What is the recommended route and dose of ketamine (intravenous anesthetic) for an 8-year-old undergoing a reduction procedure for a fractured bone?

Ketamine Route and Dosage for Bone Fracture Reduction in an 8-Year-Old Child

For an 8-year-old child undergoing a bone fracture reduction procedure, intravenous ketamine at a dose of 1.5-2 mg/kg is recommended as the most effective and safe option. 1

Recommended Route and Dosing

Intravenous (IV) Administration

• IV ketamine at 1.5-2 mg/kg provides adequate sedation for fracture reduction in pediatric patients 1
• Onset of action is rapid, typically within 30-96 seconds, allowing for quick procedural intervention 1
• Average time from IV administration to fracture manipulation is approximately 1 minute 36 seconds (range: 20 seconds to 5 minutes) 2
• Recovery time averages 84 minutes (range: 22-215 minutes) 1

Alternative: Intramuscular (IM) Administration

• If IV access cannot be established, IM ketamine at 4 mg/kg is an effective alternative 1, 2
• Onset of action is slower with IM administration, averaging 4 minutes 42 seconds (range: 60 seconds to 15 minutes) 1
• Recovery time with IM administration averages 90 minutes (range: 60-130 minutes) 1

Administration Protocol

Pre-Procedure Considerations

• Administer an antisialagogue prior to ketamine to reduce salivation 3
• Ensure continuous monitoring of vital signs including SpO2, heart rate, and blood pressure 4
• Emergency airway equipment must be immediately available 3

Procedural Monitoring

• Ketamine should be administered by or under the direction of physicians experienced in general anesthetics and airway management 3
• Maintain continuous monitoring throughout the procedure and recovery period 3
• All patients should maintain SpO2 >93% on room air 1

Efficacy and Safety Considerations

Efficacy

• Studies show that 1.5 mg/kg IV ketamine results in only 5.5% of patients requiring additional doses, compared to 54% of patients requiring additional doses when 1 mg/kg was used 1
• All patients receiving appropriate dosing achieve adequate sedation for reduction procedures 1, 2

Safety Profile

• Common side effects include:
  • Emesis (7-8% of patients) 1, 2
  • Nausea (4-5% of patients) 1
  • Ataxia (7-8% of patients) 1
  • Dysphoria (1% of patients) 1
• Serious adverse events are rare when proper monitoring is in place 2
• Airway patency and independent respiration are typically maintained 2

Clinical Pearls

• Administer IV ketamine slowly (over 60 seconds) to minimize respiratory depression and vasopressor response 3
• Consider adding midazolam (0.05 mg/kg) to reduce the risk of emergence reactions, particularly in older children 1
• Ensure the child has followed nil per os guidelines prior to ketamine administration 3
• For procedures requiring longer sedation, additional increments can be administered to maintain anesthesia 3

Contraindications and Cautions

• Avoid rapid administration as it may result in respiratory depression 3
• Purposeless and tonic-clonic movements may occur during ketamine anesthesia but do not necessarily indicate a need for additional doses 3
• The 100 mg/mL concentration of ketamine must be properly diluted before IV administration 3

By following these guidelines, ketamine provides reliable, safe, and effective sedation for pediatric fracture reduction procedures with minimal pain and high parent satisfaction 2.