Ketamine and kids: an update.

The ‘ketamine dart’ is an old and trusted standby for pediatric anesthesiologists: in the uncooperative pediatric patient, the intramuscular administration of ketamine – if necessary straight through the clothes – has proven itself as an effective approach to induce a moderate level of anesthesia while maintaining blood pressure, breathing and airway reflexes. Ketamine also is used frequently for pediatric sedation and pain relief, by anesthesiologists and nonanesthesiologists, in the Emergency Department and Intensive Care Unit. A number of developments have drawn renewed attention to ketamine for use in the adult population. The marketing in Europe of the S(+) isomer instead of the racemic mixture led to hopes that the at times troublesome side effects of ketamine could be reduced – hopes that appear to have faded (1), but that have led to the availability of a compound with a faster offset and allowing more easily titrated use in infusions. The profound analgesic properties of ketamine have been recognized anew, and a number of approaches for ketamine pain therapy in the perioperative period and for patients with chronic pain are being evaluated (2). Concerns about the use of ketamine in patients with head injury have been shown essentially unwarranted when used under appropriate conditions (3), and this has opened the way to making use of its well-described cerebral protective properties, which seem to be even more pronounced in S(+) ketamine (4). Although ketamine can induce neuronal toxicity (5), further research will likely define an appropriate place of the compound in treatment of patients with intracranial pathology. A number of these developments are applicable as much to the pediatric population as to adults, and a number of investigators have studied novel uses of ketamine in children. In this review we will, after a brief description of our current understanding of ketamine’s pharmacology, discuss the recent literature on ketamine’s use for three pediatric indications: anesthesia, sedation, and analgesia. We hope to demonstrate that there may be growing opportunities for improving patient care by using ketamine in children.