Udo SI, Rich C, Lyon J. Guideline on the Use of Intravenous Ketamine for Procedural Sedation in the Children’s Emergency Department: A Quality Improvement Project. Cureus. 2024 Dec 4;16(12):e75085. doi: 10.7759/cureus.75085. PMID: 39634206; PMCID: PMC11616467.

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Abstract
In pediatric emergency medicine, sedation is crucial for performing some therapeutic procedures in children. Ketamine is still not widely used, despite being the preferred agent due to its effectiveness and safety profile. Implementing a guideline for intravenous ketamine in emergencies requiring procedural sedation in children, as well as training and evaluating staff competencies in performing this procedure, are the aims of this study. Senior and mid-level physicians, including pediatric nurses working in the children’s emergency department (ED), have easy access to this concise repository for carrying out this procedure safely and effectively. The main objective was to implement a policy (guideline) for sedation in the children’s ED. The secondary objectives were to determine whether the introduction of this policy increased the overall satisfaction rating of procedural sedation as a service offered in the Trust, to close skill gaps among staff through targeted training, and to assess the degree of recommendation for this ongoing standard of practice, in line with the current best evidence. A retrospective review of pediatric sedation cases with fractures in the children’s ED of Buckinghamshire Healthcare National Health Service (NHS) Trust was conducted between June 2022 and August 2023. Surveys were sent out to assess attitudes, sedation skills, and compliance with the Royal College of Emergency Medicine (RCEM) guidelines. A policy for pediatric sedation with intravenous ketamine was later created and put into effect. Pre- and post-intervention data were compared to assess changes in sedation competency, compliance, and confidence. Out of the 103 pediatric fracture cases reviewed, 16 were identified as needing reduction upon initial evaluation, based on the child’s condition at presentation. However, only one (6%) was treated with ketamine sedation in the children’s ED, whereas nine cases (56%) were reduced under general anesthesia. The remainder was treated with varying use of nitrous oxide gas (Entonox) and diamorphine. Significant progress had been made after a clinical guideline for intravenous ketamine-assisted sedation in children was put into practice. Physicians reported improved knowledge of sedation techniques, knowledge of airway control, and safety in administering ketamine sedation. The percentage of respondents supporting the guidelines increased from 61% before the intervention (nValue=11) to 94% after (nValue​=17), using various metrics. These results demonstrated how well evidence-based policies and training can improve performance, competence, and safety. The use of procedural sedation in the children’s ED increased and the need for general anesthesia was significantly reduced after a uniform pediatric ketamine sedation policy was implemented. Targeted training to address skill gaps increased employee confidence and adherence to best practices.

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Del Pizzo J, Fein JA. Oral Ketamine and Midazolam for Procedural Sedation in the Pediatric Emergency Department: A Retrospective Study. Pediatr Emerg Care. 2025 Feb 1;41(2):122-126. doi: 10.1097/PEC.0000000000003291. Epub 2024 Nov 19. PMID: 39560467.

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Abstract
Introduction: Needle-free procedural sedation (PS) is an attractive option for children presenting to the emergency department (ED) who require a painful procedure, as it avoids inflicting additional pain either with intravenous line placement or intramuscular injection. While use of oral (PO) ketamine has been reported in the literature, limited information is available to guide ED-based use in children.

Methods: This is a descriptive study of the patient experience receiving PS with the following regimen: PO ketamine 6 mg/kg (max of 200 mg) with or without PO midazolam 0.5 mg/kg (max 15 mg) approximately 30 minutes before a procedure. We performed a retrospective chart review of children younger than 18 years receiving this PS regimen at a tertiary care children’s hospital ED and an affiliated community hospital ED from January 1 through September 30, 2023.

Results: Fifty-eight children were sedated with PO ketamine during the study period. The most common procedure performed was laceration repair (46.5%), followed by incision and drainage (17.3%). All but 2 children received PO midazolam along with PO ketamine. Eight patients received additional medications due to inadequate sedation. Sedation depth was clinician-reported as moderate in 74.1% (43), mild in 15.5% (9), and deep in 10.3% (6). Procedures were completed in 98.3% (57) cases. 93.1% (54) of patients had no adverse event (AE) of any kind and no patient had a significant adverse event (SAE).

Discussion: PO ketamine with or without midazolam resulted in procedure completion of a variety of procedures in the pediatric ED with minimal AE, no SAE, and without need for additional sedative medications in 86.2% (50). This regimen is an option for needle-free moderate PS in this setting. Further study is needed to clarify the benefit of the addition of midazolam to PO ketamine, rates of AE and SAE, sedation duration, and recovery times.

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Bang YJ, Kim J, Gil NS, Sim WS, Ahn HJ, Park MH, Lee SM, Kim DJ, Jeong JS. Pulmonary Atelectasis After Sedation With Propofol vs Propofol-Ketamine for Magnetic Resonance Imaging in Children: A Randomized Clinical Trial. JAMA Netw Open. 2024 Nov 4;7(11):e2433029. doi: 10.1001/jamanetworkopen.2024.33029. PMID: 39485355; PMCID: PMC11530935.

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Abstract
Importance: Little is known about the impact of different anesthetic agents used for routine magnetic resonance imaging (MRI) sedation on pulmonary function in children.

Objective: To compare the incidence of pulmonary atelectasis after MRI sedation with propofol vs propofol-ketamine.

Design, setting, and participants: This double-masked randomized clinical trial screened 117 consecutive pediatric patients aged 3 to 12 years with American Society of Anesthesiologists physical status I to II undergoing elective MRI under deep sedation from November 2, 2022, to April 28, 2023, at a tertiary referral center. Four patients met the exclusion criteria, and 5 patients refused to participate. The participants and outcome assessors were masked to the group allocation.

Interventions: During the MRI, the propofol group received 0.2 mL/kg of 1% propofol and 2 mL of 0.9% saline followed by a continuous infusion of propofol (200 μg/kg/min) and 0.9% saline (0.04 mL/kg/min). The propofol-ketamine group received 0.2 mL/kg of 0.5% propofol and 1 mg/kg of ketamine followed by a continuous infusion of propofol (100 μg/kg/min) and ketamine (20 μg/kg/min).

Main outcome and measure: The incidence of atelectasis assessed by lung ultrasonography examination.

Results: A total of 107 children (median [IQR] age, 5 [4-6] years; 62 male [57.9%]), with 54 in the propofol group and 53 in the propofol-ketamine group, were analyzed in this study. Notably, 48 (88.9%) and 31 (58.5%) patients had atelectasis in the propofol and propofol-ketamine groups, respectively (relative risk, 0.7; 95% CI, 0.5-0.8; P < .001). The incidence of desaturation and interruption of the MRI due to airway intervention or spontaneous movement did not significantly differ between the groups. The propofol-ketamine group showed a faster emergence time than the propofol group (15 [9-23] vs 25 [22-27] minutes in the propofol-ketamine vs propofol group; median difference in time, 9.0 minutes; 95% CI, 6.0-12.0 minutes; P < .001). No patient was withdrawn from the trial due to adverse effects.

Conclusions and relevance: In this randomized clinical trial, the propofol-ketamine combination reduced sedation-induced atelectasis while allowing for faster emergence compared with propofol alone.

Trial registration: cris.nih.go.kr Identifier: KCT0007699.