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Hi Rick,

As much as I love both IN medications (mostly midaz for anxiety,
fentanyl for pain) and ketamine, I have not found IN Ketamine to be
that useful.

The two main challenges are dosing and the inconsistent effect.

With the general volume max of 1 cc/nostril for IN medications, and
the higher concentration of ketamine of 100mg/cc, it is difficult of
achieve a 9 mg/kg dose once you are
dealing with a child who weighs around 20kg and above.

More importantly, the effect is variable. Plenty of studies (mostly
adult) have shown that low dose ketamine (0.5-1 mg/kg) can be
effective for pain control. But to achieve the desired dissociative
amnestic ketamine state you need to push the dose up higher to 6-9
mg/kg and even then it is often not enough to do more painful
procedures (such as fracture reductions). On the other hand,
Intramuscular ketamine (at 4-5 mg/kg) works more consistently so when
I am looking for non-IV option I don't bother with IN when the IM
route works better.

Hope this helps,

Jeff Blake
Pediatric Emergency Medicine
Mary Bridge Children's Hospital
Tacoma, Washington

On Thu, Aug 17, 2017 at 7:33 PM, Rick Place <[log in to unmask]> wrote:
> Is anyone using IN ketamine or does anyone have a protocol for this?
>
> There are plenty of other options, but every case is unique.
>
> I see literature from 1mg/kg to 9mg/kg. Seems like a crazy dosing range.
>
> Anyone with any direct experience with this?
>
> Rick Place
>
> Inova Fairfax
>
> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                  http://listserv.brown.edu/ped-em-l.html

For more information, send mail to [log in to unmask] with the message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
                 http://listserv.brown.edu/ped-em-l.html