Goyal, Ashima et al. “Prehospital Ketamine Use in Pediatrics.” Prehospital emergency care vol. 27,3 (2023): 360-365. doi:10.1080/10903127.2022.2096161
Question and methods: This study was a retrospective observational study performed through a collaborative database. Its objectives were to describe the characteristics of children who received ketamine provided by EMS, assess effectiveness of the treatment, determine whether there were deviations from the recommended dosing and if there were adverse outcomes.
Findings: Within the interval dates of this study, 1291 pediatric subjects received ketamine. 62.7% of these received it for injuries, 21.8% for behavioural disturbances and 15.5% for other procedural sedations. Significant pain reduction was noted in 29% of subjects (2 points or more) and 89.1% of patients had “clinician reported improvement” with the major adverse events of desaturation and BVM requirement seen in 1.8% and 2.2% of subjects respectively. Another concerning finding was the large number of dosing errors based on the recommendations for the subject’s indication. Among children with documented weights, 14% received 2-5x the recommended dose, 2.1% received 5-10x the dose and 1.2% received more than 10x the recommended dose.
Limitations: EMS primary impressions were used as a proxy for indications of ketamine administration and there were instances where there was disagreement between 2 reviewers. In addition, using clinician reported improvement as an indication for effectiveness does introduce a risk of bias. Finally, the deviations from recommended doses were calculated based on the national guidelines and the authors make note of not being able to ascertain whether some EMS agency protocols used alternative dosing which would significantly impact the reported dosing error frequency.
Bottom-Line/Interpretation: Overall this supports the evidence that ketamine can be an effective and relatively safe medication in prehospital care for multiple indications. It does however raise concerns about the high potential for dosing errors with multiple different doses and routes of administration depending on the indication for use, especially in the pediatric population.
Author: Sara-Pier Piscopo
Journal Club Review of Ketamine vs Opioids for analgesia in the Pediatric Prehospital Population can be found HERE.