(2) Preoperative Sedatives in Pediatric Ambulatory Surgery: Intramuscular Ketamine vs. Sevoflurane: A Systematic Review

Abstract: Problem: Outpatient pediatric anesthesia is an essential skill set for oral and maxillofacial surgeons (OMSs). Even for experienced OMSs, the use of non-pharmacological interventions including distraction, show and tell, etc. cannot always provide safe and secure IV access required to initiate the procedure.1 Notably, it is well-documented that traumatic operative experiences can lead to long-lasting postoperative behavioral complications.2 It is of the utmost importance for OMSs – particularly in elective outpatient procedures – to master appropriate management of the anxious, uncooperative child. Various routes of pharmacological premedication administration exist, and of those, the intramuscular (IM) and inhalational routes are 2 that can be administered with predictable response and are not heavily reliant on patient compliance[2]. The purpose of this systematic review is to evaluate the safety and effectiveness of intramuscular ketamine vs mask sevoflurane, for anesthesia induction in the pediatric population and to identify research goals for a future randomized clinical trial.
Materials and methods: A systematic review was conducted using two separate PubMed searches, conducted in December 2023. The goal was to answer the research question: (P) in a population of pediatric patients undergoing outpatient intravenous sedation, (I) does mask sevoflurane, (C) when compared with IM ketamine, (O) result in less adverse events? Search was conducted using search terms: 1. “(intramuscular ketamine OR sevoflurane) AND (venous access OR cannulation OR induction) AND (pediatric) and 2. “(pediatric OR children) AND (intramuscular) AND (ketamine)”. Resulting articles were screened by title/abstract followed by full text screening and exclusion based on relevance.
Methods of data analysis: Statistics were performed to calculate the primary and secondary outcomes when there was homogenous and comparable data available between the studies to analyze trends and differences between the two predictor variables.

Results: A total of 1,604 articles were found in the initial review. After first and second reviews looking at titles, and abstract, 1,306 articles were excluded. The remaining 54 articles underwent full text review, resulting in the inclusion of 13 studies. There exists a paucity of literature directly comparing IM ketamine to sevoflurane mask induction, with only 3 included studies directly comparing the 2 modalities. A total of 194 subjects were included within the 3 articles making direct comparisons of sevoflurane vs IM ketamine.
Outcome data: From the reviewed articles, higher dose IM ketamine (>2.5mg/kg-4mg/kg) showed better sedation and tolerance of IV/procedure, with a mild increase in adverse events. Older age was associated with more complications. Laryngospasms were only noted in sevoflurane groups and adverse events were associated with higher weight and early IV access ( < 105s). Intraoperative and postoperative nausea and vomiting was only seen in the ketamine group, associated with repeat doses of ketamine. Both IM ketamine and sevoflurane showed similar overall hemodynamic stability.

Conclusions: Of the current available literature, there is equivocal difference between IM ketamine and sevoflurane induction in terms of time to venepuncture, hemodynamic stability, overall operating room time, time to discharge, and adverse events. However, little literature currently exists directly comparing the two. Future research should focus on direct comparison of patient outcomes including parent satisfaction, postoperative nausea and vomiting, tolerance of procedure, and IV access success between the two groups.