Keywords
1. Prophylactic Ondansetron
2. Pediatric Ketamine Sedation
3. Emergency Department
4. Vomiting Prevention
5. Sedation Adverse Effects
As children face the prospect of painful procedures in hospital emergency departments (ED), sedation becomes a vital element of their care, ensuring minimal discomfort and anxiety. Ketamine, a well-known sedative, has facilitated procedural sedation in pediatric patients but not without its side effects, chiefly, ketamine-associated vomiting (KAV). A new review article, “Efficacy of prophylactic ondansetron versus placebo or control in reducing vomiting in children undergoing ketamine procedural sedation in the emergency department: A systematic review and meta-analysis,” published in the journal Emergency Medicine Australasia, sheds light on a potential strategy to combat this adverse outcome.
The systematic review and meta-analysis conducted by Hudson Jack L. and colleagues aim to uncover the efficacy of prophylactic ondansetron—a medication commonly used to prevent nausea and vomiting—in reducing the incidence of KAV. The findings are critical, given that KAV not only affects the comfort of young patients but also has implications for the efficiency and flow of emergency department services.
Background and Rationale
Ketamine is recognized for its safety and efficacy in providing procedural sedation, with an extensive history of use, as detailed by Grunwell et al. (2016). However, its associated complications, such as vomiting, present challenges for healthcare professionals aiming for a smooth sedation experience. The team, including Wong Julian, Durkin Michael, Gangathimmaiah Vinay, and Furyk Jeremy, embarked on this comprehensive review, mindful of the balance between effective sedation and patient well-being.
Methods
The investigators methodically sifted through various databases and trial registries as of January 14, 2023, identifying randomized controlled trials that could shed light on the primary outcome: the reduction in KAV incidence with the use of ondansetron prophylaxis. Secondary outcomes observed included the emergency department length of stay, parental satisfaction, and time until a return to a normal diet.
Findings
Pooling data from five eligible trials involving 920 participants, the meta-analysis revealed a significant overall odds ratio of 0.51 (95% CI: 0.36-0.73), suggesting that prophylactic ondansetron does, indeed, result in a notable reduction in the incidence of KAV. Intravenous and intramuscular routes of ondansetron administration showed benefits, while the impact of the oral route remained uncertain. Secondary outcomes did not show differences between groups overall.
However, despite these promising results, the quality of the evidence was evaluated as low overall. The high risk of bias and imprecision in the outcome measures signaled a call for more rigorous methodological research.
Clinical Implications and Future Directions
For clinicians on the ED’s front lines, these findings offer an actionable approach to enhancing the quality of pediatric care. By preemptively administering ondansetron, emergency medicine specialists can potentially reduce the incidence of KAV, thereby improving the procedural experience for children, as well as possibly streamlining departmental workflows.
The review also emphasizes the need for further investigation, particularly rigorous trials examining the timing and route of ondansetron administration to clarify its efficacy definitively.
Conclusion
As highlighted in the review article with DOI 10.1111/1742-6723.14372, the current evidence, although of low to moderate certainty, suggests that prophylactic ondansetron is a boon in the effort to minimize KAV in children who require ketamine for procedural sedation in the emergency department setting. The Australasian College for Emergency Medicine, aligned with the review’s contributors, supports the pursuit of higher-quality evidence to cement ondansetron’s role in this context.
By addressing one of the key adverse effects of pediatric procedural sedation, the hope is to achieve more comfortable, efficient, and parent-satisfying care experiences for our youngest patients facing emergency medical interventions.