Is there evidence that intranasal ketamine can provide adequate procedural sedation in paediatric patients?
Date First Published:
March 27, 2026
Last Updated:
March 27, 2026
Report by:
Harishanth Jeyabelen, Imerjit Manak, Emergency Medicine ST3s (Manchester Foundation Trust, UK)
Search checked by:
Imerjit Manak, Emergency Medicine ST3
Three-Part Question:
In [PED patients who require procedural sedation] is [intranasal ketamine] able to provide comparable procedural sedation to [IV ketamine]?
Clinical Scenario:
A 5-year-old patient presents to the Paediatric Emergency Department (PED) with a facial laceration requiring sutures. She is very distressed by the thought of IV cannulation for sedation due to a recent traumatic experience attempting some blood tests. You consider whether the intranasal route of delivery for ketamine could achieve adequate sedation whilst avoiding needles.
Search Strategy:
A focused database search was completed using MEDLINE and EMBASE (1974 – 2026) via the Ovid interface with the following search terms: (“Emergency department” OR “Paediatric Emergency Department” OR “Emergency room” OR exp “Emergency Service, Hospital”) AND (“intranasal ketamine” OR “intranasal” OR exp “Administration, Intranasal” OR exp “intranasal drug administration”) AND (“ketamine” OR “keta$” OR “esketamine” OR exp “Spravato” OR exp “ketamine”) AND (“child*” OR “paediatric” OR exp “Child” OR exp “Pediatrics”). No date or language filters were used in this search.
Following this, a supplementary search was conducted using the Google Scholar ‘cited by’ function to identify additional studies that had referenced our eligible papers. Additionally, the reference list of each paper was screened to identify any studies missed by the Ovid search.
Following this, a supplementary search was conducted using the Google Scholar ‘cited by’ function to identify additional studies that had referenced our eligible papers. Additionally, the reference list of each paper was screened to identify any studies missed by the Ovid search.
Search Details:
Studies were included if they met the following criteria:
- Original research and reviews
- Included paediatric patients requiring sedation in the Emergency Department
- Intranasal ketamine was used in some or all patients.
Studies were excluded if:
- Non-empirical studies
- Sedation outside of the Emergency Department setting
- Original research and reviews
- Included paediatric patients requiring sedation in the Emergency Department
- Intranasal ketamine was used in some or all patients.
Studies were excluded if:
- Non-empirical studies
- Sedation outside of the Emergency Department setting
Outcome:
The initial search resulted in 182 papers and after duplicates were removed 150 remained. Titles, abstracts and subsequently full text were reviewed for relevance and 8 relevant papers were identified. Our supplementary search identified a further relevant paper. One paper was subsequently excluded due to a lack of peer review leaving 8 papers for final inclusion.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Intranasal ketamine for procedural sedation in children: An open-label multicenter clinical trial. Rached-d’Astous S, Finkelstein Y, Bailey B, et al. 2023 Canada | n=30 Procedure: laceration repair Median age: 3.2 Dose: 6mg/kg | Phase 2 multicentre, single-arm, open-label interventional clinical trial Level 4 |
Effective procedural sedation as defined by the PERC and PECARN guidelines. Four criteria for success including Ramsey Sedation Scale and Behaviour/Response to Treatment Scale | Effective sedation - 18/30 (60%) [95% CI 45, 89] | - Unable to infer non-inferiority to IV ketamine due to absence of a comparison group - The small sample size leads to wide confidence intervals and less reliable estimation of treatment effects |
| Suboptimal but able to complete procedure - 5/30 (17%) | |||||
| Inadequate sedation - 7/30 (23%) | |||||
| Intranasal ketamine for sedation and analgesia in wound repair without local anesthesia in the Pediatric Emergency Department Caballero N, Ramírez MP, Morilla L, Mesquita M, Pavlicich V 2025 Paraguay | n=35 Procedure: laceration repair Median age: 5 Median weight: 21kg Dose: 7mg/kg | Prospective, descriptive, observational study Level 4 |
Adequate sedoanalgesia defined as Ramsay score ≥ 2 and Campbell score ≤ 3 | 29/35 (83%) | - Unable to infer non-inferiority to IV ketamine due to absence of a comparison group - Lack of statistical analysis of the main outcome prevents assessment of likelihood findings occurred due to chance - No local anaesthetic use which diverges from regular practice |
| Sedoanalgesia with ketamine in the emergency department: Factors associated with unsatisfactory effectiveness. Molina Gutiérrez MA, Fernández Camuñas M, Benito Fernández J, Mintegi S 2021 Spain | n=671 Procedures: fracture reduction, burn management, laceration repair Median age: 2-6 years (unable to find specifically for IN) Mean dose: 3.6mg/kg | Retrospective cohort study Level 3 |
Effectiveness of sedoanalgesia according to perception of providers and experience reported by patient. | IN ketamine - 28/44 (64%) | - Patients in the IN group were predominantly under 24 months old in comparison to the IV group, introducing a source of confounding influence. - The subjective outcome of provider perception leads to possible observer bias |
| Good – procedure completed without resistance and no subsequent poor recall. | IV ketamine - 542/627 (86%) | ||||
| P<0.000 | |||||
| Use of intranasal ketamine in pediatric patients in the emergency department. Guthrie AM, Baum RA, Carter C, Dugan A, Jones L, Tackett T, Bailey AM 2021 USA | n= 115 Procedures: laceration repair, orthopaedic procedures Median age: 4.6 years Mean dose: 3.9mg/kg | Prospective survey and retrospective chart review Level 4 |
Completion of procedure with IN ketamine without proceeding to use of IV sedatives in patients that were deemed to otherwise require IV sedation | 101/115 (88%) | - The subjective outcome of procedure success leads to possible observer bias - Lack of statistical analysis of the main outcome prevents assessment of likelihood findings occurred due to chance |
| Intranasal ketamine for procedural sedation in pediatric laceration repair: A preliminary report. Tsze DS, Steele DW, Machan JT, Akhlaghi F, Linakis JG 2012 USA | n=12 Procedures: laceration repair Median age: Doses: 3, 6 and 9mg/kg | Randomised, prospective, double-blind trial Comparison between varying doses of IN ketamine Level 2(b) |
Successful sedation. Failure defined as – not reaching adequate sedation (Ramsay sedation score ≥ 4) within 30 minutes or a Ramsay sedation score of 1 during laceration repair | 3mg/kg dose – 0/8 (0%) | - Unable to infer non-inferiority to IV ketamine due to absence of this group - The trial was suspended early leading to a small sample size with wide 95% confidence intervals 22-99% |
| 6mg/kg dose – 0/8 (0%) | |||||
| 9mg/kg dose - 3/4 (75%) [95% CI 22-99] | |||||
| A randomized double-blind trial of intranasal dexmedetomidine versus intranasal esketamine for procedural sedation and analgesia in young children. Nikula A, Lundeberg S, Ryd Rinder M, Lääperi M, Sandholm K, Castrén M, Kurland L. 2024 Sweden | n=30 Procedures: laceration repair and burn management Median age: 23 months Dose: 1mg/kg esketamine | Prospective, randomised, double-blind trial Comparison between IN dexmedetomidine and IN esketamine Level 2 |
Successful sedation. Failure defined as – Ramsay score 2 or high FLACC (Face, Legs, Activity, Cry, Consolability) score | 14/15 (93%) | - The small sample size makes the estimation of treatment success highly sensitive to each individual participant. - They excluded children >15kg limiting external validity |
| Intranasal analgesia and sedation in pediatric emergency care — a prospective observational study on the implementation of an institutional protocol in a tertiary children’s hospital. Nemeth M, Jacobsen N, Bantel C, Fieler M, Sümpelmann R, Eich C. 2019 Germany | n=66 Procedures: laceration repair and burn management Median age: unable to separate Dose: 4mg/kg esketamine | Prospective, observational study looking at different intranasal analgesic and sedative medications Level 4 |
Successful sedation. Failure defined as – University of Michigan sedation score > 3 or reactivity score 1 or 2 | IN ketamine - 3/4 (75%) | - Unable to infer non-inferiority to IV ketamine due to absence of a comparison group - Very small sample size in IN ketamine group, making the estimation of treatment success highly sensitive to each participant. |
| A pilot study testing intranasal ketamine for the treatment of procedural anxiety in children undergoing laceration repair. Cristoforo T, Gonzalez D, Bender M, Uy G, Papa L, Ben Khallouq BA, Clark M, Carr B, Cramm K. 2022 USA | n=25 Procedures: laceration repair Median age: 5.1 Dose: 5mg/kg | Prospective, observational study Level 4 |
5 point sedation scale – success deemed ‘calm’ or ‘drowsy’ | 20/25 (80%) | - Unable to infer non-inferiority to IV ketamine due to absence of a comparison group - The subjective outcome scales lead to possible observer bias - Anxiolysis rather than sedation being the prime aim of the study leads to a lack of generalisability |
Author Commentary:
Our review demonstrates generally favourable results for intranasal ketamine, albeit with variations in study design, sample sizes, and outcome measures. The largest studies in our sample (Guthrie et al 2021 and Gutierrez et al 2024) achieved procedural success in 86-88% of cases.
A recurring theme in the literature is a lack of agreement on a suitable dose protocol for intranasal ketamine. Generally doses of 4-9mg/kg seem to be chosen to achieve sedation with ketamine, with greater treatment failure at lower doses. Further variation is introduced with the use of esketamine, an isomer of ketamine that allows for lower doses of drug to be used intranasally but is not available at many centres. Based on the literature we would recommend an initial dose of 4mg/kg.
One area the studies fail to address is the psychological benefit of avoiding IV or IM routes which use needles. A major draw to IN ketamine for sedation is in needle-phobic children. Many of these children have had multiple distressing experiences in the past, often witnessed by their parents. IN ketamine offers a valuable needle-free sedation option and could be used to facilitate IV access allowing further IV sedation or medications as required. This could be a bridge between IN ketamine use and current practice.
A recurring theme in the literature is a lack of agreement on a suitable dose protocol for intranasal ketamine. Generally doses of 4-9mg/kg seem to be chosen to achieve sedation with ketamine, with greater treatment failure at lower doses. Further variation is introduced with the use of esketamine, an isomer of ketamine that allows for lower doses of drug to be used intranasally but is not available at many centres. Based on the literature we would recommend an initial dose of 4mg/kg.
One area the studies fail to address is the psychological benefit of avoiding IV or IM routes which use needles. A major draw to IN ketamine for sedation is in needle-phobic children. Many of these children have had multiple distressing experiences in the past, often witnessed by their parents. IN ketamine offers a valuable needle-free sedation option and could be used to facilitate IV access allowing further IV sedation or medications as required. This could be a bridge between IN ketamine use and current practice.
Bottom Line:
In paediatric patients requiring sedation, intranasal ketamine has slightly lower likelihood of success than intravenous ketamine however offers a useful needle-free alternative. With clear explanation of the evidence to parents and shared-decision making, it should be considered in severely needle-phobic children.
Level of Evidence:
Level 2: Studies considered were neither 1 or 3
References:
- Rached-d’Astous S, Finkelstein Y, Bailey B, et al.. Intranasal ketamine for procedural sedation in children: An open-label multicenter clinical trial.
- Caballero N, Ramírez MP, Morilla L, Mesquita M, Pavlicich V. Intranasal ketamine for sedation and analgesia in wound repair without local anesthesia in the Pediatric Emergency Department
- Molina Gutiérrez MA, Fernández Camuñas M, Benito Fernández J, Mintegi S. Sedoanalgesia with ketamine in the emergency department: Factors associated with unsatisfactory effectiveness.
- Guthrie AM, Baum RA, Carter C, Dugan A, Jones L, Tackett T, Bailey AM. Use of intranasal ketamine in pediatric patients in the emergency department.
- Tsze DS, Steele DW, Machan JT, Akhlaghi F, Linakis JG. Intranasal ketamine for procedural sedation in pediatric laceration repair: A preliminary report.
- Nikula A, Lundeberg S, Ryd Rinder M, Lääperi M, Sandholm K, Castrén M, Kurland L.. A randomized double-blind trial of intranasal dexmedetomidine versus intranasal esketamine for procedural sedation and analgesia in young children.
- Nemeth M, Jacobsen N, Bantel C, Fieler M, Sümpelmann R, Eich C.. Intranasal analgesia and sedation in pediatric emergency care — a prospective observational study on the implementation of an institutional protocol in a tertiary children’s hospital.
- Cristoforo T, Gonzalez D, Bender M, Uy G, Papa L, Ben Khallouq BA, Clark M, Carr B, Cramm K.. A pilot study testing intranasal ketamine for the treatment of procedural anxiety in children undergoing laceration repair.