What makes UpToDate so powerful?

  • over 10000 topics
  • 22 specialties
  • 5,700 physician authors
  • evidence-based recommendations
See more sample topics
Find Print
0 Find synonyms

Find synonyms Find exact match

Selection of medications for pediatric procedural sedation outside of the operating room
UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
Selection of medications for pediatric procedural sedation outside of the operating room
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Nov 2016. | This topic last updated: Aug 08, 2016.

INTRODUCTION — A wide range of short-acting sedative-hypnotic and analgesic medications are available for pediatric procedural sedation [1-3]. Many of these agents have multiple routes of administration. The choice of drug is based upon the type of procedure, the anticipated degree of pain, the targeted depth of sedation, and the patient's underlying medical condition. Procedures that are not painful but induce anxiety or require the child to remain still are usually performed with sedation alone. Children undergoing painful procedures require analgesia as well as sedation.

This topic will discuss the selection of medications for pediatric procedural sedation outside of the operating room. The properties of agents commonly used for procedural sedation in children; the assessment, preparation, and proper performance of procedural sedation in children outside of the operating room; and sedation in adults are discussed separately:

(See "Pharmacologic agents for pediatric procedural sedation outside of the operating room".)

(See "Preparation for pediatric procedural sedation outside of the operating room".)

(See "Procedural sedation in children outside of the operating room".)

(See "Procedural sedation in adults outside the operating room".)

NONPHARMACOLOGIC INTERVENTIONS — Nonpharmacologic interventions include behavioral and cognitive approaches, such as desensitization, distraction, reinforcing coping skills, positive reinforcement, and relaxation. These techniques are complementary to pharmacologic interventions and, in some children, may prevent the need for sedation altogether. (See "Procedural sedation in children outside of the operating room", section on 'Nonpharmacologic interventions'.)

CHOICE OF SEDATIVE AGENTS — The targeted depth of sedation and the agents used largely depend upon the anticipated degree of pain, the allowable amount of motion encountered during the procedure, and the following patient factors [2,4] (see "Preparation for pediatric procedural sedation outside of the operating room", section on 'Pre-sedation evaluation'):

Comorbidities (eg, asthma, upper respiratory tract infection)

Fasting status

Age

Ability to cooperate

Degree of anxiety

Any prior problems with specific medications

The dosing, administration, and properties of commonly used medications for pediatric sedation are listed in the tables and discussed in detail separately (table 1 and table 2). (See "Pharmacologic agents for pediatric procedural sedation outside of the operating room".)

The recommendations for sedation strategies and dosing in this topic assume that the patient is healthy (American Society of Anesthesiologists [ASA] class I or II) (table 3) and have been evaluated and prepared for sedation in accordance with guidelines designed to maximize patient safety. Those patients with ASA classes III, IV, and V, special needs, or airway abnormalities warrant consultation with a pediatric anesthesiologist or clinician with similar pediatric sedation expertise (eg, pediatric critical care or emergency physician). (See "Preparation for pediatric procedural sedation outside of the operating room", section on 'Pre-sedation evaluation' and "Preparation for pediatric procedural sedation outside of the operating room", section on 'Preparation'.)

In order to make pediatric procedural sedation as safe as possible, institutions should develop protocols that specify a pre-sedation evaluation, including a sedation plan, monitoring during the procedure and recovery, discharge and follow-up criteria, credentialing for personnel, and a quality improvement monitoring mechanism. (See "Procedural sedation in children outside of the operating room", section on 'Adverse outcomes'.)

This topic will discuss a wide range of available sedatives and analgesics. Health care providers who perform procedural sedation in children should have strong resuscitation and advanced pediatric life support skills, including advanced training in the assessment and management of the pediatric airway as well as specific training in pediatric procedural sedation. In some facilities, the use of propofol, ketamine, dexmedetomidine, or etomidate may be restricted to use by anesthesiologists or other specialists (eg, pediatric critical care or pediatric emergency medicine specialists).

In some jurisdictions, propofol is only approved for use by anesthesiologists or others with specialized pediatric procedural training. Otherwise, bolus propofol use for procedural sedation in children requires special privileging. The clinician should check local regulations.

SEDATION FOR IMAGING STUDIES — Imaging tests that are negatively impacted by motion (eg, noninterventional computed tomography [CT] or magnetic resonance imaging [MRI]) constitute the most common nonpainful procedures for which children undergo sedation. In one observational multicenter study of elective sedations provided by members of a sedation service, imaging accounted for almost 60 percent of 30,000 pediatric sedations performed outside of the operating room [5]. Ideally, the chosen agent or agents should have a quick onset of action that permits successful and safe completion of the imaging study, maintains airway reflexes, and has limited impact on breathing and hemodynamic stability [6]. It should also permit rapid recovery with few side effects, such as nausea or agitation. Because imaging studies are not painful, analgesia is not necessary.

Nonpainful imaging tests can often be performed without sedation in older cooperative children and young infants who are bundled and recently fed. However, a significant number of older infants, toddlers, and older children with intellectual disability cannot cooperate even for brief imaging tests (eg, helical computed tomography) and warrant sedation to ensure accurate imaging without excessive radiation exposure.

Computed tomography — Successful imaging with helical CT is less sensitive to patient movement than MRI and, given the rapid speed of imaging, can sometimes be done without sedation or requires only brief sedation (approximately 5 to 10 minutes). Thus, the clinician has a choice of several different agents and a variety of routes of administration. The intravenous (IV) route is preferred where maximal efficiency and throughput is desirable, such as patients undergoing urgent imaging for diagnostic purposes, because the onset of action is shorter and more predictable, and depending upon the agent, recovery is quicker (table 1) [6]. Other routes of administration (ie, oral, intranasal, or rectal) are useful in children without intravenous access, especially in settings where CT imaging is elective and longer sedation duration and recovery times are acceptable (table 2). However, if inadequate sedation or serious adverse events occur, lack of IV access may impede further management [7].

Intravenous medications — We suggest that healthy infants and children (American Society of Anesthesiologists class I or II) (table 3) who have vascular access and are undergoing sedation for CT receive intravenous (IV) propofol, dexmedetomidine, or etomidate rather than intravenous short-acting barbiturates (eg, pentobarbital or methohexital) or midazolam (table 1). In settings where IV propofol, dexmedetomidine, or etomidate are not available or their use is restricted, any of the other agents may be safely used but increased adverse events and slightly lower efficacy may occur.


Evidence identifying the best sedative agent for children undergoing CT is limited. Based upon observational studies, IV propofol, dexmedetomidine or etomidate is associated with effective sedation in over 99 percent of children undergoing CT compared with 97 to 98 percent of children receiving short-acting barbiturates or midazolam (table 1) [6,8-12]. Although lower efficacy was described for intravenous etomidate (76 percent of 17 patients) in one small trial, more than 99 percent of 446 children receiving etomidate for imaging successfully completed the procedure in a subsequent observational study [8,9].

Intravenous etomidate and propofol have a more rapid onset of action than dexmedetomidine (1 to 2 minutes versus 8 to 16 minutes, respectively) and etomidate has a shorter duration of action than dexmedetomidine (approximately 15 minutes compared with 30 minutes, respectively) [8-12]. Duration of action with propofol varies by dose and mode of administration (bolus or continuous infusion) and compares favorably with etomidate. Adverse events have been described in 2 percent of infants and children receiving etomidate or propofol sedation for imaging and 1 percent receiving dexmedetomidine. In contrast, approximately 5 percent of patients receiving IV short-acting barbiturates (eg, pentobarbital or methohexital) and up to 7 percent receiving IV midazolam experience adverse events, primarily transient oxygen desaturation and less commonly apnea [8,10,13]. Other adverse reactions that are specific to the agent have also been described as follows (table 1) (see "Pharmacologic agents for pediatric procedural sedation outside of the operating room", section on 'Sedative-hypnotic agents'):

Dexmedetomidine – Hypotension (2 percent), most commonly occurring during medication bolus [10].

Etomidate – Myoclonus (1 percent) and adrenal suppression [8].

Propofol – Pain on injection, rapid attainment of greater depth of sedation than intended [14]. Formulations of propofol contain egg lecithin, egg yolk phospholipids, and soybean oil. Consequently, some suggest that children with allergies to egg and/or soybeans should not receive propofol, whenever possible [15]. However, the use of propofol in children with known egg allergies has been described with allergic reactions occurring in approximately 2 percent of patients and no report of anaphylaxis. (See "Pharmacologic agents for pediatric procedural sedation outside of the operating room", section on 'Propofol'.)

Methohexital – Contraindicated in patients with temporal lobe epilepsy and porphyria [16]. (See "Pathogenesis, clinical manifestations, and diagnosis of acute intermittent porphyria", section on 'Medications'.)

Midazolam – Paradoxical agitation and crying (1 to 2 percent) [13].

Pentobarbital – Prolonged sleepiness with decreased activity more than 12 hours after sedation (15 of 28 children in one small trial) [9]. Pentobarbital is contraindicated in patients with porphyria. (See "Pathogenesis, clinical manifestations, and diagnosis of acute intermittent porphyria", section on 'Medications'.)

Oral, rectal, or intranasal medications — We suggest that healthy infants and children (American Society of Anesthesiologists class I or II) who do not have intravenous access and are undergoing sedation for CT receive oral pentobarbital rather than oral or intranasal midazolam or rectal thiopental (not available in the United States or Canada) or methohexital (table 2). Intranasal dexmedetomidine in a dose of 1 microgram/kg has shown effectiveness for premedication prior to local or general anesthesia, but its effectiveness for CT in children has not been studied [17-19]. We suggest that these children not receive chloral hydrate. Regardless of agent and route chosen, children should undergo monitoring of oxygen saturation and heart rate as soon as any signs of sedation are present because the risk of adverse events is not lower with these routes of administration when compared to sedation with intravenous agents. (See "Procedural sedation in children outside of the operating room", section on 'Monitoring'.)

Based upon one small clinical trial and larger observational studies, oral pentobarbital has an efficacy of 99 percent for successful completion of CT with adverse effects occurring in approximately 1 to 2 percent of patients (airway or oxygen desaturation <0.5 percent) [20-22]. The time to sedation ranges from 10 to 30 minutes and time to discharge is 90 to 100 minutes.

In comparison, although rectal methohexital or thiopental and oral or intranasal midazolam have a more rapid onset of action, small trials and larger observational studies have shown lower efficacies for successful sedation and greater potential for adverse effects in children undergoing CT [23-27]. For example, successful completion of CT with rectal methohexital or thiopental occurs approximately 95 percent and 98 percent of the time, respectively. Up to 10 percent of infants or children experience adverse effects with rectal methohexital (6 percent oxygen desaturation) and 33 percent have adverse effects following administration of rectal thiopental (11 percent oxygen desaturation) [24,25]. Rectal thiopental has also been associated with delayed effects of rectal irritation or diarrhea (over 50 percent), prolonged sleepiness (14 percent), and ataxia (13 percent). Midazolam by oral or intranasal routes achieves successful sedation in only 50 to 87 percent of patients undergoing CT, with higher efficacy in patients receiving it by the intranasal route [23,26,27].

While not a recommended agent, chloral hydrate was once the preferred sedative for infants and children less than three years of age and is still in use in some settings. However, small trials and observational studies indicate that chloral hydrate is inferior to other sedation options because of its delayed onset of action and prolonged effect (table 2) [6,7]. If chloral hydrate is used, procedural sedation protocols for monitoring should be followed because there is no consistent dose below which complications do not occur [2]. In one report of adverse sedation events, 20 of 60 children had received chloral hydrate alone or in combination with other sedatives [28]. Five of those who died or sustained permanent neurologic damage received chloral hydrate in unmonitored settings. (See "Preparation for pediatric procedural sedation outside of the operating room", section on 'Monitoring'.)

Some countries have removed chloral hydrate from national health formularies because of potential carcinogenicity although the risk of cancer from a single dose is inconclusive [3,29].

After a single oral or rectal dose of chloral hydrate, successful sedation occurs in approximately 80 percent of infants and children under three years of age, although efficacy approaches 100 percent in patients who receive a second dose when sedation is inadequate [26,30,31]. Onset of action takes up to 30 minutes after a single dose and up to 60 minutes if re-dosing is necessary. The onset and degree of sedation may be unreliable with the rectal route. Time to discharge is 120 to 240 minutes with the longer time occurring in children who require re-dosing. Oxygen desaturation occurs in up to 9 percent of patients and is highest in patients who receive a dose of 75 to 100 mg/kg [30,31]. Other acute adverse events include vomiting, hallucinations, and paradoxical agitation. Adverse effects that may persist for up to 24 hours after chloral hydrate administration include ataxia (50 percent), agitation (15 to 38 percent), and excessive sleepiness [23].

Magnetic resonance imaging — Magnetic resonance imaging (MRI) often necessitates sedation for up to one hour, and machine noise and lack of patient access pose additional challenges to achieving safe and effective sedation. We suggest that healthy infants and children (American Society of Anesthesiologists class I or II) undergoing MRI receive sedation using continuous intravenous (IV) infusion of dexmedetomidine or propofol rather than IV or oral pentobarbital (table 1 and table 2). In settings where dexmedetomidine or propofol are not available or use is restricted, we suggest IV or oral pentobarbital. We suggest that these patients not receive chloral hydrate.

Observational studies indicate that propofol and dexmedetomidine have comparable efficacy and safety as sedative agents for children undergoing MRI:

Sedation with continuous infusion of dexmedetomidine or propofol permits successful completion of MRI in approximately 97 to 99 percent of children when administered by experienced practitioners [12,32-35]. However, to achieve this level of success with dexmedetomidine infusion alone typically requires dosing that exceeds current manufacturer recommendations (table 1) [33]. Alternatively, although less commonly used and based upon limited experience, midazolam combined with dexmedetomidine can be efficacious. As an example, the combination of dexmedetomidine administered to 20 children according to manufacturer’s suggested dosing along with midazolam (0.1 mg/kg) permitted successful completion of MRI studies in all patients [34]. Current evidence does not support one approach over the other. (See "Pharmacologic agents for pediatric procedural sedation outside of the operating room", section on 'Dexmedetomidine'.)

Time to sedation is longer with dexmedetomidine than with propofol (10 versus <1 minutes, respectively) [12,32-34].

Recovery is typically complete 20 to 30 minutes after stopping a propofol infusion and 25 to 40 minutes after ending a dexmedetomidine infusion [12,32-34,36,37].

Minor adverse effects occur in up to 5 percent of children receiving propofol. However, major complications (eg, unplanned admission, aspiration, airway compromise requiring endotracheal intubation) happen uncommonly (less than 0.5 percent of patients) [12,38]. For example, in a multicenter observational study of almost 50,000 pediatric sedations with propofol, most of them performed for MRI, only four patients developed pulmonary aspiration and two patients not undergoing MRI required CPR. Very low rates (50 to 100 events out of 10,000 sedations) were also found for stridor, laryngospasm, and vomiting. However, 1.5 percent of patients required some form of airway intervention during the sedation [39]. In another multicenter observational study of 5072 children undergoing propofol sedation for MRI, rates of significant adverse events potentially requiring intervention were also low including oxygen desaturation (1.2 percent); airway obstruction (0.5 percent); unexpected apnea (0.3 percent); or a greater than 30 percent decrease in heart rate, respiratory rate, or blood pressure (0.6 percent) [38].

Dexmedetomidine causes minimal respiratory depression [7]. However, bradycardia and hypertension have been reported in up to 16 percent and 5 percent of patients, respectively [32,33]. These hemodynamic changes are dose-related. In a large observational study of 3522 children undergoing MRI who received dexmedetomidine for sedation, hypertension did not require pharmacologic intervention and did not result in any adverse outcomes [32]. For some providers, dexmedetomidine may be preferred to propofol for sedation of children with sleep apnea. As an example, observational study of 82 children undergoing MRI sleep studies, dexmedetomidine provided an acceptable level of anesthesia with fewer patients requiring an artificial airway compared to propofol (13 versus 30 percent) [40].

Dexmedetomidine should be avoided in patients for whom increases in pulmonary artery pressure or decreases in cardiac output will not be well tolerated. Dexmedetomidine should also not be given to children with AV node conduction delay or those receiving digoxin, beta blockers or other medications that slow AV node conduction. The initial bolus dose of dexmedetomidine prior to initiation of the infusion is often accompanied by hypotension that usually reversed with a bolus of fluid. (See "Pharmacologic agents for pediatric procedural sedation outside of the operating room", section on 'Dexmedetomidine'.)

Treatment of bradycardia caused by dexmedetomidine with glycopyrrolate has resulted in severe hypertension. Thus, the use of anticholinergic agents in these patients should be avoided. (See "Pharmacologic agents for pediatric procedural sedation outside of the operating room", section on 'Dexmedetomidine'.)

Although pentobarbital or chloral hydrate can effectively sedate children undergoing MRI (99 and 95 percent successful completion, respectively), the time to sedation is much greater for both agents than with propofol or dexmedetomidine and the potential for adverse events is increased [21,30,31,38,41]. As an example, in an observational multicenter study of 7079 children undergoing sedation for MRI that compared propofol with pentobarbital, sedation with pentobarbital (2007 children) was significantly associated with prolonged recovery (1 percent of patients, adjusted OR 17), unplanned admission (0.2 percent of patients, adjusted OR 6), and vomiting (0.8 percent of patients, adjusted OR 37) when compared with propofol [38]. Overall complications were also significantly greater with pentobarbital than with propofol (7 versus 5 percent, adjusted OR 1.4). Of note, no statistically significant differences for any airway event were found between patients receiving pentobarbital and those who received propofol. Although no studies have compared MRI sedation using chloral hydrate with propofol or dexmedetomidine, observational evidence for outcomes after pediatric sedation for imaging with chloral hydrate demonstrate even lower efficacy and greater risk of adverse events than described for pentobarbital [23,30,31]. Thus, as for sedation for computed tomography, we suggest that chloral hydrate not be used. (See 'Oral, rectal, or intranasal medications' above.)

If propofol, dexmedetomidine or appropriately trained providers to provide sedation with these agents are not available, then we suggest that children undergoing MRI receive IV or oral pentobarbital (table 1 and table 2). In one observational study of 2164 infants undergoing sedation with IV pentobarbital or oral pentobarbital, both routes of administration resulted in successful imaging in more than 99 percent of patients [21]. Time to sedation was longer with oral pentobarbital than with IV pentobarbital (18 versus 7 minutes, respectively) but time to discharge was not significantly different (approximately 60 to 120 minutes for both administration routes). Oral pentobarbital administration was associated with significantly fewer episodes of oxygen desaturation when compared to IV pentobarbital administration (0.2 versus 0.9 percent, respectively). However, potential differences in late effects between IV and oral pentobarbital were not reported.

SEDATION FOR OTHER NONPAINFUL PROCEDURES — In some children, physical examination (eg, genital examination to document sexual assault or routine physical examination in children with intellectual disability) or other nonpainful procedures (eg, echocardiography, electroencephalogram) can cause anxiety and lack of cooperation with the medical provider. In many situations, nonpharmacologic interventions can permit completion of the examination or test. (See "Procedural sedation in children outside of the operating room", section on 'Nonpharmacologic interventions'.)

When nonpharmacologic interventions are not sufficient and mild sedation is necessary for nonpainful procedures, we suggest that healthy children (American Society of Anesthesiologists class I or II) (table 3) receive sedation with inhaled nitrous oxide (N2O) or oral, sublingual, or intranasal midazolam rather than short-acting barbiturates (table 2). Intravenous sedation as described for computed tomography is suggested for patients who fail N2O or midazolam sedation. (See 'Computed tomography' above.)

Midazolam has both anxiolytic and amnestic properties. After oral or sublingual administration, it has an onset of action of 5 to 10 minutes with recovery occurring in approximately 60 minutes [42]. Onset of action with intranasal midazolam administration is similar to oral administration but duration of sedation is shorter (20 to 30 minutes) [43]. However, intranasal midazolam can be very irritating to some children. Pretreatment with lidocaine spray (10 mg per puff) one minute prior to intranasal midazolam administration decreases nasal mucosal irritation. An atomizer can also deliver midazolam intranasally with better comfort and with reduction of sneezing and cough when compared to direct instillation [43]. Although midazolam may be administered rectally, this route is less reliable and may cause patient discomfort.

Flumazenil is an effective reversal agent for the few patients who develop significant respiratory depression or apnea after sedation with midazolam. Flumazenil should not be used in patients with seizure disorders or those who receive benzodiazepines on a chronic basis because of the risk of precipitating seizures or withdrawal symptoms, respectively. The use of flumazenil to reverse adverse effects of benzodiazepines, including dosing and re-dosing recommendations is discussed in detail separately. (See "Benzodiazepine poisoning and withdrawal", section on 'Antidote (flumazenil)'.)

Based upon observational studies and one trial, midazolam has good efficacy and a shorter duration of action than oral or rectal pentobarbital or chloral hydrate [6,26,27,42,43]. As an example, in a trial that compared sublingual midazolam with oral chloral hydrate in 264 children undergoing echocardiogram, midazolam was associated with a 99 percent success rate for completing the examination and had fewer patients with significant oxygen desaturation when compared to chloral hydrate (5 versus 14 percent, respectively) [42]. Unlike barbiturates or chloral hydrate, midazolam is not associated with prolonged symptoms of ataxia, sleepiness, or irritability (table 2). (See 'Oral, rectal, or intranasal medications' above.)

Several small studies describe acceptable efficacy following the use of intranasal, oral, or buccal dexmedetomidine for pediatric sedation [44-46]. Thus, this approach may find future use for sedation for nonpainful procedures outside of the operating room.

SEDATION FOR PAINFUL PROCEDURES — Clinicians frequently employ procedural sedation for infants and children undergoing a variety of painful procedures including fracture reduction, laceration repair, bone marrow aspiration, central line placement, and lumbar puncture. For these procedures, chosen agents or combinations of agents must safely provide sedation and analgesia.

Analgesia — Appropriate analgesia can often lower the amount of sedative agent needed to provide adequate sedation and thus increase the safety of the procedure. The need for supplementary analgesia varies by the agents used:

Ketamine has both sedative and analgesic properties and can thus be used alone to provide sedation for painful procedures. (See 'Approach' below.)

Dexmedetomidine and nitrous oxide have limited analgesic properties that may be inadequate and warrant additional analgesic medications for moderately or severely painful procedures.

Midazolam, etomidate, and propofol, do not have analgesic properties and need to be combined with other analgesic agents. Although propofol is used alone for brief, painful procedures by some practitioners, the doses necessary to achieve adequate analgesia and control unwanted motion during the procedure may approach those used for general anesthesia.

Options for supplementary analgesia include topical, local, and regional infiltrated anesthetics and systemic analgesic medications. The commonly used agents for analgesia during pediatric procedural sedation are discussed separately. (See "Pharmacologic agents for pediatric procedural sedation outside of the operating room", section on 'Analgesic agents'.)

Approach — Patient factors (eg, last oral intake, urgency of the procedure, prior sedation experience, and comorbidities [eg, asthma, upper respiratory infection]) are key considerations for sedation strategies in children undergoing painful procedures and are discussed in detail separately. (See "Preparation for pediatric procedural sedation outside of the operating room", section on 'Pre-sedation evaluation'.)

In healthy infants and children, anticipated pain during the procedure is also an important determinant of the depth and type of sedation.

Minimally painful — In many children undergoing intravenous cannula insertion or laceration repair, local anesthetics can be delivered topically or by direct infiltration to diminish or abolish the pain without the need for sedation, especially when age-appropriate nonpharmacologic interventions are used. (See 'Nonpharmacologic interventions' above.)

The topical anesthetic most frequently used for laceration repair is the combination of lidocaine, epinephrine, and tetracaine (LET), which becomes effective in approximately 30 minutes. For intact skin, EMLA, a eutectic mixture of lidocaine-prilocaine in a cream base, and LMX 4, a nonprescription 4 percent liposomal lidocaine preparation, are also effective topical agents. They are discussed in more detail separately. (See "Topical anesthetics in children", section on 'LET' and "Topical anesthetics in children", section on 'EMLA'.)

In some children, the distress and anxiety of a minimally painful procedure is profound despite topical anesthesia and the use of nonpharmacologic techniques. For healthy infants and children (American Society of Anesthesiologists class I or II) (table 3) with significant distress or anxiety who are undergoing minimally painful procedures (eg, laceration repair or peripheral venous access with topical anesthesia) and for whom mild sedation is desired, we suggest procedural sedation with inhalation of nitrous oxide (N2O) or administration of oral or intranasal midazolam rather than topical anesthesia and nonpharmacologic interventions alone (table 2). Based upon an observational study of 295 children, five years of age or younger, who received N2O, refusal of the mask and need for restraint may occur in over 10 and 33 percent of patients, respectively [47]. If N2O is not available or not tolerated by the patient, then oral or nasal midazolam is an acceptable alternative but longer recovery time and more adverse events, especially ataxia, should be anticipated [48-51]. The method for administering N2O for procedural sedation outside of the operating room is discussed in greater detail separately. (See "Pharmacologic agents for pediatric procedural sedation outside of the operating room", section on 'Nitrous oxide'.)

This recommendation is supported by the following studies:

In a trial of 264 young children (mean age four years) undergoing facial laceration repair, N2O alone (50 percent N2O: 50 percent oxygen ratio) or combined with midazolam provided clinically significantly decreased distress during cleaning, lidocaine injection, and repair than either midazolam alone or topical anesthesia with comforting [48]. Approximately 6 percent of patients receiving N2O vomited. Patients who received midazolam took longer to recover (30 versus 20 minutes) and were more likely to report ataxia or dizziness (28 versus 2 percent) than those who received nitrous oxide alone. No serious side effects (eg, apnea, need for airway control) occurred in either group.

In a blinded, randomized trial of 90 obese or growth retarded children (aged 5 to 18 years) in whom intravenous (IV) access was expected to be difficult, use of 50 percent N2O was associated with a significantly increased success rate for IV placement when compared to oral midazolam (0.3 mg/kg, maximum dose 15 mg) or 10 percent N2O (67 versus 40 or 37 percent, respectively) [49]. Procedure time was also significantly shorter for patients who received 50 percent N2O when compared to oral midazolam.

Administration of up to 70 percent N2O with 30 percent oxygen via nasal dental mask was performed in an observational study of almost 4000 infants and children under four years of age with serious adverse events occurring in <1 percent of patients [50]. The most common painful procedures for which N2O was used included urinary catheterization, peripheral venous cannulation, lumbar puncture, and enteral tube (nasogastric or gastrostomy) placement. Vomiting occurred in approximately 2 percent of patients and was associated with inhalation of N2O for longer than 15 minutes.

In another observational study of N2O in 762 children between 1 and 17 years of age, most of whom received 70 percent N2O with 30 percent oxygen, vomiting or serious adverse events occurred in 6 and 0.2 percent of children, respectively [51]. Moderate sedation was achieved in most patients although 3 percent of children were deeply sedated.

Taken together, this evidence suggests that N2O may be more effective than midazolam for minimally painful procedures with a shorter recovery time and fewer overall adverse effects. However, a large number of patients, especially younger children may not tolerate N2O delivery and vomiting is more frequent with N2O than midazolam. N2O administration also requires special equipment and may be more costly than midazolam administration. Furthermore, N2O is not always available for administration outside of the operating room and should not be administered by pregnant personnel. (See "Pharmacologic agents for pediatric procedural sedation outside of the operating room", section on 'Nitrous oxide'.)

Moderately or severely painful — For healthy infants and children (American Society of Anesthesiologists class I or II) (table 3) who are undergoing moderately or severely painful procedures of short duration (eg, fracture reduction, bone marrow aspiration), we suggest procedural sedation with intravenous ketamine, ketamine combined with midazolam, or ketamine combined with propofol rather than opioids combined with benzodiazepines (eg, midazolam), opioids combined with etomidate, opioids combined with propofol, or nitrous oxide (N2O) alone (table 1).

Based upon observational studies and randomized trials, ketamine alone or in combination with midazolam or propofol provides more effective sedation and anxiolysis for very painful procedures, such as fracture reduction or bone marrow aspiration, than N2O alone and lower risk of respiratory events during sedation than opioids combined with midazolam, etomidate, or propofol [47,52-57]. Although vomiting may occur more frequently in patients who receive ketamine sedation without propofol than other sedation regimens, this adverse effect can be mitigated by pretreatment with ondansetron or combination sedation with propofol [58-60]. (See "Pharmacologic agents for pediatric procedural sedation outside of the operating room", section on 'Ketamine'.)

Several studies support these conclusions:

In a blinded trial of 260 children, 5 to 15 years of age, undergoing fracture reduction, patients who received ketamine combined with midazolam had clinically significantly lower distress during the procedure and higher orthopedist satisfaction than those who received midazolam and fentanyl [53]. Sedation with ketamine and midazolam was associated with clinically significantly fewer respiratory complications than midazolam and fentanyl (hypoxia: 6 versus 24 percent, respectively; breathing cues: 1 versus 12 percent, respectively; and supplemental oxygen requirement: 10 versus 20 percent, respectively). One patient in each group had laryngospasm. Patients who received ketamine and midazolam were significantly more likely to vomit during recovery (9 versus 2 percent) and had an average recovery time that was 14 minutes longer than those who received midazolam and fentanyl.

In a trial of 113 children, 3 to 18 years of age, undergoing fracture reduction, patients who received ketamine and midazolam had clinically significantly less chance of oxygen desaturation (7 versus 31 percent, respectively) and need for respiratory maneuvers (2 versus 25 percent, respectively) than those who received propofol and fentanyl [54]. Patients who received ketamine and midazolam had clinically significantly longer total sedation time compared with those who received propofol and fentanyl (62 versus 39 minutes). Distress during reduction was low in both groups. Nurse and orthopedist satisfaction was high for both regimens.

In a multicenter observational study of 1019 children younger than 18 years undergoing a variety of painful procedures including bone marrow aspiration, lumbar puncture, laceration repairs, and fracture reduction, N2O alone was associated with high rates of responsiveness to pain that varied by age and was indicated by crying (11 to 44 percent), withdrawal (18 to 43 percent), and need for restraint (8 to 34 percent) [47]. Vomiting occurred in 4 percent of patients but no significant respiratory events were reported.

In an observational study of 4252 children younger than 19 years receiving ketamine sedation at a children’s hospital, adverse respiratory events (eg, oxygen desaturation, airway obstruction, or apnea) and major respiratory events requiring airway intervention occurred in 2 and 1 percent of patients, respectively, including 29 patients with laryngospasm [61]. One patient required endotracheal intubation. Administration of morphine prior to sedation or midazolam during sedation was not associated with an increased frequency of respiratory events. As previously discussed, these rates of adverse respiratory events are much lower than those described in children receiving opioids combined with midazolam, etomidate, or propofol [53,54,56].

Thus, currently available evidence favors ketamine alone or in combination with midazolam as an effective and safe sedative regimen for children undergoing brief, painful procedures in the emergency department. There is ample evidence that propofol alone or in combination with opioids can be effective for pediatric sedation outside of the operating room for these procedures. In general, propofol based techniques carry a greater frequency of minor adverse events. Clinicians who use propofol warrant proper training and experience [39].

Although data are limited in children, the combination of propofol and ketamine for procedural sedation provides effective sedation and less vomiting than reported for ketamine alone and less respiratory depression and hypotension than described with propofol alone based upon experience in adults. (See "Procedural sedation in adults outside the operating room", section on 'Ketamine and propofol (ketofol)'.)

Evidence in children supports the adult experience as demonstrated in the following studies:

In an observational study of 219 patients, age 1 to 20 years, ketofol (propofol [10 mg/ml] in a 1:1 volume mixture with ketamine [10 mg/ml]) effectively sedated all patients with an average sedating dose of 0.8 mg/kg for both agents and a median recovery time of 14 minutes [60]. Airway intervention was necessary in three patients (1.4 percent), including one patient who needed bag-valve-mask ventilation for laryngospasm. No patients had hypotension or vomiting.

In a trial of 136 children (aged 2 to 17 years) who were receiving sedation and analgesia for fracture management with bolus doses of ketamine and propofol or ketamine alone, sedation and recovery time was statistically significantly shorter for ketamine combined with propofol (13 versus 16 minutes and 10 versus 12 minutes, respectively) [59]. Clinically significantly more vomiting occurred in children who received ketamine alone than those who received ketamine and propofol (12 versus 2 percent). Oxygen desaturation or airway obstruction was not significantly different between the two groups (9 percent for ketamine, 12 percent for ketamine and propofol) and resolved with supplemental oxygen or airway repositioning. No patient had laryngospasm or hypotension. Approximately half of the patients in each group received opioid analgesia prior to sedation.

Thus, the combination of propofol and ketamine is an option for brief, moderate to severely painful procedures. However, when this combination is used, the clinician performing the sedation must have appropriate expertise in the performance of pediatric resuscitation, pediatric airway management, and specific training in the use of propofol and the provision of deep sedation or anesthesia. Careful selection of patients and appropriate preparation and monitoring are essential to maximize the safety of this regimen. Furthermore, this combination has not been shown to be more efficacious or safer for procedural sedation in adults. (See "Preparation for pediatric procedural sedation outside of the operating room" and "Procedural sedation in adults outside the operating room", section on 'Ketamine and propofol (ketofol)'.)

Recommendations for procedural sedation in children undergoing elective diagnostic interventions (eg, gastrointestinal endoscopy, bronchoscopy, cardiac catheterization, or interventional radiology) are beyond the scope of this topic.

SUMMARY AND RECOMMENDATIONS

Nonpharmacologic interventions include behavioral and cognitive approaches such as desensitization, distraction, reinforcing coping skills, positive reinforcement, and relaxation. These techniques are complementary to pharmacologic interventions and, in some children, may prevent the need for sedation altogether. (See "Procedural sedation in children outside of the operating room", section on 'Nonpharmacologic interventions'.)

The targeted depth of sedation and the agents used largely depend upon the procedure performed, the anticipated degree of pain, allowable patient movement, and other patient factors. The recommendations for sedation strategies and dosing in this topic assume that the patient is healthy (American Society of Anesthesiologists class I or II) (table 3) and that the sedation is being performed by a properly trained health care provider with institutional oversight. (See 'Choice of sedative agents' above.)

The necessary preparation, indications, contraindications, and steps for safely performing procedural sedation in children are discussed separately. Patient factors (eg, last oral intake, urgency of the procedure, prior sedation experience, and comorbidities [eg, asthma, upper respiratory infection]) are key considerations for sedation strategies in children. (See "Preparation for pediatric procedural sedation outside of the operating room" and "Procedural sedation in children outside of the operating room".)

The properties of the specific agents with respect to pediatric sedation are listed in the tables (table 1 and table 2) and discussed in detail separately. (See "Pharmacologic agents for pediatric procedural sedation outside of the operating room".)

In some facilities, the use of propofol, ketamine, dexmedetomidine, or etomidate may be restricted to use by anesthesiologists or other specialists (eg, pediatric critical care or pediatric emergency medicine specialists). (See 'Choice of sedative agents' above.)

Imaging tests that are negatively impacted by motion (eg, noninterventional computed tomography [CT] or magnetic resonance imaging [MRI]) constitute the most common nonpainful procedures for which children undergo sedation. The selection of medications for these procedures are determined by the duration of the test and whether vascular access is present (see 'Sedation for imaging studies' above):

We suggest that healthy infants and children (American Society of Anesthesiologists class I or II) (table 3) who have vascular access and are undergoing sedation for CT receive intravenous (IV) propofol, dexmedetomidine, or etomidate rather than intravenous short-acting barbiturates (eg, pentobarbital or methohexital) or midazolam (table 1) (Grade 2C). (See 'Intravenous medications' above.)

We suggest that healthy infants and children (American Society of Anesthesiologists class I or II) (table 3) who do not have intravenous access and are undergoing sedation for CT receive oral pentobarbital rather than oral or intranasal midazolam or rectal thiopental (not available in the United States or Canada) or methohexital (table 2) (Grade 2C). We suggest that these children not receive chloral hydrate (Grade 2C). Regardless of agent and route chosen, children should undergo monitoring of oxygen saturation and heart rate as soon as any signs of sedation are present because the risk of adverse events is not lower with these routes of administration when compared to sedation with intravenous agents. (See 'Oral, rectal, or intranasal medications' above.)

We suggest that healthy infants and children (American Society of Anesthesiologists class I or II) undergoing magnetic resonance imaging receive sedation using continuous intravenous (IV) infusion of dexmedetomidine or propofol rather than IV or oral pentobarbital or oral or rectal chloral hydrate (table 1 and table 2) (Grade 2C). In settings where dexmedetomidine, propofol, or appropriately trained providers to administer these agents are not available, we suggest IV or oral pentobarbital (Grade 2C). We suggest that these patients not receive chloral hydrate (Grade 2C). (See 'Magnetic resonance imaging' above.)

When nonpharmacologic interventions are not sufficient and mild sedation is necessary for nonpainful procedures, we suggest that healthy children (American Society of Anesthesiologists class I or II) (table 3) receive sedation with inhaled nitrous oxide (N2O) or oral, sublingual, or intranasal midazolam rather than short-acting barbiturates (table 2) (Grade 2C). (See 'Sedation for other nonpainful procedures' above.)

When nonpharmacologic interventions and topical anesthetics are not sufficient and mild sedation is necessary for minimally painful procedures (eg, intravenous cannula placement), we suggest that healthy children (American Society of Anesthesiologists class I or II) (table 3) receive sedation with inhaled nitrous oxide (N2O) or oral, sublingual, or intranasal midazolam rather than short-acting barbiturates (table 2) (Grade 2C). Intravenous sedation as described for computed tomography is suggested for patients who fail N2O or midazolam sedation. (See 'Minimally painful' above and "Pharmacologic agents for pediatric procedural sedation outside of the operating room", section on 'Nitrous oxide'.)

Moderate to severely painful procedures, including fracture reduction, laceration repair, bone marrow aspiration, central line placement, and lumbar puncture frequently require procedural sedation that effectively combines sedation and analgesia. For these procedures, chosen agents or combinations of agents must safely provide sedation and analgesia. Appropriate analgesia can often lower the amount of sedative agent needed to provide adequate sedation and thus increase the safety of the procedure. The need for supplementary analgesia varies by the agents used. (See 'Sedation for painful procedures' above.)

Options for supplementary analgesia include topical, local, and regional infiltrated anesthetics and systemic analgesic medications. The commonly used agents for analgesia during pediatric procedural sedation are discussed separately. (See "Pharmacologic agents for pediatric procedural sedation outside of the operating room", section on 'Analgesic agents'.)

For healthy infants and children (American Society of Anesthesiologists class I or II) who are undergoing moderately or severely painful procedures of short duration (eg, fracture reduction or bone marrow aspiration), we suggest procedural sedation with intravenous ketamine or ketamine in combination with midazolam or propofol rather than N2O alone or opioids combined with benzodiazepines (eg, midazolam), etomidate, or propofol (table 1) (Grade 2C). Ondansetron is suggested as a premedication when ketamine is used. (See 'Moderately or severely painful' above and "Pharmacologic agents for pediatric procedural sedation outside of the operating room", section on 'Ketamine'.)

Use of UpToDate is subject to the Subscription and License Agreement.

REFERENCES

  1. Kennedy RM, Luhmann JD. Pharmacological management of pain and anxiety during emergency procedures in children. Paediatr Drugs 2001; 3:337.
  2. Krauss B, Green SM. Procedural sedation and analgesia in children. Lancet 2006; 367:766.
  3. Sahyoun C, Krauss B. Clinical implications of pharmacokinetics and pharmacodynamics of procedural sedation agents in children. Curr Opin Pediatr 2012; 24:225.
  4. Coté CJ, Wilson S, AMERICAN ACADEMY OF PEDIATRICS, AMERICAN ACADEMY OF PEDIATRIC DENTISTRY. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. Pediatrics 2016; 138.
  5. Cravero JP, Blike GT, Beach M, et al. Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: report from the Pediatric Sedation Research Consortium. Pediatrics 2006; 118:1087.
  6. Macias CG, Chumpitazi CE. Sedation and anesthesia for CT: emerging issues for providing high-quality care. Pediatr Radiol 2011; 41 Suppl 2:517.
  7. Rutman MS. Sedation for emergent diagnostic imaging studies in pediatric patients. Curr Opin Pediatr 2009; 21:306.
  8. Baxter AL, Mallory MD, Spandorfer PR, et al. Etomidate versus pentobarbital for computed tomography sedations: report from the Pediatric Sedation Research Consortium. Pediatr Emerg Care 2007; 23:690.
  9. Kienstra AJ, Ward MA, Sasan F, et al. Etomidate versus pentobarbital for sedation of children for head and neck CT imaging. Pediatr Emerg Care 2004; 20:499.
  10. Mason KP, Prescilla R, Fontaine PJ, Zurakowski D. Pediatric CT sedation: comparison of dexmedetomidine and pentobarbital. AJR Am J Roentgenol 2011; 196:W194.
  11. Mason KP, Zgleszewski SE, Prescilla R, et al. Hemodynamic effects of dexmedetomidine sedation for CT imaging studies. Paediatr Anaesth 2008; 18:393.
  12. Srinivasan M, Turmelle M, Depalma LM, et al. Procedural sedation for diagnostic imaging in children by pediatric hospitalists using propofol: analysis of the nature, frequency, and predictors of adverse events and interventions. J Pediatr 2012; 160:801.
  13. Singh R, Kumar N, Vajifdar H. Midazolam as a sole sedative for computed tomography imaging in pediatric patients. Paediatr Anaesth 2009; 19:899.
  14. Green SM, Krauss B. Propofol in emergency medicine: pushing the sedation frontier. Ann Emerg Med 2003; 42:792.
  15. Hofer KN, McCarthy MW, Buck ML, Hendrick AE. Possible anaphylaxis after propofol in a child with food allergy. Ann Pharmacother 2003; 37:398.
  16. Rockoff MA, Goudsouzian NG. Seizures induced by methohexital. Anesthesiology 1981; 54:333.
  17. Sheta SA, Al-Sarheed MA, Abdelhalim AA. Intranasal dexmedetomidine vs midazolam for premedication in children undergoing complete dental rehabilitation: a double-blinded randomized controlled trial. Paediatr Anaesth 2014; 24:181.
  18. Zhang X, Bai X, Zhang Q, et al. The safety and efficacy of intranasal dexmedetomidine during electrochemotherapy for facial vascular malformation: a double-blind, randomized clinical trial. J Oral Maxillofac Surg 2013; 71:1835.
  19. Yuen VM, Hui TW, Irwin MG, et al. Optimal timing for the administration of intranasal dexmedetomidine for premedication in children. Anaesthesia 2010; 65:922.
  20. Rooks VJ, Chung T, Connor L, et al. Comparison of oral pentobarbital sodium (nembutal) and oral chloral hydrate for sedation of infants during radiologic imaging: preliminary results. AJR Am J Roentgenol 2003; 180:1125.
  21. Mason KP, Zurakowski D, Connor L, et al. Infant sedation for MR imaging and CT: oral versus intravenous pentobarbital. Radiology 2004; 233:723.
  22. Mason KP, Sanborn P, Zurakowski D, et al. Superiority of pentobarbital versus chloral hydrate for sedation in infants during imaging. Radiology 2004; 230:537.
  23. Malviya S, Voepel-Lewis T, Prochaska G, Tait AR. Prolonged recovery and delayed side effects of sedation for diagnostic imaging studies in children. Pediatrics 2000; 105:E42.
  24. Pomeranz ES, Chudnofsky CR, Deegan TJ, et al. Rectal methohexital sedation for computed tomography imaging of stable pediatric emergency department patients. Pediatrics 2000; 105:1110.
  25. Glasier CM, Stark JE, Brown R, et al. Rectal thiopental sodium for sedation of pediatric patients undergoing MR and other imaging studies. AJNR Am J Neuroradiol 1995; 16:111.
  26. D'Agostino J, Terndrup TE. Chloral hydrate versus midazolam for sedation of children for neuroimaging: a randomized clinical trial. Pediatr Emerg Care 2000; 16:1.
  27. Harcke HT, Grissom LE, Meister MA. Sedation in pediatric imaging using intranasal midazolam. Pediatr Radiol 1995; 25:341.
  28. Coté CJ, Karl HW, Notterman DA, et al. Adverse sedation events in pediatrics: analysis of medications used for sedation. Pediatrics 2000; 106:633.
  29. American Academy of Pediatrics Committee on Drugs and Committee on Environmental Health: Use of chloral hydrate for sedation in children. Pediatrics 1993; 92:471.
  30. Cortellazzi P, Lamperti M, Minati L, et al. Sedation of neurologically impaired children undergoing MRI: a sequential approach. Paediatr Anaesth 2007; 17:630.
  31. Vade A, Sukhani R, Dolenga M, Habisohn-Schuck C. Chloral hydrate sedation of children undergoing CT and MR imaging: safety as judged by American Academy of Pediatrics guidelines. AJR Am J Roentgenol 1995; 165:905.
  32. Mason KP, Zurakowski D, Zgleszewski S, et al. Incidence and predictors of hypertension during high-dose dexmedetomidine sedation for pediatric MRI. Paediatr Anaesth 2010; 20:516.
  33. Mason KP, Zurakowski D, Zgleszewski SE, et al. High dose dexmedetomidine as the sole sedative for pediatric MRI. Paediatr Anaesth 2008; 18:403.
  34. Heard C, Burrows F, Johnson K, et al. A comparison of dexmedetomidine-midazolam with propofol for maintenance of anesthesia in children undergoing magnetic resonance imaging. Anesth Analg 2008; 107:1832.
  35. Lubisch N, Roskos R, Berkenbosch JW. Dexmedetomidine for procedural sedation in children with autism and other behavior disorders. Pediatr Neurol 2009; 41:88.
  36. Dave J, Vaghela S. A comparison of the sedative, hemodynamic, and respiratory effects of dexmedetomidine and propofol in children undergoing magnetic resonance imaging. Saudi J Anaesth 2011; 5:295.
  37. Teshome G, Belani K, Braun JL, et al. Comparison of dexmedetomidine with pentobarbital for pediatric MRI sedation. Hosp Pediatr 2014; 4:360.
  38. Mallory MD, Baxter AL, Kost SI, Pediatric Sedation Research Consortium. Propofol vs pentobarbital for sedation of children undergoing magnetic resonance imaging: results from the Pediatric Sedation Research Consortium. Paediatr Anaesth 2009; 19:601.
  39. Cravero JP, Beach ML, Blike GT, et al. The incidence and nature of adverse events during pediatric sedation/anesthesia with propofol for procedures outside the operating room: a report from the Pediatric Sedation Research Consortium. Anesth Analg 2009; 108:795.
  40. Mahmoud M, Gunter J, Donnelly LF, et al. A comparison of dexmedetomidine with propofol for magnetic resonance imaging sleep studies in children. Anesth Analg 2009; 109:745.
  41. Delgado J, Toro R, Rascovsky S, et al. Chloral hydrate in pediatric magnetic resonance imaging: evaluation of a 10-year sedation experience administered by radiologists. Pediatr Radiol 2015; 45:108.
  42. Layangool T, Sangtawesin C, Kirawittaya T, et al. A comparison of oral chloral hydrate and sublingual midazolam sedation for echocardiogram in children. J Med Assoc Thai 2008; 91 Suppl 3:S45.
  43. Chiaretti A, Barone G, Rigante D, et al. Intranasal lidocaine and midazolam for procedural sedation in children. Arch Dis Child 2011; 96:160.
  44. McMorrow SP, Abramo TJ. Dexmedetomidine sedation: uses in pediatric procedural sedation outside the operating room. Pediatr Emerg Care 2012; 28:292.
  45. Zub D, Berkenbosch JW, Tobias JD. Preliminary experience with oral dexmedetomidine for procedural and anesthetic premedication. Paediatr Anaesth 2005; 15:932.
  46. Sakurai Y, Obata T, Odaka A, et al. Buccal administration of dexmedetomidine as a preanesthetic in children. J Anesth 2010; 24:49.
  47. Annequin D, Carbajal R, Chauvin P, et al. Fixed 50% nitrous oxide oxygen mixture for painful procedures: A French survey. Pediatrics 2000; 105:E47.
  48. Luhmann JD, Kennedy RM, Porter FL, et al. A randomized clinical trial of continuous-flow nitrous oxide and midazolam for sedation of young children during laceration repair. Ann Emerg Med 2001; 37:20.
  49. Ekbom K, Kalman S, Jakobsson J, Marcus C. Efficient intravenous access without distress: a double-blind randomized study of midazolam and nitrous oxide in children and adolescents. Arch Pediatr Adolesc Med 2011; 165:785.
  50. Zier JL, Liu M. Safety of high-concentration nitrous oxide by nasal mask for pediatric procedural sedation: experience with 7802 cases. Pediatr Emerg Care 2011; 27:1107.
  51. Babl FE, Oakley E, Seaman C, et al. High-concentration nitrous oxide for procedural sedation in children: adverse events and depth of sedation. Pediatrics 2008; 121:e528.
  52. Migita RT, Klein EJ, Garrison MM. Sedation and analgesia for pediatric fracture reduction in the emergency department: a systematic review. Arch Pediatr Adolesc Med 2006; 160:46.
  53. Kennedy RM, Porter FL, Miller JP, Jaffe DM. Comparison of fentanyl/midazolam with ketamine/midazolam for pediatric orthopedic emergencies. Pediatrics 1998; 102:956.
  54. Godambe SA, Elliot V, Matheny D, Pershad J. Comparison of propofol/fentanyl versus ketamine/midazolam for brief orthopedic procedural sedation in a pediatric emergency department. Pediatrics 2003; 112:116.
  55. Roback MG, Wathen JE, Bajaj L, Bothner JP. Adverse events associated with procedural sedation and analgesia in a pediatric emergency department: a comparison of common parenteral drugs. Acad Emerg Med 2005; 12:508.
  56. Di Liddo L, D'Angelo A, Nguyen B, et al. Etomidate versus midazolam for procedural sedation in pediatric outpatients: a randomized controlled trial. Ann Emerg Med 2006; 48:433.
  57. Mandt MJ, Roback MG, Bajaj L, et al. Etomidate for short pediatric procedures in the emergency department. Pediatr Emerg Care 2012; 28:898.
  58. Langston WT, Wathen JE, Roback MG, Bajaj L. Effect of ondansetron on the incidence of vomiting associated with ketamine sedation in children: a double-blind, randomized, placebo-controlled trial. Ann Emerg Med 2008; 52:30.
  59. Shah A, Mosdossy G, McLeod S, et al. A blinded, randomized controlled trial to evaluate ketamine/propofol versus ketamine alone for procedural sedation in children. Ann Emerg Med 2011; 57:425.
  60. Andolfatto G, Willman E. A prospective case series of pediatric procedural sedation and analgesia in the emergency department using single-syringe ketamine-propofol combination (ketofol). Acad Emerg Med 2010; 17:194.
  61. Melendez E, Bachur R. Serious adverse events during procedural sedation with ketamine. Pediatr Emerg Care 2009; 25:325.
Topic 85542 Version 13.0

All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.