Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children.
OBJECTIVE
Although ketamine is one of the most commonly used sedatives to facilitate painful procedures for children in the emergency department (ED), existing studies have not been large enough to identify clinical factors that are predictive of uncommon airway and respiratory adverse events.


METHODS
We pooled individual-patient data from 32 ED studies and performed multiple logistic regressions to determine which clinical variables would predict airway and respiratory adverse events.


RESULTS
In 8,282 pediatric ketamine sedations, the overall incidence of airway and respiratory adverse events was 3.9%, with the following significant independent predictors: younger than 2 years (odds ratio [OR] 2.00; 95% confidence interval [CI] 1.47 to 2.72), aged 13 years or older (OR 2.72; 95% CI 1.97 to 3.75), high intravenous dosing (initial dose > or =2.5 mg/kg or total dose > or =5.0 mg/kg; OR 2.18; 95% CI 1.59 to 2.99), coadministered anticholinergic (OR 1.82; 95% CI 1.36 to 2.42), and coadministered benzodiazepine (OR 1.39; 95% CI 1.08 to 1.78). Variables without independent association included oropharyngeal procedures, underlying physical illness (American Society of Anesthesiologists class >or = 3), and the choice of intravenous versus intramuscular route.


CONCLUSIONS
Risk factors that predict ketamine-associated airway and respiratory adverse events are high intravenous doses, administration to children younger than 2 years or aged 13 years or older, and the use of coadministered anticholinergics or benzodiazepines.
Green
Steven M
SM
Department of Emergency Medicine, Loma Linda University Medical Center and Children's Hospital, Loma Linda, CA, USA. steve@viridissimo.com
Roback
Mark G
MG
Krauss
Baruch
B
Brown
Lance
L
McGlone
Ray G
RG
Agrawal
Dewesh
D
McKee
Michele
M
Weiss
Markus
M
Pitetti
Raymond D
RD
Hostetler
Mark A
MA
Wathen
Joe E
JE
Treston
Greg
G
Garcia Pena
Barbara M
BM
Gerber
Andreas C
AC
Losek
Joseph D
JD
D000293:Adolescent; D000367:Age Factors; D000778:Anesthetics, Dissociative / Q000008:administration & dosage* / Q000009:adverse effects*; D001569:Benzodiazepines / Q000008:administration & dosage; D002648:Child; D002675:Child, Preschool; D018680:Cholinergic Antagonists / Q000008:administration & dosage; D004636:Emergency Service, Hospital; D004638:Emergency Treatment; D005260:Female; D006801:Humans; D015994:Incidence; D007223:Infant; D007262:Infusions, Intravenous; D007649:Ketamine / Q000008:administration & dosage / Q000009:adverse effects*; D008297:Male; D011237:Predictive Value of Tests; D012137:Respiratory System / Q000187:drug effects*; D012307:Risk Factors
D000778:Anesthetics, Dissociative; D018680:Cholinergic Antagonists; D001569:Benzodiazepines; D007649:Ketamine