Systematic Review of Pediatric Ketamine in Emergency Department Procedural Sedation: Frequency and Predictors of Adverse Events.

STUDY OBJECTIVE: We sought to compile the reported frequencies of adverse events from studies including ≥250 subjects of pediatric emergency department (ED) ketamine sedation by the intravenous route and determine their variances and pooled estimates. We then inventoried the described predictor variables and estimated their clinical importance.

METHODS: Systematic review of studies including ≥250 subjects of children receiving intravenous ketamine in the ED for pediatric procedural sedation published after a 2009 systematic review.

RESULTS: We identified 20 qualifying studies totaling 58,752 children. There were no reported patient deaths or permanent adverse outcomes/neurologic deficits. The pooled frequency estimate of other sentinel outcomes (ie, tracheal intubation, neuromuscular blockade, chest compressions, aspiration, vasoactive drugs) was 0.0041% (95% confidence interval 0.0010% to 0.016%), or 1 per 24,390 sedation encounters. Serious adverse events (defined as sentinel above plus positive pressure ventilation, oral airway, bolus intravenous fluids, sedation insufficient, escalation of care or hospitalization) were noted in 0.33%, with 3 identified predictors: age ≥10 years, upper respiratory infection, and coadministered opioids. Their magnitude of effect was modest; however, we estimate 1 additional serious adverse event for every 106, 114, and 161 ketamine sedations, respectively. Nonpredictors were American Society of Anesthesiologists physical status and coadministered benzodiazepines.

CONCLUSION: In this large systematic review, we found that sentinel adverse events were extremely rare, strongly supporting the safety of ED ketamine for procedural sedation of children. The clinical predictor variables studied showed modest or no association with serious adverse events.