Ketamine-Propofol Mix: Recommended Age Range for Sedation
The ketamine-propofol combination can be safely administered to pediatric patients as young as 1 month of age through adolescence (up to 20 years), with the strongest evidence supporting use in children aged 1-15 years for procedural sedation. 1, 2
Pediatric Age Range Evidence
Established Safety Across Age Groups
Infants and young children (1 month to 3 years): Ketamine has been studied in combination with midazolam in children as young as 1 month, demonstrating safety in this age group 1. While propofol monotherapy is not FDA-approved for induction below age 3 years or maintenance below 2 months 3, the addition of ketamine to propofol has been used safely in children aged 1-13 years 4.
School-age children (5-15 years): The highest quality randomized controlled trial evidence comes from this age group, where ketamine-midazolam demonstrated superior safety compared to fentanyl-midazolam, with significantly less hypoxia (6% vs 25%) 1. This age range represents the most robust evidence base for ketamine combinations 2.
Adolescents and young adults (up to 20 years): Ketamine combinations have been documented as safe in patients up to age 20 years in gastroenterology studies 1.
Propofol Component Age Restrictions
FDA-Approved Age Limits for Propofol
Propofol alone is FDA-approved for anesthesia induction in children ≥3 years and maintenance in children ≥2 months 3
Propofol is NOT approved for pediatric ICU sedation or MAC sedation at any age due to safety concerns, including reports of serious adverse events and mortality in critically ill children 3
Clinical Practice with Ketamine-Propofol Combination
The addition of ketamine to propofol appears to mitigate some of propofol's respiratory depression risks, allowing for safe use across a broader pediatric age spectrum than propofol alone 5, 4
In a study of children aged 1-13 years receiving propofol-ketamine for auditory brainstem response testing, zero patients experienced oxygen desaturation or apnea, compared to 11.4% desaturation and 17.1% apnea with propofol alone 4
Dosing Considerations by Age
Age-Related Dosing Adjustments
Younger children require higher weight-based doses of ketamine due to increased clearance rates. For IV ketamine alone, recommended doses increase from 2 mg/kg in adults to 2.125 mg/kg in 2-year-olds 6
When combining ketamine with propofol, typical dosing is ketamine 0.25-0.5 mg/kg followed by propofol 0.4-1 mg/kg, with the ketamine component reducing total propofol requirements by approximately 30% 5, 7
Infusion rates for combined ketamine-propofol maintenance range from 2.5-3.5 mg/kg/hour for ketamine component, with higher rates needed in younger children 6
Critical Safety Considerations
Contraindications Across All Ages
Avoid ketamine component in patients with ischemic heart disease, cerebrovascular disease, uncontrolled hypertension, or increased intracranial pressure, regardless of age 8
Emergence reactions occur in 10-30% of adults but are less common in children, and the addition of propofol appears to minimize this risk 1, 8
Monitoring Requirements
Continuous pulse oximetry, heart rate, and blood pressure monitoring are mandatory for all ages receiving ketamine-propofol combinations 8
Capnometry should be strongly considered for early detection of hypoventilation, particularly given the deeper sedation achieved with this combination 8
Equipment for airway management must be immediately available, as respiratory support may be needed despite the combination's favorable respiratory profile 1, 8
Adult Use Considerations
While the question focuses on pediatric use, ketamine-propofol combinations are also used in adults, though ketamine monotherapy is less common in adults due to higher rates of emergence reactions (10-30% vs lower rates in children) 1. The combination approach helps mitigate this concern 8, 7.