IN sedation protocol

Intranasal sedation protocol:

General points:

Midazolam, ketamine, dexmedetomidine and sufentanil are the most commonly used sedative medications for IN delivery.
- Midazolam results in mild somnolence with resultant reduction in anxiety and probably amnesia. It will not make the patient unconscious.
  - Be aware that midazolam causes some nasal burning for 30-45 seconds when administered.
  - In small children you should administer lidocaine 2% or 4% - 0.2 ml per nostril 5 minutes prior to the midazolam to stop the burning.

Sufentanil will also cause deeper sedation and in doses over 1.5 mcg/kg has been noted to cause respiratory depression.
Dexmedetomidine takes longer to take effect (20 minutes) and lasts longest of all (over 1 hour).

Combination therapy with midazolam plus either sufentanil or ketamine may work better than any of the medications alone
Newer data discussed above suggests that IN dexmedetomidine may be the best option for sedation if more than just mild sedation is needed and prolonged affect is required (also slower onset of action).

Reasonable IN starting dose:
- Midazolam 0.4 to 0.5 mg/kg
  - Use the lower dose for minor, non-painful procedures such as radiographic imaging
  - Use the higher dose for better sedation prior to procedures such as laceration repair
- Ketamine 10 mg/kg
- Sufentanil 1 to 1.5 mcg/kg (this is a higher dose than required for pain control and increases the risk for respiratory depression)
- Dexmedetomidine 2-3 mcg/kg
- Combined dosing:
  - Midazolam plus sufentanil: 0.2 to 0.3 mg/kg of midazolam plus 0.75 to 1 mcg/kg of sufentanil
  - Midazolam plus ketamine: 0.2 to 0.3 mg/kg of midazolam plus 5 mg/kg of ketamine
Use only concentrated midazolam (5 mg/ml) and ketamine formulations
Be sure to monitor oxygen saturation in all patients
Ideal volume is 0.3 to 0.5 ml per nostril, maximum is 1 ml per nostril, more will just run out nose.
Nasal naloxone and flumazenil can be used as reversal agents