Safety of ketamine for reducing fractures in a pediatric emergency department

Background and objective. Ketamine is one of the most widely used drugs for analgesia and sedation when reducing fractures in pediatric emergency departments (EDs). We aimed to analyze the safety of intravenous (IV) ketamine when administered by physicians who are not anesthesiologists. Methods. Prospective observational study of adverse events (AEs) related to pediatric ED specialists' use of analgesia and sedation when reducing fractures in children under the age of 14 years between 2011 and 2019. Multivariate analysis was used to identify independent risk factors for AEs. Results. We analyzed 1509 cases of IV ketamine administration for analgesia and sedation. The median age of patients was 8 years (interquartile range, 5-11 years). All had American Society of Anesthesiologists risk classifications of 1 or 2 and Mallampati scores of I or H. Prior to the procedure, 937 children (62.1%) had been administered an opioid analgesic. AEs were observed in 201 children (13.3%; 95% CI, 11.7%-15.1%); 71 experienced respiratory complications (4.7%; 95% CI, 3.2%-5.3%). No child required intubation, other advanced resuscitation maneuvers, or hospital admission because of a ketamine-related AE. Age was the only independent risk factor for developing an AE. The odds ratio (OR) for any type of AE in children aged 8 years or older was 1.9 (95% CI, 1.4-2.6). The OR for respiratory AEs in children aged 6 years or older was 2.6 (95% CI, 1.3-5.6). Opioid administration did not increase risk for AEs. Conclusions. Pediatric emergency physicians who are not anesthesiologists can safely administer IV ketamine for reducing fractures. Prior use of opioids is not associated with greater risk for respiratory AEs after ketamine use.