Procedural sedation (peds)

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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[1]

  • 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) [2]
  • 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). [2]
  • Placing the patient on ETCO2 + SpO2 is ideal[3]
  • 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
      • 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[4]

  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

Disposition

  • Monitor until patient alert, at baseline level of consciousness, have purposeful neuromuscular activity, and have baseline vital signs [5]
  • Not necessary to tolerate oral challenge [6]

See Also

References

  1. ↑ http://emcrit.org/wp-content/uploads/Sedation_Checklist-8-1-10.pdf
  2. ↑ 2.0 2.1 ACEP Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department full text
  3. ↑ Deitch K, Miner J, Chudnofsky CR, Dominici P, Latta D. Does end tidal CO2 monitoring during emergency department procedural sedation and analgesia with propofol decrease the incidence of hypoxic events? A randomized, controlled trial. Ann Emerg Med. 2010 Mar;55(3):258-64.
  4. ↑ Cincinnati Children's Hospital "The Pocket" 2010-2011
  5. ↑ Joint Commission on Accreditation of Healthcare Organizations. Care of patients: examples of compliance. in: Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, IL; 1999:87-91
  6. ↑ Newman DH, Azer MM, Pitetti RD, et al. When is a patient safe for discharge after procedural sedation? The timing of adverse effect events in 1367 pediatric procedural sedations. Ann Emerg Med. 2003;42(5):627
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