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Following Jim's point- we all know ketamine is a great drug for sedation,
pain control and amnesia.

So introducing it to our pediatric patients for multiple reasons through
multiple routes of administration will have excellent short term effects
and advantages, but we do not know what the long term effects will be.

No real evidence- just a concern for unintended consequences.

On Sun, Aug 20, 2017 at 2:12 PM, jim tsung <[log in to unmask]> wrote:

> With a drug/opioid epidemic raging on, is it advisable to expose kids to
> the idea of putting stuff up your nose, sniffing or snorting after
> experiencing IN administration of controlled substances in the ED?    How
> many children go on to experiment after IN administration of controlled
> substances in the ED?  I think IV/IM use presents a better barrier to the
> majority of kids that dislike needle sticks.
>
> Jim Tsung
> ________________________________
> From: Pediatric Emergency Medicine Discussion List <
> [log in to unmask]> on behalf of Chamberlain, James <
> [log in to unmask]>
> Sent: Sunday, August 20, 2017 4:47:05 AM
> To: [log in to unmask]
> Subject: Re: IN ketamine
>
> I've never understood why someone would want to administer ketamine
> intranasally. Ketamine is a highly lipophilic drug. Therefore, absorption
> through the mucous membranes will be slow and erratic.
>
> In contrast, midazolam is perfectly designed for IN administration, being
> hydrophilic in solution, but then changing to lipophilic (with ring
> closure) once at physiologic pH. Rapid and reliable absorption, then rapid
> distribution to CNS.
>
> We have to remember basic pharmacologic principles when we start tinkering
> with treatments.
>
> Jim Chamberlain
>
>
>
> Sent from my Verizon, Samsung Galaxy smartphone
>
>
> -------- Original message --------
> From: "Tsze, Daniel S." <[log in to unmask]>
> Date: 8/20/17 01:25 (GMT+01:00)
> To: [log in to unmask]
> Subject: Re: IN ketamine
>
> 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 Children易s 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
>
> >
>
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>
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