Preanesthetic nebulized ketamine vs preanesthetic oral ketamine for sedation and postoperative pain management in children for elective surgery

Abstract

Preoperative anxiety is a major problem in children leading to a poor outcome. Preanesthetic oral ketamine is generally used in children but has less bioavailability due to the first-pass effect. Even ketamine has an unpleasant taste. Preanesthetic inhaled ketamine is also reported effective and safe in children. The objectives of the study were to compare the effectiveness and safety of preanesthetic nebulized ketamine against preanesthetic oral ketamine for sedation and postoperative pain management in children. Children received 10 mg/kg oral ketamine (children received preanesthetic oral ketamine [OK cohort], n = 142), or nebulized with 3 mg/kg ketamine (children were preanesthetic nebulized with ketamine [NK cohort], n = 115), or received apple juice (children suspectable to preoperative ketamine and received apple juice only [OA cohort], n = 126) before anesthesia for elective surgery. Data regarding preoperative hemodynamic parameters, sedation score measurements, postoperative pain management, postoperative nausea and vomiting management, and postoperative complications were collected and analyzed. Preoperative hemodynamic parameters for oral and nebulized ketamine administration were stable. Nebulized ketamine was provided higher sedation than apple juice ( P = .002, q = 4.859) and oral ketamine ( P = .002, q = 3.526). Children of NK cohort had required fewer fentanyl consumption until discharge than those of OA (55.45 ± 7.19 μG/ child vs 65.15 ± 15.24 μG/ child, P < .0001, q = 9.859) and OK (55.45 ± 7.19 μG/child vs 60.19 ± 8.12 μG/child, P < .0001, q = 4.953) cohorts. Children of the NK cohort had consumed higher ondansetron syrup than those of the OA cohort but fewer than those of the OK cohort until discharge. Gastrointestinal side effects were reported in the OK cohort, and nose irritation and drowsiness were reported in the NK cohort. Like preanesthetic oral ketamine, preanesthetic inhaled ketamine also has safety for children. Preanesthetic inhaled ketamine can provide effective sedation in low doses during operation than preanesthetic oral ketamine. Level of evidence: III.

Pharmacological strategies to reduce perioperative anxiety in children – a narrative review

“…One trial used 10mgkg -1 oral racemic ketamine. Surprisingly, compared to placebo this did not improve sedation 93 .…”

“…It is difficult to assess the efficacy of ketamine, as there are not many trials that compare ketamine premedication to placebo. Oral ketamine 10mgkg -1 did not produce significant effects on preoperative sedation score, compared to placebo (anxiety scores 4.31±0.79 vs 4.21±0.79, p=0,002) but it was successful in the reduction of perioperative pain 93 . In another trial, 60% percent of patients had calm parental separation after 6mgkg -1 ketamine.…”

“…Funk et al reported a success rate (anxiolysis, behavior at separation) of 90% with the combination of oral ketamine 3mgkg -1 and midazolam 0,25mgkg -1 versus 70% and 51% with respectively midazolam 0,5mgkg -1 and ketamine 6mgkg -1 alone 98 . Nebulized ketamine was able to provide effective sedation but did not have any advantage over nebulized dexmedetomidine as mask acceptance was lower 36,93 . However, the combination of oral ketamine 3mgkg -1 and intranasal dexmedetomidine 2µgkg -1 is promising as this combines the onset time of ketamine with the reliability of dexmedetomidine 86 .…”

“…Based on limited research, doses of 2 or 3mgkg -1 are acceptable. Nebulizing might induce nose irritation but leads to better sedation and less perioperative opioid requirements than oral ketamine 93 .…”

Comparison between oral midazolam versus oral ketamine plus midazolam as preanesthetic medication in autism spectrum disorder: double-blind randomized clinical trial

“…Although not available in oral formulation, parenteral formulation of S (+)-ketamine has been used as preanesthetic by oral or nasal route, 6 , 7 and more recently by fogging. 8 Despite an obvious and increasing demand, the literature provides little data on preanesthetic medications in the autistic population. 9 Premedication makes the experience less unpleasant for the patient and family members, decreases the possibility of physical stabilization, and facilitates multiprofessional management to the individual with ASD.…”