Adding ketamine to an opioid in a patient-controlled analgesia device: is it really relevant in the pediatric population?

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We read with a great interest the meta-analysis performed by Assouline et al. concerning adding ketamine to patient-controlled analgesia on postoperative pain management. The study1 is of high quality and is performing according to recent recommendation on systematic reviews, especially concerning the trial sequential analysis.
However, studies included in this meta-analysis mixed both adults and children studies and only 2 pediatric studies were included in this meta-analysis. We have performed to date 2 meta-analyses concerning the effects of administering ketamine to children.2,3 Results displayed no evidence of a decrease in postoperative pain associated with the administration of ketamine and a slight evidence for an opioid sparing effect of this compound in this special population (0.04 mg/kg decrease of morphine consumption over the first postoperative day) when ketamine was administered during 24 hours after surgery. When applied to adult patients, this would make a decrease of 2.8 mg during the first postoperative day, while overall results displayed by the meta-analysis performed by Assouline et al. displayed a decrease of 13 mg during the first postoperative day (4.5 times greater).
We would caution, on the basis of our meta-analyses of ketamine in children, that the robustly favorable effects of ketamine in patient-controlled analgesia found in a predominantly adult population may not be seen in children.
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