Open Access Open Access  Restricted Access Subscription or Fee Access

Ketamine infusions as an adjunct for sedation in critically ill children

Peter N. Johnson, PharmD, BCPS, BCPPS, FPPA, FCCM, Rebecca Mayes, PharmD, Eszter Moore, PharmD, Stephen Neely, MPH, Amy L. Nguyen, PharmD, BCPPS, Jamie L. Miller, PharmD, BCPS, BCPPS, FPPA


Objective: Limited reports have described ketamine’s role as an adjunct sedative. The purpose was to describe ketamine’s role as an adjunct to achieve goal sedation in mechanically ventilated children.

Design: Retrospective, descriptive study.

Setting: Thirteen-bed pediatric intensive care unit (ICU) and 12-bed pediatric cardiovascular ICU.

Participants: Seventy-three ketamine courses were included, representing 62 mechanically ventilated children <18 years receiving ketamine for 12 hours.

Main outcome measure(s): The primary outcome was to determine the median dose and time to achieve goal sedation (80 percent of State Behavioral Scale scores between 0 and –1) based on ketamine’s place in therapy as an adjunct in the sedation regimen. Secondary outcomes included a comparison of sedative dosing pre- and post-ketamine initiation between place in therapy groups and paralyzed/nonparalyzed patients, and identification of ketamine-attributed adverse drug event (ADEs) or iatrogenic withdrawal syndrome (IWS).

Results: The median age was 1.0 years (interquartile range: 0.4-4.9). Ketamine was initiated as first-line (n = 7; 9.6 percent), second-line (n = 39; 53.4 percent), third-line (n = 26; 35.6 percent), or fourth-line (n = 1; 1.4 percent) sedation. The median initial and peak doses were 0.6 mg/kg/h (0.3-0.6) and 0.9 mg/kg/h (0.9-1.2), respectively. The median dose and time to achieve goal sedation was 0.8 mg/kg/h (0.6-1.1) and 2 hours (1-7), respectively. ADEs were noted during three courses (4.1 percent) and IWS after discontinuation of one course (1.4 percent).

Conclusions: The majority were initiated on ketamine as a second- or third-line adjunct sedative. The median initial dose was 0.6 and dose to achieve goal sedation was 0.8 mg/kg/h. Ketamine-attributed ADEs and IWS episodes were rare.


ketamine, sedation, pedi

Full Text:



Anand KJS, Clark AE, Willson DF, et al.: Opioid analgesia in mechanically ventilated children: Results from the multicenter Measuring Opioid Tolerance Induced by Fentanyl Study. Pediatr Crit Care Med. 2013; 14: 27-36.

Twite MD, Rashid A, Zuk J, et al.: Sedation, analgesia, and neuromuscular blockade in the pediatric intensive care unit: Survey of fellowship training programs. Pediatr Crit Care Med. 2004; 5: 521-532.

Mody K, Kaur S, Mauer EA, et al.: Benzodiazepines and development delirium in critically ill children: Estimating the causal effect. Crit Care. 2018; 46: 1486-1491.

Heiberger AL, Ngorsuraches S, Olgun G, et al.: Safety and utility of continuous ketamine infusion for sedation in mechanically ventilated pediatric patients. J Pediatr Pharmacol Ther. 2018; 23: 447-454.

Neunhoeffer F, Hanser A, Esslinger M, et al.: Ketamine infusion as a counter measure for opioid tolerance in mechanically ventilated children: A pilot study. Pediatr Drugs. 2017; 19: 259-265.

Tobias JD, Martin LD, Wetzel RC: Ketamine by continuous infusion for sedation in the pediatric intensive care unit. Crit Care Med. 1990; 18: 819-821.

Barbi E, Rizzello E, Taddio A: Use of ketamine continuous infusion for pediatric sedation in septic shock. Pediatr Emerg Care. 2010; 26: 689-690.

Ito H, Sobue K, Hirate H: Use of ketamine to facilitate opioid withdrawal in a child. Anesthesiology. 2006; 104: 1113.

Strube PJ, Hallam PL: Ketamine by continuous infusion in status asthmaticus. Anaesthesia. 1986; 41: 1017-1019.

Denmark TK, Crane HA, Brown L: Ketamine to avoid mechanical ventilation in severe pediatric asthma. J Emerg Med. 2006; 30: 163-166.

Allen JY, Marcias CG: The efficacy of ketamine in pediatric emergency department patients who present with acute severe asthma. Ann Emerg Med. 2005; 46: 43-50.

Petrillo TM, Fortenberry JD, Linzer JF, et al.: Emergency department use of ketamine in pediatric status asthmaticus. J Asthma. 2001; 38: 657-664.

Rock MJ, Reyes De La Rocha S, L’Hommedieu CS, et al.: Use of ketamine in asthmatic children to treat respiratory failure refractory to conventional therapy. Crit Care Med. 1986; 14: 514-516.

Nehama J, Pass R, Bechtler-Karsch A, et al.: Continuous ketamine infusion for the treatment of refractory asthma in a mechanically ventilated infant: Case report and review of the pediatric literature. Pediatr Emerg Care. 1996; 12: 294-297.

Agrawal A, Shrivastava J: Intravenous ketamine for refractory bronchospasm precipitated by H1N1 infection. Front Pediatr. 2014; 2: 24.

Youssef-Ahmed MZ, Silver P, Nimkoff L, et al.: Continuous infusion of ketamine in mechanically ventilated children with refractory bronchospasm. Intensive Care Med. 1996; 22: 972-976.

Park S, Choi AY, Park E, et al.: Effects of continuous ketamine infusion on hemodynamics and mortality in critically ill children. PLoS One. 2019; 14: e0224035.

Moore E, Mayes R, Harkin M, et al.: Extended duration ketamine infusions in critically ill children: A case report and review of the literature. J Pediatr Intensive Care. 2020; 1-8. DOI:10.1055/s-0040-1713144.

Golding CL, Miller JL, Gessouroun MR, et al.: Ketamine continuous infusions in critically ill infants and children. Ann Pharmacother. 2016; 50: 234-241.

Flint RB, Brouwer CNM, Kranzlin ASC, et al.: Pharmacokinetics of S-ketamine during prolonged sedation at the pediatric intensive care unit. Paediatr Anaesth. 2017; 27: 1098-1107.

Kinder KL, Lehman-Huskamp KL, Gerard JM: Do children with high body mass indices have a higher incidence of emesis when undergoing ketamine sedation? Pediatr Emerg Care. 2012; 28: 1203-1205.

WHO Multicentre Growth Reference Study Group: WHO Child Growth Standards: Length/Height-for-Age, Weight-for-Age, Weight-for-Length, Weight-for-Height and Body Mass Index-for-Age: Methods and Development. Geneva, Switzerland: World Health Organization, 2006. Available at Accessed July 22, 2020.

Centers for Disease Control and Prevention: Children’s BMI tool for schools. 2011. Available at Accessed July 22, 2020.

Ibach BW, Miller JL, Woo S, et al.: Characterization of tolerance in children during fentanyl continuous infusions. J Pediatr Intensive Care. 2017: 6; 83-90.

Flynn JT, Kaelber DC, Baker-Smith CM, et al.: Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017; 140: e20171904.

Curley MA, Harris SK, Fraser KA, et al.: State Behavioral Scale: A sedation assessment instrument for infants and young children supported on mechanical ventilation. Pediatr Crit Care Med. 2006; 7: 107-114.

Johnson PN, Skrepnek G, Golding CL, et al.: Relationship between rate of fentanyl infusion and time to achieve sedation in nonobese and obese critically ill children. Am J Health Syst Pharm. 2017; 74: 1174-1183.

Franck LS, Scoppettuolo LA, Wypij D, et al.: Validity and generalizability of the Withdrawal Assessment Tool-1 (WAT-1) for monitoring iatrogenic withdrawal syndrome in pediatric patients. Pain. 2012; 153: 142-148.



  • There are currently no refbacks.