- Design
- Systematic review of observational studies (≥250 patients each)
- Population
- 58,752 children receiving IV ketamine for ED procedural sedation
- Primary outcome
- Frequency and predictors of adverse events
- Effect
- Sentinel events 0.0041% (1 in 24,390); serious adverse events 0.33%
This systematic review in Annals of Emergency Medicine, published in May, gathered 20 studies with at least 250 children each — 58,752 in total — receiving intravenous ketamine for procedural sedation in the emergency department since a 2009 review.
There were no deaths or permanent neurological harm. Sentinel events — intubation, neuromuscular blockade, chest compressions, aspiration or vasoactive drugs — occurred in about 1 per 24,390 sedations. Serious adverse events, a wider group including brief positive pressure ventilation or an oral airway, occurred in 0.33%. Age 10 or over, an upper respiratory infection and co-administered opioids each modestly raised that risk; ASA class and benzodiazepines did not.
For emergency teams who still hesitate over ketamine in children, this is strong reassurance. The predictors are worth knowing but should prompt preparation rather than avoidance.
- Consider IV ketamine as a first-choice agent for painful procedures in children in the ED.
- Prepare airway equipment and skills; transient airway support is the commonest serious event.
- Take extra care in children aged 10 or over and those with a current respiratory infection.
- Avoid adding opioids unless needed, as they modestly raise the risk of serious events.
- Do not exclude a child solely because of ASA class.
Why it matters
Excess caution about ketamine still leads to under-sedation or general anaesthesia for minor procedures.
Don't overread it
The studies were observational and from experienced centres; the safety record depends on trained teams and monitoring.
The statistics, in plain English
A rate of 0.0041% (95% CI 0.0010% to 0.016%) means sentinel events are so rare that even large single studies see almost none. The predictors added about one serious event per 106 to 161 sedations each.
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