Ketamine for Analgosedation in Critically Ill Mechanically Ventilated Children: A Systematic Review and Meta-Analysis

Area of Science:

• Pediatric Critical Care Medicine
• Pharmacology
• Evidence-Based Medicine

Background:

• Analgosedation is crucial for critically ill children on invasive mechanical ventilation (IMV).
• Ketamine is an alternative analgosative with potential benefits, but its efficacy compared to other agents in this population is unclear.
• Limited high-quality evidence exists regarding ketamine's role in pediatric intensive care unit (PICU) analgosedation.

Purpose of the Study:

• To systematically review and meta-analyze the available evidence comparing continuous ketamine infusion to other analgosedatives in critically ill children receiving IMV.
• To assess the impact of ketamine on key patient-important outcomes, including ventilation duration, opioid exposure, delirium, withdrawal, length of stay, hypotension, and mortality.

Main Methods:

• Systematic review and meta-analysis of randomized controlled trials (RCTs) and nonrandomized studies.
• Searched multiple electronic databases and trial registries up to September 1, 2025.
• Assessed risk of bias and certainty of evidence using established tools (ROBIS, GRADE).
• Pooled data using random-effects models.

Main Results:

• Included 3 RCTs and 5 nonrandomized studies (n=1436).
• Ketamine showed no significant effect on IMV duration (low certainty).
• Ketamine may reduce opioid exposure (low certainty).
• Effects on delirium, withdrawal, length of stay, hypotension, and mortality were uncertain due to low certainty evidence and study limitations.

Conclusions:

• A paucity of high-quality studies limits understanding of ketamine's role in pediatric analgosedation.
• Current evidence, mostly of very low certainty, suggests potential benefits in opioid reduction but uncertainty in other outcomes.
• Methodologically rigorous RCTs are essential to clarify ketamine's efficacy and safety in critically ill children on IMV.