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TOPLINE:

A systematic review including 67,871 children found that serious adverse events during intravenous ketamine procedural sedation in the emergency department (ED) were extremely rare, supporting the overall safety of ketamine use in pediatric emergency care.

METHODOLOGY:

• Researchers conducted a systematic review of 20 studies including 67,871 individuals younger than 21 years who received intravenous ketamine for procedural sedation in EDs.
• From each study, they determined the frequency of airway and respiratory adverse events (airway obstruction, apnea, laryngospasm, and oxygen desaturation) as well as vomiting and recovery agitation.
• The primary outcome was a composite of serious adverse events, including sentinel events (life-threatening events such as tracheal intubation, neuromuscular blockade, chest compressions, aspiration, and administration of vasoactive drugs) or intermediate events (potentially serious events requiring airway support or escalation of care), according to the Tracking and Reporting Outcomes of Procedural Sedation quality monitoring tool.

TAKEAWAY:

• The pooled frequency of sentinel events during pediatric ketamine sedation was 0.0087% (95% CI, 0.003%-0.021%), with no deaths or permanent neurologic deficits reported.
• Sentinel events occurred in 0.34% of pediatric ketamine sedations and were more common in children older than 10 years (odds ratio [OR], 3.9), those with upper respiratory infections (OR, 3.7), and those co-administered opioids (OR, 2.9).
• Physical status, defined by the American Society of Anesthesiologists, and benzodiazepine use did not predict serious adverse events.

IN PRACTICE:

"Our most important finding is that the most serious 'sentinel' adverse events were extremely rare (1 per 11,558 sedation encounters) such that most practitioners are unlikely to encounter them in their careers. These data strongly validate the safety of ED ketamine procedural sedation for children," the authors wrote. 

SOURCE:

The study was led by Steven M. Green, MD, Loma Linda University in Loma Linda, California. It was published online on May 15, 2026, in Annals of Emergency Medicine.

LIMITATIONS:

The included studies varied in patient populations, ketamine doses, procedural indications, and ED settings, which may have contributed to differences in adverse event rates. Three studies also included small numbers of patients receiving intramuscular or intranasal ketamine, with intravenous-only outcomes unavailable. Many studies were retrospective, which may have led to underreporting of less serious adverse events such as vomiting and recovery agitation. In addition, variations in outcome definitions and reliance on locally assigned outcomes such as apnea may have affected consistency across the studies.

DISCLOSURES:

The study did not receive any funding. The authors reported having no competing interests.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.