4.2 Sedation and procedural pain
Parenteral ketamine (intravenous/ intramuscular) is often used for sedation during outpatient as well as inpatient procedures, including lumbar puncture, bone marrow aspiration, and biopsies, with good efficacy and tolerable adverse effects.74Intramuscular administration has the advantage of not requiring intravenous access but has been associated with a slightly higher incidence of adverse events.75 For sedation, ketamine is also frequently combined with other agents like midazolam, propofol, and dexmedetomidine.76,77,78,79 Pellier et al prospectively evaluated a combination of midazolam (IV, 25 mcg/kg) and ketamine (IV, 0.5-2 mg/kg) for procedural sedation in children with cancer, and found it to be safe and effective.80 Some of the undesirable adverse effects of intravenous ketamine used for sedation such as hypersalivation and tachycardia may be alleviated by using atropine.81 An oral mixture of ketamine, midazolam, and atropine was found to be equivalent to intramuscular administration of these drugs for procedural sedation during minor oncological procedures in children.82 However, a trial evaluating the analgesic effect of oral ketamine (1 mg/kg) for procedural analgesia before bone marrow examination did not find any significant benefit over placebo.83 Similarly, oral ketamine sedation (8-15 mg/kg) was found to be insufficient in children with cancer undergoing radiotherapy.84 Thus, while intravenous ketamine has gained widespread popularity as a procedural agent, the role of oral ketamine is yet to be established. Intranasal ketamine has also been used for sedation in children. Yang et al described the use of intranasal ketamine and dexmedetomidine in 17948 children for procedural sedation and concluded it to be satisfactorily effective with fewer adverse events.85 Table 3 provides a summary of the prospective trials of ketamine (sample size ≥ 10) for procedural pain or sedation in children with cancer.