Feasibility and safety of ketamine for procedural sedation in pediatric patients undergoing electrophysiology procedures: A cohort study

Simone Gulletta; Francesco Fioravanti; Luca Barca; Francesca Caparra; Valentina Martello; Jacopo D'Andria Ursoleo; Nikita Tanese; Lorenzo Rampa; Alberto Barengo; Gabriele Paglino; Caterina Bisceglia; Giovanni Battista Forleo; Marco Schiavone; Paolo Emilio Della Bella; Fabrizio Monaco

doi:10.1016/j.ijcard.2025.133917

Feasibility and safety of ketamine for procedural sedation in pediatric patients undergoing electrophysiology procedures: A cohort study

Int J Cardiol. 2025 Sep 20:443:133917. doi: 10.1016/j.ijcard.2025.133917. Online ahead of print.

Authors

Affiliations

¹ Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy. Electronic address: gulletta.simone@hsr.it.
² Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy.
³ Vita-Salute San Raffaele University, Faculty of Medicine and Surgery, School of Medicine, IRCCS San Raffaele Scientific Institute, Milan, Italy.
⁴ Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
⁵ Department of Cardiology, Azienda Ospedaliera-Universitaria "Luigi Sacco", Milan, Italy.
⁶ Department of Clinical Electrophysiology and Cardiac Pacing at Monzino Cardiology Center, Milan, Italy.

PMID: 40983184
DOI: 10.1016/j.ijcard.2025.133917

Abstract

Introduction: Electrophysiology (EP) procedures in the pediatric population are often performed aided by anesthetic support under general anesthesia (GA), provided they require a delicate balance between appropriate sedation depth, analgesia, immobility, and hemodynamic stability. GA is still the standard of care but shows several limitations. Ketamine sedation (KS) offers an alternative to GA with preserved respiratory and cardiovascular function, yet its role in pediatric EP procedures remains understudied.

Methods: We retrospectively included 217 consecutive pediatric patients (<18 years) who underwent their first EP procedure at our center between 2016 and 2024. Patients received either KS (n = 37) or GA (n = 180) based on anesthesiologist and cardiologist preference. Primary endpoints were the GA conversion rate, perioperative complications, "door-to-door" operating room occupation time and postprocedural recovery time. Secondary endpoints included results of the electrophysiology study (EPS), change in electrocardiography parameters before, during and after drug infusion and difference of vital signs behavior between the two groups. Propensity score matching (PSM) was performed to correct for age, body mass index (BMI), type of procedure and sex.

Results: Before PSM, compared with the GA group, the KS cohort was older (mean age 13.5 ± 4.5 vs. 11.3 ± 3.2 years in GA; p = 0.02), while sex distribution and BMI were similar. After PSM, there were no significant differences between the tested variables. No KS patient required GA conversion or experienced complications (e.g., emergence delirium). Shorter operating room door-to-door occupation time (KS 79.3 ± 47.2 min; p = 0.0026 vs GA 100.8 ± 37.2 min) and shorter recovery room time were reported in the KS group compared to the GA group (15 ± 19 min vs 41.5 ± 14 min; p = 0.001). No significant differences in the EPS result was observed between the two groups (19.4 % vs. 22.7 %; p = 0.59). In KS patients, electrocardiographic parameters remained stable before, during and at the end of procedure.

Conclusions: Ketamine-based sedation is a safe and effective alternative to GA for pediatric EP procedures, maintaining hemodynamic and electrocardiographic stability. Moreover, KS enhances operating room efficiency by reducing both periprocedural and recovery times.

Keywords: Deep sedation; Electrophysiological study; General anesthesia; Ketamine; Pediatric anesthesia.