Ketamine for Pediatric Bone Reduction Sedation
Ketamine is the preferred agent for pediatric bone reduction procedures due to its superior efficacy in providing complete sedation (100% efficacy rate), excellent safety profile with lower rates of respiratory depression compared to alternatives, and its unique ability to provide both potent analgesia and amnesia through its dissociative mechanism. 1
Mechanism and Benefits
- Ketamine works through N-methyl-D-aspartate glutamate receptor antagonism, creating a dissociative state that provides potent sedation, analgesia, and amnesia during painful procedures like bone reduction 1
- Unlike other sedatives, ketamine maintains airway reflexes and respiratory drive, making it particularly valuable in the pediatric population where airway complications are a primary concern 1
- Ketamine provides superior behavioral distress scores during orthopedic manipulation compared to alternatives like propofol/fentanyl (OSBD-R scores of 0.084 vs 0.278) 1
Dosing for Bone Reduction
- For IV administration: 1.5-2 mg/kg provides optimal sedation with only 5.5% of patients requiring additional doses (compared to 54% when using 1 mg/kg) 2, 3
- For IM administration: 4 mg/kg is recommended when IV access is challenging 1, 3
- Onset of action is rapid: 30-96 seconds for IV route and approximately 3-5 minutes for IM route 2, 4
Safety Profile
- Ketamine demonstrates a superior safety profile compared to fentanyl/midazolam combinations, with significantly lower rates of:
- Hypoxemia (6% vs 24%, p=0.001)
- Need for breathing cues (1% vs 12%, p=0.001)
- Airway interventions (6% vs 11%) 1
- The incidence of laryngospasm is very low (0.9-1.4% of cases) 1
- Recovery time averages 84 minutes (range: 22-215 minutes) 2, 3
Monitoring Requirements
- Continuous monitoring of vital signs including oxygen saturation, heart rate, and blood pressure is essential 2, 5
- Patients should maintain oxygen saturation >93% on room air during the procedure 2
- A provider skilled in airway management should supervise the sedation 4
Common Side Effects
- Emesis (7-8% of patients)
- Nausea (4-5% of patients)
- Ataxia (7-8% of patients)
- Dysphoric emergence reactions (1% of patients) 2, 3
Clinical Pearls
- Consider adding midazolam (0.05 mg/kg) to reduce emergence reactions, particularly in older children 2
- Ketamine/propofol combinations may offer slightly faster recovery times (13 vs 16 minutes) and less vomiting (2% vs 12%) compared to ketamine alone 6
- FDA warning: Repeated or prolonged use in children under 3 years may have potential negative effects on developing brains 7
- Parental satisfaction is significantly higher with ketamine compared to alternatives (92% vs 65%, p=0.02) 1, 4
Contraindications and Cautions
- Use with caution in patients with:
- Increased intracranial pressure
- Hypertension
- Psychiatric disorders (due to potential emergence reactions)
- Age under 3 months 1
Ketamine has consistently demonstrated superior efficacy and safety compared to alternative sedation regimens for pediatric bone reduction procedures, making it the agent of choice when there are no specific contraindications.