Dexmedetomidine in combination with ketamine for pediatric procedural sedation or premedication: A meta-analysis

Objective: To evaluate effectiveness of combinational use of dexmedetomidine and ketamine (DEX-KET) for pediatric procedural sedation or premedication. Methods: Relevant studies were identified after a literature search in electronic databases and study selection was based on precise eligibility criteria. Meta-analyses of mean differences were performed to examine differences in sedation onset and recovery times between DEX-KET and comparators. Changes from baseline in heart rate (HR), respiratory rate, oxygen saturation, and mean arterial pressure (MAP), were pooled. Meta-analyses of proportions were performed to estimate incidence of adverse events. Results: 15 studies (1087 patients) were included. Onset of sedation was significantly shorter in DEX-KET than in DEX group. HR declined in DEX-KET group from start (-3.5 beats per minute (BPM) [95% CI: -5.1, -1.9]) through midpoint (-7.2 BPM [95% CI: -12.1, -2.3]) and at end of sedation (-8.7 BPM [95% CI: -13.1, -4.4]). Decrease in HR after DEX administration at start was -11.6 BPM [95% CI: -16.0, -7.1] and remained consistent afterward. There was no change in MAP during DEX-KET sedation. However, after DEX administration, MAP decreased by -6.9 [95% CI: -10.4, -3.3] at start, -7.8 [95% CI: -11.4, -4.2] at middle, and by -6.6 [95% CI: -14.4, 1.1] at end of sedation. Incidence of hypotension was 3% [95% CI: 0, 9] in DEX-KET, 7% [95% CI: 2,14] in DEX, and 0% [95% CI: 0, 2] in KET groups. Incidence of bradycardia was 2% [95% CI: 0, 6] with DEX-KET and 12% [95% CI: 5, 20] with DEX. Incidence of oxygen desaturation was 3% [95% CI: 0, 8] in DEX-KET, 2% [95% CI: 0, 6] in DEX, 12% [95% CI: 5, 20] in KET, and 13% [95% CI: 6, 21] in PROP-KET groups. MIDA-KET sedation had 13% [95% CI: 4, 25] incidence of tachycardia. Conclusions: DEX-KET for pediatric sedation results in better sedation outcomes than DEX or KET by shortening onset of sedation and recovery while maintaining hemodynamic and respiratory stability with low incidence of adverse events. DEX sedation was associated with higher incidence of bradycardia. Higher incidence of oxygen desaturation was observed with KET and PROP-KET whereas MIDA-KET was associated with higher incidence of tachycardia. (c) 2021 Elsevier Inc. All rights reserved.