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Aim: In children, intravenous anesthetic premedication can be distressing. Intranasal (IN) ketamine offers a less invasive approach., Materials and Methods: We included randomized trials of IN ketamine in anesthetic premedication in children 0-19 years. We performed electronic searches of MEDLINE, EMBASE, Google Scholar, CINAHL, Cochrane Library, Web of Science, Scopus, clinical trial registries and conference proceedings., Results: Among the 23 trials (n = 1680) included, IN ketamine adequately sedated 220/311 (70%) for face mask application, 217/308 (70%) for caregiver separation, 200/371 (54%) for iv. insertion and 19/30 (63%) for monitor application. Vomiting was the most common adverse effect (35/1579 [2.2%])., Conclusion: There is a need for sufficiently powered, methodologically rigorous trials, using psychometrically evaluated, objective outcome measures to meaningfully inform practice.

Background: Ketamine is commonly used for procedural sedation and analgesia (PSA) in children. Evidence suggests it can be administered intranasally (IN). We sought to review the evidence for IN ketamine for PSA in children., Methods: We performed a systematic review of randomized trials of IN ketamine in PSA that reported any sedation-related outcome in children 0 to 19 years. Trials were identified through electronic searches of MEDLINE (1946-2016), EMBASE (1947-2016), Google Scholar (2016), CINAHL (1981-2016), The Cochrane Library (2016), Web of Science (2016), Scopus (2016), clinical trial registries, and conference proceedings (2000-2016) without language restrictions. The methodological qualities of studies and the overall quality of evidence were evaluated using the Cochrane Collaboration's Risk of Bias tool, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, respectively., Results: The review included 7 studies (n = 264) of children ranging from 0 to 14 years. Heterogeneity in study design precluded meta-analysis. Most studies were associated with a low or unclear risk of bias and outcome-specific ratings for quality of evidence were low or very low. In four of seven studies, IN ketamine provided superior sedation to comparators and resulted in adequate sedation for 148/175 (85%) of participants. Vomiting was the most common adverse effect; reported by 9/91 (10%) of participants., Conclusions: IN ketamine administration is well tolerated and without serious adverse effects. Although most participants were deemed adequately sedated with IN ketamine, effectiveness of sedation with respect to superiority over comparators was inconsistent, precluding a recommendation for PSA in children.