alone resulted in the lowest incidence of serious adverse events (17 [0.4%]) and significant interventions (37 [0.9%]) compared to just propofol or a combination of ketamine with propofol or fentanyl. [20]

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