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Ketamine for Pediatric Airway Induction

July 2, 2020


Written by Aaron Lacy

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In critically ill children undergoing tracheal intubation (TI), use of ketamine as an induction agent was associated with fewer hemodynamic adverse events when compared to other induction agents.

Why does this matter?
Even when there is clinical indication for TI, induction, sedation, and positive pressure ventilation can pose risks to a critically ill child. Ketamine, through its intrinsic sympathomimetic effects and inhibition of norepinephrine reuptake, is thought to help counteract some of the risk of induction leading to hypotension in adult patients. It is important to know if this holds true in the critically ill pediatric population.

Ramp up those sympathetics
In this retrospective review, NEAR data of 10,750 children (age 0-17) who underwent TI was analyzed. Primary outcome was the rate of adverse hemodynamic events during TI. In total, adverse hemodynamic events occurred in 5.5% of all TIs (hypotension 3.3%, cardiac arrest 1.4%, dysrhythmias 1.3%). 32% of all inductions in this study were done with ketamine, and after adjusting for covariates when comparing ketamine versus other induction agents, there was significantly lower odds of an adverse hemodynamic event (aOR, 0.74; 95% I, 0.58-0.95; p = 0.019).

Interestingly, in both children with hemodynamic instability/shock versus other indication for TI, the odds of adverse hemodynamic events were lower (OR 0.64; 95% CI, 0.49-0.84; p = 0.001 and 0.79; 95% CI, 0.65-0.93; p = 0.006, respectively) as the induction dose of ketamine increased (quartile increase in mg/kg ketamine dose of 0.88, 1.49, 2.00, 3.20).

Just as ketamine has gained popularity in adult patients as an induction agent, this study gives credence that it soon might be a go-to induction agent in the pediatric population. If clinically appropriate, I plan on using a generous dose of ketamine for my next induction of a pediatric patient.

Ketamine Use for Tracheal Intubation in Critically Ill Children Is Associated With a Lower Occurrence of Adverse Hemodynamic Events. Crit Care Med. 2020 Jun;48(6):e489-e497. doi: 10.1097/CCM.0000000000004314.

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