Pedi Sedation


Caution: monitor child at all times (pulse oximeter) and other vital signs (most hospitals have specific policies and procedures outlining obligatory monitoring) with appropriate antidotes & airway management apparatus bedside; use only drugs with which you are comfortable & familiar; ask about last meal (better to delay a non-emergent procedure if child ate a full meal in last 3 hrs)

IV Agents

These agents should ONLY be administered by clinicians trained and experienced in pediatric procedural sedation using continuous non-invasive electronic monitoring of oxygenation, heart rate and blood pressure. End-tidal carbon dioxide monitoring is also suggested. Resuscitation equipment, medications, and personnel skilled in advanced pediatric life support and knowledgeable of sedatives and reversal agents must be present. Please refer to UpToDate topics on procedural sedation in children for more details.
Agents Initial IV dose* Repeat intravenous dose (prn to achieve desired level of sedation) Onset (minute) Duration (minutes) Comments
Ketamine

1 to 1.5 mg/kg

when given with propofol, reduce initial dose to 0.5 mg/kg

0.5 to 1 mg/kg repeat every 10 minutes titrating to desired level of sedation 1 to 2 15 to 30
  • Provides sedation AND analgesia for moderately to severely painful procedures. Less respiratory depression and complications than propofol alone or combinations of opioids with midazolam or with propofol.
  • Common adverse events: Vomiting, emergence reaction, frequency of vomiting is reduced by premedication with ondansetron (0.15 mg/kg, typical dose 4 mg) or by co-administration of propofol
  • Laryngospasm and apnea occur rarely and are more common with intramuscular administration
  • Relative contraindications and precautions: Age younger than 12 months, active pulmonary infections (including URI), known or suspected cardiac disease, suspected increased intracranial pressure (eg, head trauma with signs or symptoms, intracranial mass, or hydrocephalus), glaucoma or acute eye injury (open globe), porphyria, thyroid disease
  • Absolute contraindications: Age younger than 3 months or patients with known or suspected psychosis
Midazolam

6 mo - 5 yr: 0.05 to 0.1 mg/kg IV, max single dose 2 mg 

6 - 12 yr: 0.025 to 0.05 mg/kg IV, max single dose 2 mg

After initial IV dose, repeat after 2 to 5 minutes titrating to desired level of sedation

6 months to 5 years: up to 0.2 mg/kg per dose (maximum total dose 6 mg),

6 to 12 years: 0.1 mg/kg (maximum total dose 10 mg)

 

1 to 3 15 to 60, depending upon total dose administered
  • Provides sedation but NO analgesia. For painful procedures, an analgesic agent (eg, ketamine, fentanyl) should be co-administered.
  • Provides amnesia, mild anxiolysis, and mild sedation for procedures that do not require full immobility (eg, laceration repair with local topical anesthesia)
  • When combined with fentanyl can produce moderate or deep sedation, but less effective and more adverse respiratory events reported when compared to sedation with ketamine alone or combined with propofol
  • Flumazenil can reverse effects but should be avoided in patients with seizure disorder or who are chronically maintained on benzodiazepines
  • Common adverse effects: Respiratory depression, and apnea, especially when combined with opioid medications (eg, fentanyl); paradoxical reactions, including hyperactivity, aggressive behavior, and inconsolable crying
Propofol

Initiate infusion at 25 mcg/kg/min and titrate gradually to response (range 50 to 200 mcg/kg/min)

OR

0.5 to 1 mg/kg IV bolus dose (children two years of age and older)

1 to 2 mg/kg IV bolus dose (infants 6 months to 2 years of age)

Significant dose reduction necessary for patients who are debilitated or with reduced cardiac output

Not applicable for continuous IV infusion, titrate infusion rate as needed

OR

Additional IV bolus dose 0.5 mg/kg every 3 to 5 minutes titrating as needed up to 3 mg/kg. Wait at least 3 to 5 minutes between doses to assess effect.

 

≤0.5 5 to 15 after single bolus dose, longer after prolonged infusion or when repeated bolus doses are given
  • Provides sedation but NO analgesia. For painful procedures, an analgesic agent (eg, ketamine, fentanyl) should be co-administered. Commonly used for diagnostic imaging (CT, MRI).
  • Rapid onset of sedation with good neurologic recovery. Reduces intracranial pressure.
  • Peripheral injection site painΔ
  • Common adverse events: Respiratory depression, oxygen desaturation, apnea, hypotension, and/or rapid transition to deeper levels of sedation, especially with overly rapid administration of bolus injection
  • Absolute contraindications: Egg or soy allergy, porphyria

 

Dexmedetomidine

1 to 3 mcg/kg loading dose (over 10 minutes) followed by 0.5 to 2 mcg/kg/hr continuous infusion

Children younger than 5 years of age may require maintenance infusion rates at the higher end of the range shown
Not applicable for continuous infusion, titrate infusion rate as needed 5 to 10 30 to 70
  • Sedation and modest analgesia without respiratory depression. Commonly used for diagnostic imaging (CT, MRI).
  • Common adverse events: Bradycardia, hypertension, or, especially with loading dose, hypotension
  • Relative contraindications: Children who are debilitated, inadequately hydrated, or have reduced cardiac output
  • Absolute contraindication: Patients receiving digoxin or other medications acting on sinus node or with sinus node dysfunction

 

Pentobarbital 1 to 2 mg/kg IV, max 100 mg per dose 1 to 2 mg/kg IV every 3 to 5 minutes titrate up to 6 mg/kg to desired sedation 1 to 5 15 to 90, duration is dose dependent
  • Short-acting barbiturate option for noninvasive diagnostic procedures. Better efficacy seen in children <8 years old.
  • Common adverse effects: Respiratory depression, hypotension, and increased heart rate, especially with intravenous use or combination with opioid or benzodiazepine, emergence reactions
  • Relatively contraindicated in patients with cardiac or hepatic insufficiency or hypovolemic shock
  • Absolute contraindications: Porphyria
Etomidate

0.1 to 0.3 mg/kg IV

Lower dose in children with renal or hepatic insufficiency

 

0.05 mg/kg every 3 to 5 minutes titrate up to 0.6 mg/kg total dose to desired sedation ≤0.5 5 to 15
  • Rapid onset and recovery. Commonly used for brief diagnostic imaging (eg, head CT).
  • Reduces intracranial pressure. Hemodynamic and respiratory stability maintained in most patients making it a good choice if cardiovascular status is unknown or compromised (eg, trauma patient).
  • Common adverse effects: Pain at the injection site, transient nonepileptiform myoclonus, vomiting. Myoclonus and vomiting reduced by premedication with midazolam.
  • Relatively contraindicated in children with severe illness such as suspected sepsis
  • Absolutely contraindications: Children with congenital or acquired adrenal insufficiency
Methohexital 0.5 to 1 mg/kg IV 0.5 mg/kg IV (maximum 40 mg per dose)every 2 to 5 minutes, titrate up to 2 mg/kg (160 mg total dose) 0.5 to 1 5 to 10
  • Short-acting barbiturate option for noninvasive diagnostic procedures. More adverse events than pentobarbital.
  • Common adverse effects: Respiratory depression, hypotension, and myocardial depression
  • Relative contraindications: Patients with cardiac, liver, or renal insufficiency
  • Absolute contraindications: Porphyria or partial seizure disorder (may precipitate seizures)

 

 

PO, SL, Rectal, or intranasal Routes

Sedation with these agents can result in significant respiratory depression and other adverse effects. Children should receive appropriate monitoring by personnel skilled in pediatric resuscitation until full recovery has occurred. Please refer to UpToDate topics on procedural sedation in children for more details.
Agent Dose Onset (minutes) Duration (minutes) Comments
Midazolam

0.25 to 0.5 mg/kg PO or SL, maximum 20 mg

0.2 to 0.3 mg/kg IN, maximum 10 mg*

Buccal dosing is as for IN
20 to 30 30 to 60

Midazolam has poor oral bioavailability (15 to 35 percent). IN, SL, and buccal has bioavailability approaching 70 to 80 percent during gradual administration.

Provides amnesia, mild anxiolysis, and mild sedation for procedures that do not require full immobility (eg, laceration repair with local topical anesthesia)

Flumazenil can reverse effects but should be avoided in patients with seizure disorder or who are chronically maintained on benzodiazepines

Common adverse effects: Respiratory depression and apnea, especially if combined with opioids or other sedatives; paradoxical reactions, including hyperactivity, aggressive behavior, and inconsolable crying
Pentobarbital

Younger than 4 years: 3 to 6 mg/kg PO/PR, maximum 100 mg

4 years and older: 1.5 to 3 mg/kg PO/PR, maximum 100 mg
15 to 45 60 to 240

Short-acting barbiturate option for noninvasive diagnostic procedures. Better efficacy seen in children <8 years old

Common adverse effects: Respiratory depression, hypotension, and increased heart rate, especially with intravenous use or combination with opioid or benzodiazepine

Relatively contraindicated in patients with cardiac or hepatic insufficiency or hypovolemic shock

Absolute contraindications: Porphyria
Methohexital 25 mg/kg PR, maximum 500 mg 5 to 10 30 to 90

Short-acting barbiturate option for noninvasive diagnostic procedures. More adverse events than pentobarbital

Common adverse effects: Respiratory depression, hypotension, and myocardial depression

Relative contraindications: Patients with cardiac, liver, or renal insufficiency

Absolute contraindications: Porphyria or partial seizure disorder (may precipitate seizures)
Thiopental 5 to 30 mg/kg PR, maximum 700 mg 10 to 15 30 to 60

Short-acting barbiturate that is less commonly used.

Common adverse effects: Respiratory depression, Hypotension, and myocardial depression

Relative contraindications: Patients with cardiac, liver, or renal insufficiency

Absolute contraindications: Porphyria
Chloral hydrate

50 to 75 mg/kg PO/PR, maximum 1 gram

May give repeat dose of 50 mg/kg (maximum 500 mg) 30 minutes after initial dose if needed
10 to 15 60 to 240

Traditional option for noninvasive diagnostic procedures in infants and young children but inferior to other options listed above because of prolonged effect and greater risk for adverse reactions. Also, not available in some countries, due to concern for potential carcinogenicity

Less reliable sedation in patients older than 3 years of age

Common adverse effects: Gastrointestinal irritation and vomiting with oral use, prolonged sedation, coma, paradoxical agitation, respiratory depression, especially in young term and preterm infants

Tachyarrhythmia with excessive dosing

Relative contraindications: Patients with cardiac, liver, or renal insufficiency

General

  1.  Fentanyl:
    • Dosing: 2-3 mcg/kg IV; 15-20 mcg/kg PO
    • Safe, effective; short t1/2
    • "Lollipop" form (200, 300, 400 mcg Oralets)
    • Side effects reversible with naloxone
    • Emesis, facial pruritis potential ADR's
    • No intrinsic anesthetic effect
  2.  Midazolam (Versed):
    • Dosing: 0.1 mg/kg IV/IM; 0.5 mg/kg PO; 0.4-0.5 mg/kg pr
    • No prepared oral or rectal dose available use IV form
    • Safe & effective PO
    • +/- incr complications with narcotics
    • Amnestic effect beneficial
    • No intrinsic analgesic effect
  3.  Ketamine:
    • Dosing: 2-4 mg/kg IM, 1 mg/kg IV, 6 mg/kg pr
    • Dissociative anesthetic
    • Rapid onset (1-2 min), short t1/2
    • Wide safety margin
    • Laryngospasm rare occurrence; observe closely
    • Use with 0.01 mg/kg IM of Atropine; min 100 mcg, max 500 mcg
    • Midazolam 0.05-0.1 mg/kg IM to emergence rxn phenomenon
  4. Morphine:
    • Dosing: 0.1 mg/kg IV/IM
  5. Chloral hydrate:
    • Dosing: 50-75 mg/kg PO or rectally (up to 100 mg/kg prn)
    • Fast onset, few side effects, wide safety margin
    • No analgesic effect
    • Best for radiologic procedures
    • Rectal route preferred: is foul-tasting  nausea & vomiting
  6. Nitrous oxide:
    • Dosing: 30% N2O (50% has not been tested in pediatric population)
    • Only effective >8 yo
    • Difficult to manage, requires close monitoring & drug scavenger system.
  7.  Propofol:
    • Currently being used in some EDs
    • Establish departmental protocol before its use, as deep sedation & general anesthesia may result