Refractory symptoms in paediatric palliative care: can ketamine help?

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Franca Benini, Sabrina Congedi, Luca Giacomelli, Simonetta Papa, Aashni Shah, Gregorio Milani

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Background: One of the main challenges for paediatric palliative care (PPC) is the management of concomitant, different and severe symptoms that frequently affect the quality of life of PPC patients and are often refractory to commonly used pharmacological treatments. Consequently, many efforts are still needed to find the best therapeutic options to handle these refractory conditions. Since the first synthesis of ketamine in the 1960s, its pharmacokinetic and pharmacodynamic properties have been largely investigated and its potential wide range of clinical applications has become clear. However, this molecule still receives poor attention in some areas, including in children and PPC. This narrative review analyses the use of ketamine in children and the potential extension of its applications in PPC in order to provide new options for treatment in the PPC setting.

Methods: Scientific papers published before October 2020 on MEDLINE, EMBASE and the Cochrane Library were considered. The cited references of the selected papers and the authors’ personal collections of literature were reviewed. The terms “palliative care”, “ketamine”, “neuropathic pain”, “procedural pain”, “status epilepticus”, “refractory pain” and “child”, adding “age: birth–18 years” on a further filter were used for the search.

Discussion: The use of ketamine in PPC should be more widely considered due to its overall favourable safety profile and its efficacy, which are supported by an increasing number of studies, although in settings different from PPC and of mixed quality. Ketamine should be proposed according to a case-by-case evaluation and the specific diagnosis and the dosage and route of administration should be tailored to the specific needs of patients. Furthermore, there is evidence to suggest that ketamine is safe and efficacious in acute pain. These findings can prompt further research on the use of ketamine for the treatment of acute pain in PPC.

Conclusion: Ketamine could be a suitable option after the failure of conventional drugs in the treatment of different refractory conditions in PPC.

Keywords: children, clinical needs, ketamine, paediatric palliative care.

Citation: Benini F, Congedi S, Giacomelli L, Papa S, Shah A, Milani G. Refractory symptoms in paediatric palliative care: can ketamine help? Drugs in Context 2021; 10: 2021-2-5. DOI: 10.7573/dic.2021-2-5

Contributions: SG and SP contributed to the literature research and wrote the first draft. All other authors have critically contributed to the analysis of evidence and provided major intellectual input to the paper. All authors have read and approved the final version of the paper before submission.

Disclosure and potential conflicts of interest: The authors declare no conflicts or financial interest in any product or service mentioned in the manuscript, including grants, equipment, medications, employment, gifts and honoraria. All authors have approved the version to be published. The International Committee of Medical Journal Editors (ICMJE) Potential Conflicts of Interests form for the authors is available for download at:

Acknowledgements: None.

Funding declaration: There was no funding associated with the preparation of this article.

Copyright: Copyright © 2021 Benini F, Congedi S, Giacomelli L, Papa S, Shah A, Milani G. Published by Drugs in Context under Creative Commons License Deed CC BY NC ND 4.0 which allows anyone to copy, distribute, and transmit the article provided it is properly attributed in the manner specified below. No commercial use without permission.

Correct attribution: Copyright © 2021 Benini F, Congedi S, Giacomelli L, Papa S, Shah A, Milani G. Published by Drugs in Context under Creative Commons License Deed CC BY NC ND 4.0.

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Correspondence: Franca Benini, Centro Regionale Veneto di Terapia del Dolore and Cure Palliative Pediatriche, Hospice Pediatrico, Padua, Italy. Email:

Provenance: Submitted; externally peer reviewed.

Submitted: 23 February 2021; Accepted: 15 April 2021; Publication date: 19 May 2021.

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