Intranasal Ketamine Dosing for Pediatric Sedation
Direct Answer
For a 12.9 kg child requiring procedural sedation, intranasal ketamine is NOT the recommended route based on current evidence-based guidelines. The American College of Emergency Physicians recommends either IV ketamine 1.5-2 mg/kg (19-26 mg for this child) or IM ketamine 4 mg/kg (52 mg for this child), both combined with atropine 0.01 mg/kg (0.13 mg) 1, 2.
Why Intranasal Route Is Not Recommended
Intranasal ketamine lacks sufficient evidence for procedural sedation in children - the guideline evidence exclusively supports IV and IM routes for this indication 1, 2.
Intranasal midazolam was significantly inferior to IM ketamine in head-to-head comparison, with only 70% of patients cooperative during suturing versus 100% with IM ketamine 1.
The intranasal route is primarily studied for depression treatment in adults, not pediatric procedural sedation, making extrapolation inappropriate 3, 4.
Recommended Alternative: IV Ketamine Protocol
The preferred approach is IV ketamine 1.5-2 mg/kg (19-26 mg total) combined with atropine 0.01 mg/kg (0.13 mg) 2, 5.
Dosing Rationale
The 1.5 mg/kg dose is superior to 1.0 mg/kg, with only 5.5% requiring additional doses versus 54% with lower dosing 1, 2, 5.
Onset occurs within 30-96 seconds, allowing rapid procedural intervention 2, 5.
Success rate for procedure completion is 98.9% with appropriate dosing 2.
Administration Details
Atropine 0.01 mg/kg (minimum 0.1 mg, maximum 0.5 mg) must be co-administered to prevent hypersalivation and potentially reduce post-procedural vomiting 1, 2.
Continuous monitoring is mandatory: pulse oximetry, heart rate, blood pressure, and capnography when available 2, 5.
Maintain oxygen saturation >93% on room air throughout the procedure 5.
Alternative: IM Ketamine Protocol (If No IV Access)
If IV access is unavailable, use IM ketamine 4 mg/kg (52 mg total) with atropine 0.01 mg/kg (0.13 mg) 1, 2, 5.
IM Route Advantages
Faster onset than alternative sedatives (3 minutes versus 18 minutes for meperidine/promethazine/chlorpromazine) 1.
Shorter time to discharge compared to other IM sedative combinations 1, 2.
100% of patients achieved adequate sedation in guideline-cited studies 1.
IM Dosing Considerations
Repeat doses of 2-4 mg/kg IM may be given after 5-10 minutes if needed, though this is rarely required with proper initial dosing 5.
Average recovery time is approximately 90 minutes 5.
Expected Adverse Effects and Management
Recovery agitation occurs in 7.1% of pediatric patients, more common in younger children 2.
Laryngospasm occurs in 0.9-1.4% but serious airway complications are rare 2.
Hypoxemia occurs in 1.6-7.3%, typically transient and responsive to supplemental oxygen 5.
Adjunctive Midazolam Consideration
Midazolam 0.05 mg/kg IV may be added to reduce emergence reactions, though evidence is mixed on efficacy for reducing agitation 2, 5.
The combination does not decrease recovery agitation in younger children but may benefit those over 10 years old 2.
Critical Pitfall to Avoid
Underdosing ketamine is the most common error, resulting in inadequate sedation requiring supplemental doses in over 50% of patients when using suboptimal dosing 2, 5. Always use the full recommended dose of 1.5-2 mg/kg IV or 4 mg/kg IM 1, 2.