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.