What is the recommended dose for intramuscular (IM) sedation in a one-year-old child without intravenous (IV) access?

Intramuscular Sedation Dosing for a One-Year-Old Child Without IV Access

For a one-year-old child requiring sedation without IV access, the recommended intramuscular (IM) dose is 4-5 mg/kg of ketamine, often combined with 0.05 mg/kg of midazolam. 1

Medication Options and Dosing

Primary Option: Ketamine IM

• Dose: 4-5 mg/kg IM 1, 2
• Onset of action: Within 3-5 minutes after administration 3
• Duration: Approximately 30-45 minutes of adequate sedation 2
• Maximum total dose: Should not exceed manufacturer recommendations based on weight

Adjunctive Medication: Midazolam IM

• Dose: 0.05-0.15 mg/kg IM 3, 4
• For a one-year-old, doses of 0.1-0.15 mg/kg are typically effective 4
• Maximum dose: Total dose usually does not exceed 10 mg 4

Administration Protocol

1. Pre-sedation assessment:

   • Ensure appropriate NPO status
   • Verify no contraindications to ketamine (increased ICP, psychosis, severe hypertension)
   • Have emergency equipment immediately available

2. Medication administration:

   • Administer ketamine 4-5 mg/kg IM in large muscle mass (preferably thigh) 1, 2
   • If using midazolam as adjunct, administer 0.05-0.15 mg/kg IM 3, 4
   • Consider atropine 0.02 mg/kg IM to reduce secretions (optional) 2

3. Monitoring:

   • Continuous pulse oximetry
   • Regular vital sign assessment
   • Observe for airway patency and respiratory effort

Expected Timeline

• Onset: Satisfactory sedation typically occurs within 3-5 minutes 3, 2
• Duration: Adequate working conditions for approximately 30 minutes 2
• Recovery: Average time to discharge is 76-103 minutes from administration 5, 2

Potential Adverse Effects and Management

1. Respiratory:

   • Airway complications are rare (1.4%) but personnel skilled in airway management must be present 1
   • Have appropriate-sized equipment for suctioning, oxygenation, and ventilation immediately available 3

2. Emergence reactions:

   • Less common in young children but may occur 1
   • Midazolam co-administration helps reduce incidence 2

3. Emesis:

   • May occur during recovery phase
   • Position patient appropriately to prevent aspiration

Important Considerations

• IM ketamine provides more reliable sedation than lower doses of IV ketamine in situations without IV access 5, 2
• The combination of ketamine with midazolam provides excellent procedural conditions while reducing emergence reactions 2
• Recovery time is longer with IM administration compared to IV administration 5
• Personnel with skills in airway management must be present and prepared to respond when these agents are administered 3

Caution

• If the patient has cardiovascular dysfunction or volume depletion, dosing may need adjustment 3
• Ventilatory support may be necessary; always be prepared to provide respiratory support 3
• Monitor oxygen saturation throughout the procedure and recovery 3

Remember that IM administration provides reliable sedation but has a slower onset and longer duration compared to IV administration, requiring appropriate monitoring throughout the procedure and recovery period.