This page is for pediatric patients. For adult patients, see: Procedural sedation.
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]
- Establish NPO status for at least 4 hours (non-emergent)
- Obtain informed consent
- AMPLE history
- 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
- Gather appropriate equipment and supplies
- BVM, airway equipment
- Suction
- Naloxone for rescue, if appropriate
- Apply HR monitor, pulse-ox, BP cuff (on opposite side from pulse-ox); perform time out
- Parenteral sedation agents (see above)
- Perform procedure
- 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
- ↑ http://emcrit.org/wp-content/uploads/Sedation_Checklist-8-1-10.pdf
- ↑ 2.0 2.1 ACEP Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department full text
- ↑ 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.
- ↑ Cincinnati Children's Hospital "The Pocket" 2010-2011
- ↑ 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
- ↑ 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