Design: Systematic review of studies with at least 250 subjects each
Population: 58,752 children receiving intravenous ketamine for ED procedural sedation
Primary outcome: Frequency and predictors of sedation adverse events
Effect: Sentinel events about 1 per 24,000; serious adverse events 0.33%

Ketamine is the workhorse of paediatric procedural sedation in the emergency department, and this systematic review assembles the largest safety picture to date: 20 studies and 58,752 children given intravenous ketamine.

The reassurance is strong. There were no reported deaths and no permanent adverse outcomes. Sentinel events, such as intubation, aspiration or chest compressions, were pooled at about 1 per 24,000 sedations. Serious adverse events overall occurred in 0.33%, and only three predictors emerged, each with modest effect: age 10 years or older, a current upper respiratory infection, and co-administered opioids. ASA physical status and co-administered benzodiazepines were not predictive.

The practical message is to proceed with ketamine sedation confidently in children, while using the three predictors to flag the small number at marginally higher risk and to reconsider routinely adding an opioid during the sedation.

Systematic review of 20 studies and 58,752 children sedated with intravenous ketamine in the ED.
No deaths and no permanent adverse outcomes were reported.
Sentinel events (intubation, aspiration, chest compressions) pooled at about 1 per 24,000.
Serious adverse events occurred in 0.33%; predictors were age 10+, upper respiratory infection and opioids.
ASA status and co-administered benzodiazepines did not predict serious events.

Why it matters

It puts a hard number on ketamine's safety, countering lingering caution, and names the few factors that actually matter.

The statistics, in plain English

A sentinel-event rate near 1 in 24,000 is extremely low, though it comes from pooled observational reports that may under-capture events. The named predictors raise risk only modestly, roughly one extra serious event per 100 to 160 sedations.