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


  • 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


  • 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


  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