What are the recommended doses of Versed (midazolam) and ketamine for conscious sedation in a 28 kg child?

Recommended Dosing of Versed (Midazolam) and Ketamine for Conscious Sedation in a 28 kg Child

For a 28 kg child requiring conscious sedation, the recommended doses are midazolam 0.05-0.1 mg/kg IV (1.4-2.8 mg) followed by ketamine 1-1.5 mg/kg IV (28-42 mg), with careful titration to effect.

Midazolam (Versed) Dosing

Intravenous Administration

• Initial dose: 0.05-0.1 mg/kg (1.4-2.8 mg for a 28 kg child) 1
• Administer slowly over 2-3 minutes
• Wait an additional 2-3 minutes to fully evaluate sedative effect before initiating procedure or repeating dose
• Maximum total dose: Up to 0.4 mg/kg (11.2 mg) may be needed but usually does not exceed 10 mg 1

Important Considerations for Midazolam

• For a 28 kg child (approximately 6-8 years old), use the dosing recommendations for the 6-12 years age group
• Titrate slowly to desired clinical effect to avoid respiratory depression
• Reduce dose when combined with ketamine or other CNS depressants 1, 2
• Higher risk of respiratory depression when combined with opioids 3

Ketamine Dosing

Intravenous Administration

• Initial dose: 1-1.5 mg/kg IV (28-42 mg for a 28 kg child) 4
• When combined with midazolam: 1-2 mg/kg (28-56 mg) 3
• May be titrated in increments if needed for adequate sedation

Important Considerations for Ketamine

• Ketamine provides both sedation and analgesia through dissociative effects
• Efficacy for procedural sedation approaches 100% in clinical studies 3
• Consider using lower initial doses (1 mg/kg) for older children/adolescents 4
• Onset of action is rapid (within 1-2 minutes) for IV administration

Monitoring and Safety

Required Monitoring

• Continuous pulse oximetry
• Heart rate and blood pressure monitoring
• Consider capnography for early detection of hypoventilation 3
• Close observation of respiratory status and level of consciousness

Potential Adverse Effects

1. Respiratory:

   • Hypoxemia occurs in approximately 6% of children receiving ketamine/midazolam 3
   • Airway obstruction or hypoventilation may occur, especially with higher doses

2. Cardiovascular:

   • Tachycardia (common with ketamine)
   • Potential hypotension (more common with midazolam)

3. Other:

   • Emergence reactions (8.7%) 5
   • Increased secretions (17.6%) 5
   • Nausea and vomiting (9.2%) 5

Practical Administration Tips

Preparation

• Have airway management equipment immediately available
• Ensure IV access is secure before administration
• Have reversal agents available (flumazenil for midazolam)

Administration Sequence

1. Administer midazolam first (1.4-2.8 mg IV over 2-3 minutes)
2. Wait 2-3 minutes to assess effect
3. Then administer ketamine (28-42 mg IV)
4. Titrate additional doses as needed for adequate sedation

Recovery

• Monitor until return to baseline consciousness
• Typical recovery time is 65-85 minutes after ketamine administration 4
• Ensure patient has stable vital signs before discharge

Common Pitfalls to Avoid

1. Rapid administration: Administering either drug too quickly increases risk of respiratory depression and hypotension

2. Oversedation: Using excessive doses can lead to deeper sedation than intended with increased risk of adverse events

3. Inadequate monitoring: Failure to continuously monitor vital signs and sedation level can lead to missed early signs of complications

4. Age-inappropriate dosing: Children require weight-based dosing, and younger children often need higher mg/kg doses than older children 6

5. Failure to recognize drug interactions: The combination of midazolam and ketamine has synergistic effects requiring dose reduction of both agents 3, 1

By following these guidelines and carefully titrating to effect, you can safely provide effective conscious sedation for a 28 kg child while minimizing the risk of adverse events.