PROCEDURAL ANALGOSEDATION WITH INTRAVENOUS KETAMINE PERFORMED BY PEDIATRICIANS IN THE PEDIATRIC EMERGENCY DEPARTMENT: THE REGINA MARGHERITA CHILDREN’S HOSPITAL EXPERIENCE

C.M. Pini¹, Y. Xu², E. Dall' Olio¹, M. Pagano¹, A.G. Delmonaco¹, M. Taglietto³, E. Castagno¹, C. Bondone¹ | ¹Emergency Pediatrics Department, Regina Margherita Children's Hospital, Torino; ²Residency Program in Pediatrics, University of Torino; ³Pediatric Anesthesia and Resuscitation Department, Regina Margherita Children's Hospital, Torino

INTRODUCTION
Recognizing and managing pain is a key objective in every pediatric Emergency Department (ED). Preventing pain during procedures is equally important, and procedural analgosedation (PAS) is an effective mean of achieving this. Among the drugs used for moderate to deep PAS, ketamine stands out due to its analgesic, sedative, and dissociative properties, while maintaining cardiovascular and respiratory stability. These characteristics make it suitable for use by non-anesthesiologist medical staff, provided they receive appropriate training in its administration and in managing potential side effects¹. The aims of this retrospective study are:
1. To describe the training completed by ED pediatricians at the Regina Margherita Children’s Hospital (OIRM) in Turin for the administration of intravenous (IV) ketamine for PAS
2. To analyze the use of ketamine in the pediatric ED in order to identify potential areas for improvement.
METHODS
The study was conducted in the pediatric ED of OIRM, which treats approximately 40,000 patients annually. Pediatricians at the OIRM ED underwent a structured training program consisting of three 4-hour theoretical and practical sessions, held within the hospital and supervised by an anesthesiologist experienced in PAS. Key topics included drug interactions, monitoring systems, and the assessment of vital function recovery following PAS. During training, pediatricians were mentored by anesthesiologists and progressively gained autonomy in performing IV ketamine PAS. Upon successfully completing a final assessment, they were authorized to independently administer IV ketamine for PAS in the ED, in accordance with the regional protocol “Management of acute and procedural pain in children in out-of-hospital settings, emergency departments, and pediatric units of Piedmont hospitals”.
RESULTS
Between July 1, 2023, and April 30, 2025, 7 pediatricians completed the training. The training focused on identifying suitable candidates for PAS, understanding the pharmacodynamics and pharmacokinetics of IV ketamine, monitoring and evaluating full recovery post-PAS, and managing potential adverse effects. All participating pediatricians were PALS certified. A total of 24 IV ketamine PAS procedures were performed. All patients were classified as ASA I or II. The mean dosage was 1.4 mg/kg (SD 0.48). In 22 out of 24 cases, ketamine was combined with other sedative or analgesic agents, administered either locally or systemically. Only one mild adverse event (regurgitation) was recorded. Patients were monitored during and after PAS, and the sedation was considered effective in all but one case. However, a standardized sedation scale (Pediatric Sedation State Scale, PSSS) was explicitly documented in only two cases.
CONCLUSIONS
Ketamine has proven to be a safe and effective agent for PAS when administered by appropriately trained pediatricians. Expanding this training to all ED pediatricians is crucial. PAS implementation should include standardized methods for data collection and consistent use of validated sedation assessment tools².