Is ketamine safe for traumatic brain injury? A systematic review and meta-analysis.

INTRODUCTION

Traumatic brain injury (TBI) is a medical emergency requiring immediate intervention, often necessitating sedation and endotracheal intubation. For these procedures, anesthetic agents such as ketamine are frequently employed. Historically, ketamine has been associated with increased intracranial pressure (ICP), raising concerns about its use in TBI patients and suggesting a potentially poor prognosis. However, recent studies have challenged this paradigm, indicating that ketamine may be safe in this context. This study aims to evaluate the safety of ketamine administration in patients with TBI and its hemodynamic effects.

METHODS

This systematic review and meta-analysis was registered in PROSPERO under protocol number CRD420251103556 and received no financial support. The PRISMA methodology was applied, based on prior studies retrieved from PubMed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL). Inclusion criteria comprised studies involving patients with traumatic brain injury who received ketamine for tracheal intubation or analgosedation, compared to other anesthetic agents or placebo. Exclusion criteria included overlapping populations, conference abstracts, and studies published before 2015.

RESULTS

The initial search of PubMed, Embase, and Cochrane yielded 246 records. After removal of duplicates and exclusion based on title and abstract screening according to eligibility criteria, 19 studies were fully reviewed, and 15 met the inclusion criteria and were included in the final analysis, including 4 RCTs. For hospital mortality, no statistically significant difference was observed between groups (RR = 1.18; 95 % CI [0.90, 1.55]; p = 0.23; I2 = 37.9 %). The statistical analysis showed no statistically significant difference in ICP elevation between the ketamine and no-ketamine groups in patients with baseline ICP < 20 mmHg (RR = 0.67; 95 %CI [0.45, 1.01]; p = 0.054; I2 = 0.0 %). A controversial finding was the association of ketamine use with hypotension episodes (RR = 1.47; 95 %CI [1.22, 1.78]; p < 0.01; I2 = 0.0 %).