What are the clinical guidelines for using ketamine in infants and toddlers?

Clinical Guidelines for Ketamine Use in Infants and Toddlers

Ketamine is recommended for procedural sedation in infants and toddlers with atropine premedication, particularly for intubation and invasive procedures in septic shock, as it maintains cardiovascular stability while providing effective sedation and analgesia. 1

Dosing Guidelines

Intravenous (IV) Administration

• Initial dose: 1-1.5 mg/kg IV 2
• Supplemental dosing: 0.25-0.5 mg/kg as needed 2
• Age-specific considerations:
  • 2-year-olds: 2.125 mg/kg 3
  • 6-year-olds: 2 mg/kg 3
  • 12-year-olds: 1.75 mg/kg 3

Intramuscular (IM) Administration

• Initial dose: 3-4 mg/kg IM 2, 4
• Optimal dose range: 4-5 mg/kg IM (provides adequate sedation in 93-100% of children) 4
• Onset of action: 3-5 minutes 2
• Duration of action: 15-30 minutes 2

Indications

1. Procedural sedation for:

   • Orthopedic procedures 1
   • Wound management 1
   • Laceration repair 1
   • Burn care 1
   • Lumbar puncture 1

2. Intubation and invasive procedures in septic shock 1

   • Maintains cardiovascular stability through:
     • Blocking nuclear factor-kappa B transcription
     • Reducing systemic interleukin-6 production
     • Maintaining intact adrenal axis 1

Monitoring Requirements

• Continuous pulse oximetry
• Heart rate and blood pressure monitoring every 5 minutes
• Close observation of respiratory status and level of consciousness 2
• Consider capnography for early detection of hypoventilation 2
• For moderate to deep sedation: continuous capnography and ECG 2

Safety Profile

Advantages

• Maintains cardiovascular stability 1
• High efficacy rate (approaching 100% in clinical studies) 1, 2
• Rapid onset of action 2
• Low rate of significant adverse events without serious sequelae 1

Adverse Effects

• Respiratory events:

  • Hypoxemia (SpO₂ <90%): approximately 1.6% with ketamine alone 2
  • Laryngospasm: 0.9-1.4% in general ED settings 1
  • Higher risk (8.2%) in children undergoing gastrointestinal procedures, particularly in children <6 years (13.9%) 1

• Other common adverse effects:

  • Emesis: 7-14% of cases 2
  • Recovery agitation: more common in younger children 2
  • Ataxia during recovery: 7% of cases 2
  • Tachycardia 2

Special Considerations for Infants and Toddlers

1. Dosing considerations:

   • Younger children require higher weight-based dosing 3, 5
   • Careful titration is essential 2

2. Safety concerns:

   • FDA notes that safety and effectiveness have not been established in patients below 16 years of age 6
   • Animal studies suggest potential neuroapoptosis with NMDA receptor antagonists during rapid brain development 6, 7
   • The window of vulnerability may extend from third trimester through first several months of life 6

3. Adjunctive medications:

   • Atropine: Recommended as premedication (0.02 mg/kg) to reduce secretions 1, 8
   • Midazolam: Often used in combination (0.05-0.1 mg/kg IV) 2
     • Does not decrease recovery agitation 1
     • May decrease incidence of emesis 1
     • Increases risk of respiratory depression when combined 2
     • Doses above 0.3 mg/kg should be used with caution due to risk of desaturation 5

Recovery and Discharge

• Recovery time:

  • IV ketamine: 65-85 minutes 2
  • IM ketamine: approximately 90 minutes (range 60-130 minutes) 2, 8

• Discharge criteria:

  • Return to baseline consciousness
  • Stable vital signs
  • Ability to maintain airway independently 2

Important Caveats and Pitfalls

1. Avoid etomidate in pediatric septic shock as it's associated with increased mortality due to inhibition of adrenal corticosteroid biosynthesis 1

2. Limited data in neonates: Little has been published on ketamine use in newborns with shock, so no firm recommendations can be made for this specific age group 1

3. Risk of respiratory depression: Higher when combined with other sedatives or opioids 2

4. Developmental concerns: Animal studies suggest potential neurotoxicity during periods of rapid brain development 6, 7

5. Contraindications:

   • History of airway instability
   • Active pulmonary infection or disease
   • Increased intracranial pressure
   • Psychosis