Hi Rick

We have a protocol for IN ketamine at our institution:

- 0.5-1 mg/kg, max dose 50 mg for analgesia
- 3-9 mg/kg, max dose 300 mg for procedural sedation

For analgesia, most of our providers still order IN fentanyl instead of IN
ketamine, mostly because we have found that the former works well and we
are very familiar with it, with little impetus to adopt the latter (so

For procedural sedation, the large volume required when giving 9 mg/kg
with the concentration we have available (100 mg/mL) for some children is
one concern.  

The other is that our protocol requires the same monitoring and staffing
(full monitors, sedation nurse, sedation MD) for IN ketamine as for IV

For kids who require procedural sedation/anxiolysis for lac repairs, we
have very good success with IN midazolam (which we are now also using with
IN lidocaine to ameliorate the nasal burning), which does not require the
same monitoring as IV/IN ketamine, making IN midazolam preferable from a
resource/flow perspective in this context.

For kids who require procedural sedation for fracture reductions, our
group is very comfortable with IV ketamine, with some concern with the
ability to quickly re-dose or titrate up with IN ketamine if needed, which
are some of the reasons we have not used IN ketamine for that indication.

Daniel Tsze

Director of Pain Management and Sedation Program
Division of Pediatric Emergency Medicine
NYP Morgan Stanley Children©ös Hospital
Assistant Professor of Pediatrics at CUMC
Department of Pediatrics
Columbia University College of Physicians and Surgeons
New York, NY

On 2017-08-17, 10:33 PM, "Pediatric Emergency Medicine Discussion List on
behalf of Rick Place" <[log in to unmask] on behalf of
[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
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