Thank you Daniel.

This is an excellent summary and hits home with my experience almost to the

And this is my sense of IN ketamine without the experience.

Low dose is ineffective for decent sedation but might provide some pain
relief. But does it do anything better than fentanyl.

Ditto midazolam. Which I love. I am using it more and more. To calm
agitated asthmatics who don't love the mask. For UA catheterizations on
kids old enough to remember (e.g. 15 minutes). Lac repairs.

And IN ketamine is full procedural sedation, regardless of the dose.

So all of the headache with a variable, inconsistent result that could be
achieved with other IN agents.

It is perhaps a solution without a need?


On Sat, Aug 19, 2017 at 6:23 PM, Tsze, Daniel S. <[log in to unmask]>

> 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
> far).
> 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
> ketamine.
> 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 ChildrenĀ¹s 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
> >The URL for the PED-EM-L Web Page is:
> >       

For more information, send mail to [log in to unmask] with the message: info PED-EM-L
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