Written by Shannon Markus
This systematic review suggests that non-injectable ketamine (oral or intranasal) can provide effective and safe pediatric procedural sedation, particularly compared with other oral agents, although the certainty of evidence is low.
Sedation without the stick
This systematic review assessed noninjectable ketamine (oral and intranasal) for pediatric procedural sedation in the emergency department. Using PRISMA methodology and a comprehensive multi-database search through July 2025, 12 studies (7 RCTs, 5 observational; n=1,484) were included. Oral ketamine at 5–10 mg/kg, particularly when combined with midazolam, generally achieved adequate sedation with onset of 15–35 minutes and duration of 60–265 minutes, while intranasal ketamine demonstrated faster onset (~10 minutes). Duration for IN ketamine was 238 minutes, but this was only derived from a single study. Sedation success exceeded 80% in several cohort studies, and higher oral doses or combination regimens were associated with reduced need for additional “rescue” sedation. No study reported serious cardiopulmonary adverse events requiring invasive airway intervention; minor adverse effects were uncommon and comparable to oral midazolam. The study was strengthened by rigorous methodology and structured bias assessment; limitations include substantial heterogeneity in dosing, routes, procedures, and outcome definitions, with overall low certainty of evidence for many efficacy outcomes.
How does this change my practice?
This review doesn’t change my preference for IV ketamine, given its speed and predictability. That said, I’m more open to flexibility in select cases based on the safety and comfort benefits highlighted here. Oral or intranasal ketamine seem like a reasonable way to spare kids the trauma of an IV stick, but my eyes popped a little when I saw the upper range of sedation duration with oral ketamine (265 minutes?!?). Importantly, most studies compared PO/IN ketamine to other ORAL agents—not IV ketamine. While Non-IV ketamine looks favorable relative to other oral sedatives, the time tradeoff between IV and non-IV ketamine is really hard to justify in a busy ED.
Source
Non-Injectable Ketamine for Pediatric Sedation in the Emergency Department: A Systematic Review. Acad Emerg Med. 2025 Dec;32(12):1344-1355. doi: 10.1111/acem.70163. Epub 2025 Oct 10. PMID: 41069251.
