Procedural sedation (peds)

This page is for pediatric patients. For adult patients, see: Procedural sedation

Sedation levels

Sedation levels

Level	Definition	Comments
Minimal Sedation	Standard pain medications
Moderate Sedation	Awake and able to respond to questions	use in: LP, I+D
Dissociative Sedation	Trance-like state, airway reflexes preserved
Deep Sedation	React purposefully to painful stimuli	use in: Reduction
General Anesthesia	Unarousable, requires intubation/advanced airway

Procedural Checklist

• Consent in chart
• PIV with fluids running
• ETCO2 and NC connected to patient
• Airway preparation
  • Suction with Yankauer attached
  • BVM attached to wall oxygen
  • Oral/nasal airways
  • Mac/Miller blades
  • ET tubes with stylets
• Meds at bedside
  • Sedation Meds
  • Narcan 0.4mg if opioid being used, not drawn up
  • Epinephrine, cardiac syringe (1:10,000) unopened and 10 cc NS Flush with needle
  • Glycopyrrolate, 1 vial; not drawn up
• Strongly consider child life

Fasting

• No need to delay procedure based on fasting time. Preprocedural fasting for any duration has not demonstrated a reduction in the risk of emesis or aspiration when administering procedural sedation and analgesia (ACEP Level B)
• Some specialty societies recommend:
  • 2-hour fasting time for clear liquids
  • 4-hour fasting time for breast milk
  • 6-hour fasting time for solids

Airway Monitoring

• Capnography may be used as an adjunct to pulse oximetry and clinical assessment to detect hypoventilation and apnea earlier than pulse oximetry and/or clinical assessment alone. However, there is a lack of evidence that capnography reduces the incidence of serious adverse events (neurologic injury caused by hypoxia, aspiration, death) (ACEP Level B).
• Placing the patient on ETCO2 + SpO2 is ideal
• Position the patient in a position you would intubate if needed (ear at level of sternal notch)
• Consider nasal airway in patients with likely OSA

Sedation Medications

Oral Sedation

• Consider if only sedation without analgesia required
• Midazolam 0.5-1mg/kg PO 10-20min prior to procedure
• Chloral hydrate 50-75mg/kg PO 30min prior to procedure
  • May give additional 25-50mg/kg PO x 1 after 30min if needed

1. • • Midazolam 0.5-1 mg/kg, Max 20mg (10-20 min before procddure)
     • Chloral hydrate 50-70mg/kg PO 30 min prior to procedure, then repeat 25-50 mg/kg x 1 in 30 min if needed (max 1g/day infants; 2g/day older children)

Intranasal sedation

• Give 1mL at a time alternating nare. Contraindicated if significant URI
• Midazolam 0.2mg/kg IN
• Fentanyl 2mcg/kg IN

Parenteral sedation agents

Agent	Initial Dose	Repeat Dose	Max Dose	Onset	Duration	Contraindicaitons/Cautions	Notes
Ketamine (IV)	1 mg/kg	2-4 mg/kg	50-100 mg/dose	1 min	5-10 min	Excessive secretions; airway manipulation; concern for emergenc reaction
Ketamine (IM)			4mg/kg per dose	3-4 min	30 min	Excessive secretions; airway manipulation; concern for emergenc reaction
Midazolam (IV)	0.1 mg/kg	50% of original dose	2mg/dose; 3-4 doses max			Liver disease; kidney disease	Consider in
Fentanyl (IV)	1 mcg/kg	q3-5 min					May be reveresed with naloxone
Etomidate	0.15 mg/kg		10 mg	30-60 sec	2-3 min	Apnea
Propofol	0.5-1 mg/kg	same at 3-5 min intervals		30 sec	3-10 min
Pentobarbital	1mg/kg			1 min	15 min	Hypovolemic shock, CHF, hepatic

Example Protocol

1. Establish NPO status for at least 4 hours (non-emergent)
2. Obtain informed consent
3. AMPLE history
4. Prepare
   • Estblish IV access, if necessary
   • Apply topical anesthetics (e.g. EMLA); allow >30 min for onset
   • Strongly consider Child Life consult, if available
   • If only sedation without analgesia is required, consider oral sedation (see above)
   • Intranasal dosing (can give 1mL per nostril at a time; contraindicated if signifiant URI)
     • Midazolam 0.2/kg, max 10mg (10-20 min prior to procedure)
     • Fentanyl 2mcg/kg, max 100mcg
5. Gather appropriate equipment and supplies
   • BVM, airway equipment
   • Suction
   • Naloxone for rescue, if appropriate
6. Apply HR monitor, pulse-ox, BP cuff (on opposite side from pulse-ox); perform time out
7. Parenteral sedation agents (see above)
8. Perform procedure
9. Monitor for at least 30 min following last dose of IV medication

Side Effects

• Desaturation
  • Stimulate
    • Try pressure behind ear
  • Jaw thrust
  • Nasal airway
  • BVM
  • NIV
  • LMA
  • Intubation

Disposition

• Monitor until patient alert, at baseline level of consciousness, have purposeful neuromuscular activity, and have baseline vital signs
• Not necessary to tolerate oral challenge

See Also

• Procedural sedation
• Intranasal sedation