What Is the Optimal Dose of Intramuscular Ketamine for Pediatric Sedation?

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Abstract
Objective: The optimal dose of IM ketamine for ED procedural sedation in children is not known. The authors wished to quantify the dose‐response of ketamine with respect to sedation adequacy, time to discharge, and adverse effects in order to identify an optimal dose. Methods: The study was a consecutive case series of 1,022 children ≤15 years of age given IM ketamine in the EDs of a university medical center and an affiliated county hospital over a nine‐year period. Adequacy of sedation, time to discharge, and adverse effects were compared with dose administered. Results: Doses in the sample averaged 3.96 ± 0.69 mg/kg, with a range of 0.48 to 9.09 mg/kg. Children judged to be adequately sedated received higher doses compared with those inadequately sedated (3.94 ± 0.44 mg/kg vs 3.77 ± 0.49 mg/kg, p = 0.041), and a nonsignificant trend was noted toward uniformly adequate sedation with increasing dose (≤91% at <4.00 mg/kg, 93% at 4.00‐4.49 mg/kg, and 100% at ≥4.50 mg/kg). No significant difference or trend in time to discharge or adverse effects was noted between the children receiving <4.00 mg/kg and those receiving ≥4.00 mg/kg of ketamine, and the study had power (α= 0.05, β= 0.20) to detect a 9‐minute difference in times to discharge, a 3.3% difference in rates of airway complications, a 5.6% difference in rates of emesis, and a 12.3% difference in rates of recovery agitation. Conclusion: Ketamine doses of 4 to 5 mg/kg IM produced adequate sedation in 93%‐100% of children, suggesting that this dosing range may be optimal for ED procedural sedation. No difference in time to discharge or adverse effects was observed for lower or higher doses.