What is the recommended dose of ketamine (ketamine hydrochloride) for sedation in pediatric (peds) patients?

Ketamine Dosing for Pediatric Sedation

For procedural sedation in children, administer 1.5-2 mg/kg IV or 4 mg/kg IM ketamine, as the 1.5 mg/kg IV dose requires fewer redoses and achieves adequate sedation in a single administration compared to lower doses. 1, 2

Intravenous Dosing

The optimal IV starting dose is 1.5 mg/kg rather than 1.0 mg/kg. 1, 2

• 1.5 mg/kg IV achieves adequate sedation with a single dose in most patients, whereas 1.0 mg/kg requires significantly more redosing (median 2 doses vs 1 dose, p=0.02). 2
• The lower 1.0 mg/kg dose paradoxically results in higher total cumulative dosing (1.71 mg/kg vs 1.60 mg/kg, p<0.01) due to repeated administrations. 2
• Only 5.5% of patients receiving 1.5 mg/kg require additional ketamine, compared to 54% with 1.0 mg/kg. 1
• Onset of action occurs within 30-96 seconds with IV administration. 3, 1
• Recovery time averages 84 minutes (range 22-215 minutes) after IV dosing. 3, 1

Dosing for Combination Therapy

• When combining with midazolam, use ketamine 1-2 mg/kg IV plus midazolam 0.05-0.1 mg/kg IV. 3
• This combination achieves 100% procedural success rates for orthopedic and laceration procedures. 3

Intramuscular Dosing

For IM administration, use 4 mg/kg as the initial dose. 3, 1

• Repeat doses of 2-4 mg/kg IM may be given after 5-10 minutes if needed. 1
• Onset occurs within 3-5 minutes with IM administration. 3, 1
• Recovery time averages 90 minutes (range 60-130 minutes) after IM dosing. 3
• Mean effective IM dose in clinical practice is 5.5 mg/kg (range 3.65-8.91 mg/kg). 3

IM Combination Regimens

• For younger children (ages 1-7 years), IM ketamine 3 mg/kg combined with midazolam 0.05 mg/kg and glycopyrrolate is safe and effective. 3
• This regimen achieves cooperative sedation in 70% of patients, with 30% requiring an additional 1 mg/kg ketamine dose. 3

Age-Specific Considerations

Younger children require higher weight-based doses than older children and adults. 4

• 2-year-olds: 2.125 mg/kg IV for single-dose sedation 4
• 6-year-olds: 2.0 mg/kg IV for single-dose sedation 4
• 12-year-olds: 1.75 mg/kg IV for single-dose sedation 4
• Recovery agitation is more common in younger children (OR 0.79 per year of age, p<0.001). 3
• Emesis increases with age (OR 1.25 per year, p<0.001). 3

Safety Profile and Adverse Events

Ketamine demonstrates excellent respiratory safety with serious airway complications occurring in only 1.4% of patients, none requiring intubation. 3

• Transient desaturations occur in 1.6-8.4% of patients and respond to simple interventions (oxygen, repositioning, stimulation). 3, 5
• Mild recovery agitation occurs in 17.6% of patients; moderate-to-severe agitation in only 1.6%. 3, 1
• Emesis without aspiration occurs in 6.7-19.4% of cases. 3, 1
• Increased secretions occur in 17.6% of patients. 5
• No serious sequelae or hospitalizations due to ketamine in large cohort studies. 3

Critical Monitoring Requirements

Continuous monitoring of oxygen saturation, heart rate, and blood pressure is mandatory throughout sedation. 1

• Maintain SpO2 >93% on room air during procedures. 3, 1
• Have bag-valve-mask ventilation and intubation equipment immediately available. 3, 6
• Do not discharge until patient returns to baseline mental status. 6

Common Pitfalls to Avoid

Avoid using 1.0 mg/kg IV as the initial dose—this leads to more frequent redosing and higher cumulative doses without improving safety. 2

• Do not administer midazolam >0.3 mg/kg, as desaturation risk increases significantly at this threshold. 5
• Avoid adding midazolam in children >10 years old, as it increases recovery agitation (35.7% vs 5.7%, p<0.001) without benefit. 3
• Single large doses cause deeper sedation and delayed recovery compared to split-dose or infusion techniques. 4

Alternative Dosing Strategies

For continuous painful procedures, consider an initial bolus of 0.25-0.35 mg/kg IV followed by infusion at 2.5-3.5 mg/kg/hour for more even sedation and faster recovery (20 minutes to light sedation). 4

• For intermittent painful stimuli, use initial dose of 1.5 mg/kg IV with half-dose "top-up" at 8 minutes for same sedation depth but earlier recovery. 4