Intranasal medication administration isn’t new, but it’s been gaining popularity in the emergency department and outpatient arena, particularly for analgesic and sedative medication.
 
The attractiveness of this administration route isn’t just the avoidance of painful intramuscular injections, as it also may have favorable pharmacokinetics (PK) in terms of central nervous system (CNS) penetration.

However, putting theory into practice is often challenging. Here are a few tips to make intranasal administration successful:

1. Don’t use it for deep sedation.
Need a fracture reduced or a large laceration repaired in an uncooperative child? Then intranasal administration might not be the best option. Although there’s the theory of improved PK into the CNS, administering the required volume into a patient’s nose isn’t ideal, practically speaking.
 
Take ketamine, for example. Most evidence suggests using about a 9 mg/kg intranasal dose for procedural sedation.1 In a 20-kg child, even using the 100 mg/kg concentration is about 1.8 mL. Since administration into each nostril shouldn’t exceed 1 mL, this dose would require 2 administrations or, if you’re feeling lucky, 1 in each nostril at the same time.
 
A cooperative child can become very uncooperative and make this task challenging. In the event that the administration is successful, the volume might not be rapidly absorbed and thus drip down the child’s posterior pharynx, where it likely stings and has a terrible taste, causing the child to vomit and risk aspiration.
 
Without full absorption, the desired level of deep sedation may be challenging to achieve. While intramuscular administration has its disadvantages, it may be favorable for painful or long procedures.
2. Approach from the side.
Counseling patients and/or parents before intranasal administration is crucial. Parents should understand that, although the child might not like the sensation or taste, it’s much better than a needle.
 
At the same time, approaching the child straight on with the syringe can cause anxiety and make for a difficult situation. Coming in from the side or over the top of the child’s head can facilitate easy administration.

3. Check residual volume.
Depending on the particular atomizer used, a residual amount will be left in the device. To ensure the appropriate dose is delivered, make sure to check this volume. For the commonly available mucosal atomization device, this volume is 0.1 mL.2

4. Administer Up, Out, and In
When you’re finally ready to administer the dose of any given medication through the intranasal route, make sure to insert the atomizer firmly into the nose and aim it slightly to the top of the ear on the same side of the nostril being used. After doing so, push the plunger firmly as fast as possible to ensure the drug is delivered in a mist, rather drips. The atomization of the drug will facilitate complete and rapid absorption, which is essential for this route of administration.2

References
1. Tsze DS, Steele DW, Machan JT, Akhlaghi F, Linakis JG. Intranasal ketamine for procedural sedation in pediatric laceration repair: a preliminary report. Pediatr Emerg Care. 2012 Aug;28(8):767-770.
2. MAD Nasal procedure guidelines. lmana.com. Accessed April, 24, 2016.