title: Efficacy and adverse effects of ketamine as an additive for paediatric caudal anaesthesia: a quantitative systematic review of randomized controlled trials.
abstract: BACKGROUND
  The aim of this quantitative systematic review was to assess the efficacy and adverse effects of ketamine added to caudal local anaesthetics in comparison with local anaesthetics alone in children undergoing urological, lower abdominal, or lower limb surgery.
  
  
  METHODS
  The systematic search, data extraction, critical appraisal, and pooled data analysis were performed according to the PRISMA statement. All randomized controlled trials (RCTs) were included in this meta-analysis and relative risk (RR), mean difference (MD), and the corresponding 95% confidence intervals (CIs) were calculated using the Revman(®) statistical software for dichotomous and continuous outcomes.
  
  
  RESULTS
  Thirteen RCTs (published between 1991 and 2008) including 584 patients met the inclusion criteria. There was a significant longer time to first analgesic requirements in patients receiving ketamine in addition to a local anaesthetic compared with a local anaesthetic alone (MD: 5.60 h; 95% CI: 5.45-5.76; P<0.00001). There was a lower RR for the need of rescue analgesia in children receiving a caudal regional anaesthesia with ketamine in addition to local anaesthetics (RR: 0.71; 95% CI: 0.44-1.15; P=0.16).
  
  
  CONCLUSIONS
  Caudally administered ketamine, in addition to a local anaesthetic, provides prolonged postoperative analgesia with few adverse effects compared with local anaesthetics alone. There is a clear benefit of caudal ketamine, but the uncertainties about neurotoxicity relating to the dose of ketamine, single vs repeated doses and the child's age, still need to be clarified for use in clinical practice.
authors.affiliation: Department of Anesthesiology and Intensive Care, University Hospital of Münster, Albert-Schweitzer-Str. 33, 48149 Münster, Germany.
authors.forename: A
authors.initials: A
authors.lastname: Schnabel
authors.forename: D M
authors.initials: DM
authors.lastname: Poepping
authors.forename: P
authors.initials: P
authors.lastname: Kranke
authors.forename: P K
authors.initials: PK
authors.lastname: Zahn
authors.forename: E M
authors.initials: EM
authors.lastname: Pogatzki-Zahn
mesh_terms: D000005:Abdomen / Q000601:surgery; D000763:Anesthesia, Caudal; D000778:Anesthetics, Dissociative / Q000009:adverse effects; D000779:Anesthetics, Local / Q000008:administration & dosage / Q000009:adverse effects; D002648:Child; D002675:Child, Preschool; D003627:Data Interpretation, Statistical; D005260:Female; D006801:Humans; D007223:Infant; D007649:Ketamine / Q000009:adverse effects; D035002:Lower Extremity / Q000601:surgery; D008297:Male; D009068:Movement / Q000187:drug effects; D009407:Nerve Block; D019637:Orthopedic Procedures; D010147:Pain Measurement; D010149:Postoperative Pain / Q000188:drug therapy / Q000453:epidemiology; D016032:Randomized Controlled Trials as Topic; D018570:Risk Assessment; D016896:Treatment Outcome; D014554:Urination; D013520:Urologic Surgical Procedures
chemical_list: D000778:Anesthetics, Dissociative; D000779:Anesthetics, Local; D007649:Ketamine