Intranasal ketamine for procedural sedation and analgesia in children: A systematic review.
BACKGROUND
Ketamine is commonly used for procedural sedation and analgesia (PSA) in children. Evidence suggests it can be administered intranasally (IN). We sought to review the evidence for IN ketamine for PSA in children.


METHODS
We performed a systematic review of randomized trials of IN ketamine in PSA that reported any sedation-related outcome in children 0 to 19 years. Trials were identified through electronic searches of MEDLINE (1946-2016), EMBASE (1947-2016), Google Scholar (2016), CINAHL (1981-2016), The Cochrane Library (2016), Web of Science (2016), Scopus (2016), clinical trial registries, and conference proceedings (2000-2016) without language restrictions. The methodological qualities of studies and the overall quality of evidence were evaluated using the Cochrane Collaboration's Risk of Bias tool, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, respectively.


RESULTS
The review included 7 studies (n = 264) of children ranging from 0 to 14 years. Heterogeneity in study design precluded meta-analysis. Most studies were associated with a low or unclear risk of bias and outcome-specific ratings for quality of evidence were low or very low. In four of seven studies, IN ketamine provided superior sedation to comparators and resulted in adequate sedation for 148/175 (85%) of participants. Vomiting was the most common adverse effect; reported by 9/91 (10%) of participants.


CONCLUSIONS
IN ketamine administration is well tolerated and without serious adverse effects. Although most participants were deemed adequately sedated with IN ketamine, effectiveness of sedation with respect to superiority over comparators was inconsistent, precluding a recommendation for PSA in children.
Department of Pediatrics, Schulich School of Medicine and Dentistry, London, Ontario, Canada.|Division of Emergency Medicine, London Health Sciences Centre, London, Ontario, Canada.|Children's Health Research Institute, London Health Sciences Centre, London, Ontario, Canada.
Naveen
http://orcid.org/0000-0003-1540-0413
N
Poonai
Division of Emergency Medicine, London Health Sciences Centre, London, Ontario, Canada.
Kyle
K
Canton
Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada.|Women and Children's Health Research Institute, University of Alberta, Edmonton, Alberta, Canada.
Samina
S
Ali
Department of Pediatrics, Schulich School of Medicine and Dentistry, London, Ontario, Canada.
Shawn
S
Hendrikx
Division of Emergency Medicine, London Health Sciences Centre, London, Ontario, Canada.
Amit
A
Shah
Department of Pediatrics, Schulich School of Medicine and Dentistry, London, Ontario, Canada.|Children's Health Research Institute, London Health Sciences Centre, London, Ontario, Canada.
Michael
M
Miller
Department of Pediatrics, Schulich School of Medicine and Dentistry, London, Ontario, Canada.|Division of Emergency Medicine, London Health Sciences Centre, London, Ontario, Canada.|Children's Health Research Institute, London Health Sciences Centre, London, Ontario, Canada.
Gary
G
Joubert
Department of Pediatrics, Schulich School of Medicine and Dentistry, London, Ontario, Canada.|Children's Health Research Institute, London Health Sciences Centre, London, Ontario, Canada.
Michael
M
Rieder
Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Alberta.
Lisa
L
Hartling
D000281:Administration, Intranasal; D000293:Adolescent; D000700:Analgesics / Q000008:administration & dosage*; D002648:Child; D002675:Child, Preschool; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage*; D007223:Infant; D007231:Infant, Newborn; D007649:Ketamine / Q000008:administration & dosage*; D016032:Randomized Controlled Trials as Topic
D000700:Analgesics; D006993:Hypnotics and Sedatives; D007649:Ketamine