What makes UpToDate so powerful?

  • over 11000 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 ©2017 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 ©2017 UpToDate, Inc.
Selection of medications for pediatric procedural sedation outside of the operating room
View in Chinese
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Apr 2017. | This topic last updated: Mar 23, 2017.

INTRODUCTION — 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 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".)

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

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 during the procedure, and the following patient factors [1,2] (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 and development level

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".)

In some facilities, the use of specific sedatives may be restricted to use by anesthesiologists or other specialists (eg, pediatric critical care or pediatric emergency medicine specialists). For example, in some settings, 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 be aware of local requirements.

Safety requirements — Safe use of sedative agents outside of the operating room requires careful attention to the following factors:

Selection and preparation of patients – The patient should be evaluated and prepared for sedation in accordance with guidelines designed to maximize patient safety. This assessment, includes an American Society of Anesthesiologists (ASA) classification (table 3) and helps to identify patients at higher than normal risk for sedation. (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'.)

Those patients with ASA class IV, and V, special needs, or airway abnormalities warrant consultation with a pediatric anesthesiologist. These patients are at increased risk for sedation-related adverse events and should be cared for by individuals who are specifically trained and experienced with high-risk pediatric procedural sedation. Ideally, they should be cared for by providers working in an organized sedation service that has ancillary personnel with sedation expertise and an ongoing quality improvement program.

Competency of the sedation provider – 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. (See "Procedural sedation in children outside of the operating room", section on 'Performing procedural sedation'.)

Institutional oversight – Institutions should develop guidelines and requirements that support the safe practice of pediatric sedation, including credentialing of individual providers and measurement and assessment of the quality of sedation care. In settings where pediatric procedural sedation is routine (eg, children's hospitals), a pediatric sedation service can provide efficient and effective sedation and is a systematic support for the safe performance of sedation. (See "Procedural sedation in children outside of the operating room", section on 'Adverse outcomes'.)

SEDATION FOR IMAGING STUDIES — Imaging can often be performed without sedation in older cooperative children and young infants (up to six months of age) who are bundled and recently fed. Furthermore, as newer technologies decrease the image capture time for computed tomography (CT), many uncooperative patients can be imaged without sedation [3].

However, a significant number of older infants, toddlers, and older children with intellectual disability cannot cooperate even for brief imaging tests (eg, helical CT) and warrant sedation to ensure accurate imaging without excessive radiation exposure. Thus, imaging tests that are negatively impacted by motion (eg, noninterventional CT or magnetic resonance imaging [MRI]) constitute the most common nonpainful procedures for which children undergo sedation [4].

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 [5]. The regimen should also permit rapid recovery with few side effects, such as nausea or agitation. Because imaging studies are not painful, analgesia is not necessary.

Computed tomography

Approach — Successful imaging with helical CT is less sensitive to patient movement than MRI and, given the rapid speed of imaging, can frequently be done without sedation or requires only brief sedation (approximately 5 to 10 minutes). As an example, in one case series of 104 patients undergoing helical CT, only 9 percent received sedation [6].

When sedation is required, the clinician has a choice of several different agents as discussed below.

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, titration is easier, and (depending upon the agent), recovery is quicker (table 1) [5]. (See 'Intravenous medications' below.)

Other routes of administration are feasible for children without IV 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]. Thus, we prefer to provide IV sedation whenever possible. (See 'No intravenous access' below.)

Intravenous medications — We recommend that healthy infants and children (American Society of Anesthesiologists [ASA] class I or II) (table 3) who have vascular access and are undergoing sedation for CT receive IV propofol, dexmedetomidine, ketamine, or etomidate rather than IV short-acting barbiturates (eg, pentobarbital or methohexital) or midazolam (table 1).

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) [5,8-12]. Although lower efficacy was described for IV 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 [8,9,13]. Based upon a review of prospectively collected registry data from over 22,000 children, IV ketamine is also frequently used for imaging; radiologic procedures accounted for almost 25 percent of reported use in the study [13]. Although not specifically reported for radiologic procedures, 99.8 percent of all procedures were successfully completed which suggests that IV ketamine has similar efficacy for CT when compared with propofol, etomidate, or dexmedetomidine. However, when used as a single agent, ketamine may be associated with random movement in some patients.

IV ketamine, 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 ketamine and propofol varies by dose and mode of administration (bolus or continuous infusion) and compares favorably with etomidate.

Evidence is lacking to suggest that major adverse events (eg, laryngospasm, aspiration, apnea requiring airway intervention, or need for resuscitation) varies by the medication used to sedate for CT. Adverse events that are not necessarily life-threatening have been described in 2 percent of infants and children receiving etomidate or propofol sedation for imaging and 1 percent receiving dexmedetomidine. By 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 respiratory depression with transient oxygen desaturation [8,10,14]. Less commonly apnea has been described, especially in patients receiving short-acting barbiturates.

Other adverse reactions that are specific to the agent are described in the table (table 1) and discussed separately. (See "Pharmacologic agents for pediatric procedural sedation outside of the operating room", section on 'Sedative-hypnotic agents'.)

No intravenous access — We prefer administration of IV medications, whenever possible, for uncooperative children undergoing CT. (See 'Intravenous medications' above.)

When an IV cannot be placed, medication options and route of administration include (table 2):

Oral or intranasal midazolam

Intranasal dexmedetomidine

Intramuscular ketamine

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 [15-17]. Furthermore, sedation takes approximately 30 minutes to achieve. Thus, intramuscular ketamine may be preferred when timely imaging is necessary. Intramuscular ketamine is associated with more adverse events and serious adverse events than midazolam or dexmedetomidine. Furthermore, random motion may occur during ketamine sedation which can impair successful completion of the study. (See "Pharmacologic agents for pediatric procedural sedation outside of the operating room", section on 'Ketamine'.)

Preliminary evidence suggests that intranasal dexmedetomidine (2. 5 mcg/kg) may be more effective than midazolam for producing adequate sedation with similar onset of sedation (approximately 30 minutes) and time to discharge (approximately 40 minutes). As an example, in a trial of 59 children undergoing CT, 20 of 30 children receiving intranasal dexmedetomidine required no further sedation for CT versus 7 of 29 children given oral midazolam (0.5 mg/kg) [18]. Further study is needed to determine the optimal dosing for intranasal dexmedetomidine.

Regardless of agent and route chosen, children should undergo monitoring of oxygen saturation and heart rate according to recommendations because the risk of adverse events is significant regardless of the route of administration. (See "Procedural sedation in children outside of the operating room", section on 'Monitoring'.)

Despite their relatively high efficacy when compared with oral or intranasal midazolam or intranasal dexmedetomidine, we do not endorse the use of oral or rectal short-acting barbiturates (eg, pentobarbital or methohexital) because of their long duration of sedation relative to the short imaging time, high rates of adverse events during sedation, and potential for delayed adverse events, including prolonged sleepiness and ataxia [15-17,19-24].

Chloral hydrate is no longer recommended for sedation in children and is not available in many countries, including the United States. 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 [25,26].

Magnetic resonance imaging — MRI often necessitates sedation for up to one hour. Furthermore, machine noise and lack of patient access pose additional challenges to achieving safe and effective sedation. We suggest that healthy infants and children (ASA class I or II) (table 3) undergoing MRI receive sedation using propofol or dexmedetomidine (table 1). Because it has a shorter time to recovery and discharge [27], experienced providers often administer propofol given as a bolus of 2 to 4 mg/kg followed by an infusion at 150 to 200 mcg/kg/minute.

Propofol may be also preferred in children with increases in pulmonary artery pressure, decreases in cardiac output, children with AV node conduction delay, or those receiving digoxin, beta blockers or other medications that slow AV node conduction.

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) [28].

Sedation with continuous infusion of propofol or dexmedetomidine permits successful completion of MRI in approximately 97 to 99 percent of children when administered by experienced practitioners [12,27,29-31]. Time to sedation is longer with dexmedetomidine than with propofol (10 versus <1 minutes, respectively) [12,27,29,30]. Recovery is typically complete 20 to 30 minutes after stopping a propofol infusion and 25 to 40 minutes after ending a dexmedetomidine infusion [12,27,29,30,32,33].

However, to achieve this level of success with dexmedetomidine infusion alone typically requires dosing that exceeds current manufacturer recommendations (table 1) [30]. 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 [27]. Current evidence does not support one approach to dexmedetomidine dosing over the other. (See "Pharmacologic agents for pediatric procedural sedation outside of the operating room", section on 'Dexmedetomidine'.)

Either propofol or dexmedetomidine can be used safely for MRI sedation, propofol may cause more need for airway intervention or IV fluid administration. Dexmedetomidine can be associated with marked bradycardia. (See "Pharmacologic agents for pediatric procedural sedation outside of the operating room", section on 'Propofol' and "Pharmacologic agents for pediatric procedural sedation outside of the operating room", section on 'Dexmedetomidine'.)

Although pentobarbital by the oral or IV route was used in the past to sedate children undergoing MRI , the potential for adverse events may be increased and recovery time tends to be longer with a high rate of delirium during emergence when compared to propofol or dexmedetomidine infusion (table 1) [20,34-37].

Proper administration, dosing, adverse effects, contraindications, and precautions for propofol and dexmedetomidine are discussed in greater detail separately. (See "Pharmacologic agents for pediatric procedural sedation outside of the operating room", section on 'Sedative-hypnotic agents'.)

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 oral, sublingual, or intranasal midazolam or intranasal dexmedetomidine rather than short-acting barbiturates (table 2). Inhaled nitrous oxide is also a reasonable option, although use of a nasal or face mask can be challenging in selected patients.

Intravenous (IV) sedation as described for computed tomography is suggested for patients who fail midazolam sedation. (See 'Computed tomography' above.)

Several small studies describe acceptable efficacy following the use of intranasal, oral, or buccal dexmedetomidine for pediatric sedation that appears equivalent or superior to midazolam, depending upon the procedure and has not been associated with significant adverse events [38-41]. Oral doses in these studies have ranged from 2.5 to 4 mcg/kg. An intranasal dose of 2.5 mcg/kg provided effective sedation for computed tomography in approximately two-thirds of patients.

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]. Due to the low pH and the benzyl alcohol preservative, intranasal midazolam can be irritating when administered. Pretreatment with lidocaine spray (10 mg per puff) 1 minute prior to intranasal midazolam administration decreases nasal mucosal irritation. An atomizer is preferred for the delivery of midazolam intranasally for better comfort and reduction of sneezing and cough when compared with direct instillation [43]. Although midazolam may be administered rectally, this route is less reliable.

Midazolam has good efficacy for nonpainful procedures that permit motion [42,43] and has a shorter duration of action than oral or rectal pentobarbital (<1 hour versus 1 to 4 hours, respectively). Unlike barbiturates, midazolam is not associated with prolonged symptoms of ataxia, sleepiness, or irritability (table 2). (See 'No intravenous access' above.)

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)'.)

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.

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 procedures (eg, peripheral intravenous [IV] cannula insertion or laceration repair in regions of the body where occasional movement does not interfere with the procedure) – Minimal sedation, often best achieved with midazolam or inhaled nitrous oxide. (See 'Minimally painful procedures' below.)

Moderate to severely painful procedures (eg, fracture reduction) or laceration repair where movement will interfere significantly with performance of the procedure) – Deep sedation, typically reached with ketamine alone, propofol alone (brief procedures), ketamine combined with propofol, or propofol combined with fentanyl. The provider should be aware that any of these regimens can produce general anesthesia depending upon the initial dose and frequency of re-dosing. (See 'Moderately or severely painful procedures' below.)

Appropriate analgesia can often lower the amount of sedative agent needed to provide adequate sedation and is essential to increase the safety of the procedure.

The need for supplementary analgesia varies by the agents used for sedation:

Ketamine has both sedative and analgesic properties and can thus be used alone to provide sedation for moderate to severely painful procedures. However, for wound repair, local anesthetic (eg, topical lidocaine-epinephrine-tetracaine [LET] gel or infiltration of a local anesthetic) or a regional nerve block is also typically used, especially if the repair is estimated to take longer than 10 to 15 minutes. (See 'Moderately or severely painful procedures' below.)

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

Propofol, midazolam, and etomidate do not have analgesic properties and should 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. Propofol alone may be appropriate when local or regional anesthesia provides complete pain control. (See 'Moderately or severely painful procedures' below.)

Although options vary, typical approaches to analgesia by type of procedure include:

Wound repair

Topical anesthetic (eg, lidocaine-epinephrine-tetracaine) (see "Topical anesthetics in children")

Local infiltration of anesthetic (see "Subcutaneous infiltration of local anesthetics" and "Subcutaneous infiltration of local anesthetics", section on 'Procedure')

Regional anesthesia (eg, lacerations of the face, fingertip, distal toe, plantar foot, or penis) as described separately:

-Facial lacerations (see "Assessment and management of facial lacerations", section on 'Facial nerve blocks')

-Fingertip and distal toe (see "Digital nerve block", section on 'Digital block procedures')

-Plantar foot (see "Lower extremity nerve blocks: Techniques", section on 'Tibial block')

-Penis (see "Management of zipper injuries", section on 'Dorsal penile block')

Closed reduction of fractures

Opioid analgesia (eg, fentanyl) (see "Evaluation and management of pain in children", section on 'Opioids')

Hematoma block (distal radial fractures) (see "Distal radius fractures in adults", section on 'Hematoma block')

Bier block (fractures of the hand or forearm) (see "Overview of anesthesia and anesthetic choices", section on 'Intravenous regional anesthesia')

Regional anesthesia (eg, pain control for femoral fractures) (see "Lower extremity nerve blocks: Techniques")

Lumbar puncture or bone marrow aspiration – Topical anesthetic followed by local infiltration of anesthetic (see "Topical anesthetics in children" and "Subcutaneous infiltration of local anesthetics")

Minimally painful procedures — In many children undergoing IV 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 and "Topical anesthetics in children", section on 'LET' and "Topical anesthetics in children", section on 'EMLA' and "Subcutaneous infiltration of local anesthetics".)

When nonpharmacologic interventions and local anesthetics are not sufficient and minimal sedation is necessary for minimally painful procedures (eg, peripheral IV line placement, urethral catheterization, small laceration repair, or nasogastric tube placement), we suggest that healthy children (American Society of Anesthesiologists [ASA] class I or II) (table 3) receive sedation with inhaled nitrous oxide (N2O); oral, sublingual, or intranasal midazolam; or intranasal dexmedetomidine rather than short-acting barbiturates (table 2). When N2O is available and tolerated by the patient, it is preferred to midazolam as summarized below. Intranasal dexmedetomidine has been used for minimal sedation but requires more study before it can be routinely recommended.

When compared to N2O, midazolam, or intranasal dexmedetomidine, oral or rectal barbiturates are associated with higher rates of adverse effects, especially respiratory depression, (thiopental or methohexital) or prolonged duration of sedation (pentobarbital) (table 2).

Nitrous oxide – Because it has a shorter recovery time and fewer overall adverse effects, nitrous oxide (N2O) may be preferred to midazolam in cooperative children for the following reasons [44-47]:

The onset of action is short (<1 minute).

Recovery is typically faster (<20 minutes versus 30 to 60 minutes, respectively).

For selected procedures, N2O may also have greater efficacy. For example, in a trial, of over 250 children undergoing facial laceration repair, N2O or N2O combined with midazolam decreased distress to a greater extent than midazolam alone or lidocaine with comforting [44]. In another trial of 90 children in whom IV access was expected to be difficult, use of N2O was associated with a significantly increased success rate for IV placement when compared to oral midazolam [45]. Procedure time was also significantly shorter for patients who received 50 percent N2O when compared to oral midazolam.

Adverse events following N2O use are typically self-limited with vomiting being most common (approximately 6 to 7 percent of patients, primarily those with longer duration of inhalation or who also received opioids) [44,46-48]. Serious adverse effects (eg, post-procedure desaturation, apnea, stridor, aspiration, laryngospasm, or airway obstruction) are rare (eg, 0.2 percent in two observational studies and one case report of aspiration and laryngospasm) [47-49]). Thus, N2O use requires the same level of preparation and vigilance as other sedative agents. (See "Preparation for pediatric procedural sedation outside of the operating room" and "Procedural sedation in children outside of the operating room", section on 'Performing procedural sedation'.)

The method for administering N2O for procedural sedation and additional precautions are discussed in greater detail separately. (See "Pharmacologic agents for pediatric procedural sedation outside of the operating room", section on 'Nitrous oxide'.)

Midazolam – Based upon one large observational study, up to one-third of patients, especially children younger than 4 years of age, may not tolerate N2O delivery [50]. Such patients are good candidates for oral or intranasal midazolam [46]. Midazolam is also a reasonable alternative when N2O is not available. If the intranasal route of administration is chosen, pretreatment with lidocaine spray (10 mg per puff) 1 minute prior to intranasal midazolam administration and use of an atomizer is suggested [43].

Dexmedetomidine – Preliminary evidence suggests that intranasal dexmedetomidine may be equivalent to midazolam. In a trial of 40 young children (mean age three years) undergoing laceration repair, intranasal (IN) dexmedetomidine (2 mcg/kg) was similar to INl midazolam (0.4 mg/kg) for anxiolysis during repair but was associated with less anxiety during positioning with significantly more children showing no anxiety at this time point (70 versus 11 percent) [41]. Although evidence for safety and efficacy for this specific use of IN dexmedetomidine in children is limited, results from small trials where IN dexmedetomidine was used for other purposes (eg, nonpainful procedures, dental procedures, or preoperative sedation) support safety and efficacy that is potentially equivalent to midazolam [51-56]. Larger studies are needed to determine optimal dosing and to identify more infrequent side effects.

Moderately or severely painful procedures — For healthy infants and children (ASA 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 IV ketamine, ketamine combined with propofol, or fentanyl combined with propofol rather than opioids combined with benzodiazepines (eg, midazolam) or etomidate. When ketamine is used, a prophylactic dose of ondansetron may reduce post-procedure vomiting. (See "Pharmacologic agents for pediatric procedural sedation outside of the operating room", section on 'Ketamine'.)

Dosing and administration of specific IV sedation drugs used for moderate or deep sedation are provided in the table (table 1) and discussed separately. (See "Pharmacologic agents for pediatric procedural sedation outside of the operating room".)

Based upon observational studies and randomized trials, ketamine alone or in combination with propofol and fentanyl combined with propofol provides similar sedation efficacy for moderate to severely painful procedures [57], such as fracture reduction or bone marrow aspiration when compared with regimens that combine opioids (typically fentanyl) with midazolam [58-60] or etomidate [61,62]. All of the above IV regimens have a rapid onset of effect ranging from 30 seconds for etomidate and propofol to 1 to 2 minutes for ketamine alone or midazolam with fentanyl (table 1). Recovery from sedation using ketamine alone or ketamine with propofol ranges from 15 to 30 minutes which is longer than for etomidate or propofol (5 to 15 minutes) but shorter than for midazolam with fentanyl (15 to 60 minutes). Providers using propofol should have specific training in the use of propofol and the provision of deep sedation or anesthesia [63].

The IV regimens vary in terms of the frequency of important adverse events. (See "Pharmacologic agents for pediatric procedural sedation outside of the operating room".)

With recommended dosing, ketamine sedation tends to preserve airway reflexes and is associated with fewer airway or respiratory adverse events that require intervention than fentanyl combined with propofol, midazolam, or etomidate. On the other hand, vomiting and agitation during emergence are more frequent following ketamine sedation than with the other regimens although avoidance of high dosing (≥2.5 mg/kg initial dose or total dose ≥5 mg/kg) may reduce the frequency of these adverse events [64] and prophylactic ondansetron significantly reduces vomiting [65]. Hypotension, which occurs frequently during sedation with propofol, is not described following ketamine sedation. (See "Pharmacologic agents for pediatric procedural sedation outside of the operating room", section on 'Ketamine'.)

Although data are limited in children, the combination of propofol and ketamine for procedural sedation appears to provide effective sedation and less vomiting than reported for ketamine alone and less hypotension than described with propofol alone. However, adverse respiratory events including laryngospasm can still occur. Suggested dosing for this regimen is provided separately. (See "Pharmacologic agents for pediatric procedural sedation outside of the operating room", section on 'Ketamine'.)

Propofol combined with fentanyl is preferred by some sedation practitioners because it is equally efficacious to ketamine or ketamine combined with propofol and may produce a shorter and smoother recovery [66]. (See "Pharmacologic agents for pediatric procedural sedation outside of the operating room", section on 'Propofol'.)

Remifentanil combined with propofol has been used for anesthesia and deep sedation in children. However, evidence is lacking regarding the safety of this regimen when used outside of the operating room or pediatric intensive care unit.

Nitrous oxide alone for these procedures is associated with high levels of responsiveness to pain (up to 40 percent of patients) and need for restraint (up to one-third of patients) and is not recommended [50].

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 decrease the amount of sedation required or prevent the need for sedation altogether. (See "Procedural sedation in children outside of the operating room", section on 'Nonpharmacologic interventions'.)

The necessary preparation, indications, contraindications, monitoring, 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 and dosing for pediatric sedation are listed in the tables (table 1 and table 2) and provided 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, hospitalists, or pediatric emergency medicine specialists). (See 'Choice of sedative agents' above.)

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 safe performance of pediatric sedation requires proper selection and evaluation of patients, appropriate preparation, and the performance of sedation by providers with appropriate training and institutional support in accordance with guidelines designed to maximize patient safety. (See "Preparation for pediatric procedural sedation outside of the operating room" and "Procedural sedation in children outside of the operating room", section on 'Performing procedural sedation'.)

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. Successful imaging with helical CT is less sensitive to patient movement than MRI and, given the rapid speed of imaging, can frequently be done without 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):

For providers that are trained in the use of potent short-acting sedatives and work in well-supported sedation systems, we recommend that healthy infants and children (American Society of Anesthesiologists [ASA] class I or II) (table 3) who have vascular access and are undergoing sedation for CT receive intravenous (IV) bolus doses of propofol, dexmedetomidine, ketamine, or etomidate rather than IV short-acting barbiturates (eg, pentobarbital or methohexital) or midazolam (table 1) (Grade 1B). When used as a single agent, ketamine may be associated with random movement in some patients. (See 'Intravenous medications' above.)

We prefer administration of IV medications, whenever possible, for uncooperative children undergoing CT. When an IV cannot be placed, medication options and route of administration include intramuscular ketamine, oral or intranasal midazolam, and intranasal dexmedetomidine (table 2). However, successful completion of the procedure is lower than for IV agents. (See 'No intravenous access' above.)

For providers that are trained in the use of potent short-acting sedatives and work in well-supported sedation systems, we suggest that healthy infants and children (ASA class I or II) undergoing magnetic resonance imaging receive sedation using continuous IV infusion of propofol or dexmedetomidine (table 1) (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 (ASA class I or II) (table 3) receive sedation with oral, sublingual, or intranasal midazolam or intranasal dexmedetomidine rather than short-acting barbiturates (table 2) (Grade 2C). Nitrous oxide (N2O) is also a reasonable option, but the use of a mask for delivery can be challenging in these patients. (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, IV cannula placement), we suggest that healthy children (ASA class I or II) (table 3) receive sedation with inhaled nitrous oxide (N2O); oral, sublingual, or intranasal midazolam; or intranasal dexmedetomidine (Grade 2C). IV sedation as described for CT is suggested for patients who fail sedation with these agents. (See 'Minimally painful procedures' 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, abscess incision and drainage, central line placement, arthrocentesis, and lumbar puncture frequently require procedural sedation that effectively combines sedation and analgesia. Appropriate analgesia is essential to 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. Typical approaches to analgesia by type of procedure are provided above. (See 'Approach' above.)

For healthy infants and children (ASA class I or II) who are undergoing moderately or severely painful procedures of short duration (eg, fracture reduction or bone marrow aspiration) by providers that are trained in the use of potent short-acting sedatives and work in well-supported sedation systems, we suggest procedural sedation with IV ketamine, ketamine in combination with propofol, or propofol combined with fentanyl rather than opioids combined with benzodiazepines (eg, midazolam) or etomidate (table 1) (Grade 2C). When ketamine is used, a prophylactic dose of ondansetron may reduce post-procedure vomiting. The provider should be aware that propofol produces deep sedation and general anesthesia and that any of the other regimens can produce deep sedation or general anesthesia depending upon the initial dose and frequency of re-dosing. (See 'Moderately or severely painful procedures' 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. Krauss B, Green SM. Procedural sedation and analgesia in children. Lancet 2006; 367:766.
  2. 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.
  3. Zhu X, McCullough WP, Mecca P, et al. Dual-energy compared to single-energy CT in pediatric imaging: a phantom study for DECT clinical guidance. Pediatr Radiol 2016; 46:1671.
  4. 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.
  5. Macias CG, Chumpitazi CE. Sedation and anesthesia for CT: emerging issues for providing high-quality care. Pediatr Radiol 2011; 41 Suppl 2:517.
  6. Sacchetti A, Carraccio C, Giardino A, Harris RH. Sedation for pediatric CT scanning: is radiology becoming a drug-free zone? Pediatr Emerg Care 2005; 21:295.
  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. Grunwell JR, Travers C, McCracken CE, et al. Procedural Sedation Outside of the Operating Room Using Ketamine in 22,645 Children: A Report From the Pediatric Sedation Research Consortium. Pediatr Crit Care Med 2016; 17:1109.
  14. Singh R, Kumar N, Vajifdar H. Midazolam as a sole sedative for computed tomography imaging in pediatric patients. Paediatr Anaesth 2009; 19:899.
  15. 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.
  16. 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.
  17. Harcke HT, Grissom LE, Meister MA. Sedation in pediatric imaging using intranasal midazolam. Pediatr Radiol 1995; 25:341.
  18. Ghai B, Jain K, Saxena AK, et al. Comparison of oral midazolam with intranasal dexmedetomidine premedication for children undergoing CT imaging: a randomized, double-blind, and controlled study. Paediatr Anaesth 2017; 27:37.
  19. 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.
  20. Mason KP, Zurakowski D, Connor L, et al. Infant sedation for MR imaging and CT: oral versus intravenous pentobarbital. Radiology 2004; 233:723.
  21. Mason KP, Sanborn P, Zurakowski D, et al. Superiority of pentobarbital versus chloral hydrate for sedation in infants during imaging. Radiology 2004; 230:537.
  22. 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.
  23. 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.
  24. Conway A, Rolley J, Sutherland JR. Midazolam for sedation before procedures. Cochrane Database Syst Rev 2016; :CD009491.
  25. Sahyoun C, Krauss B. Clinical implications of pharmacokinetics and pharmacodynamics of procedural sedation agents in children. Curr Opin Pediatr 2012; 24:225.
  26. American Academy of Pediatrics Committee on Drugs and Committee on Environmental Health: Use of chloral hydrate for sedation in children. Pediatrics 1993; 92:471.
  27. 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.
  28. 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.
  29. 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.
  30. Mason KP, Zurakowski D, Zgleszewski SE, et al. High dose dexmedetomidine as the sole sedative for pediatric MRI. Paediatr Anaesth 2008; 18:403.
  31. Lubisch N, Roskos R, Berkenbosch JW. Dexmedetomidine for procedural sedation in children with autism and other behavior disorders. Pediatr Neurol 2009; 41:88.
  32. 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.
  33. Teshome G, Belani K, Braun JL, et al. Comparison of dexmedetomidine with pentobarbital for pediatric MRI sedation. Hosp Pediatr 2014; 4:360.
  34. Cortellazzi P, Lamperti M, Minati L, et al. Sedation of neurologically impaired children undergoing MRI: a sequential approach. Paediatr Anaesth 2007; 17:630.
  35. 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.
  36. 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.
  37. 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.
  38. McMorrow SP, Abramo TJ. Dexmedetomidine sedation: uses in pediatric procedural sedation outside the operating room. Pediatr Emerg Care 2012; 28:292.
  39. Zub D, Berkenbosch JW, Tobias JD. Preliminary experience with oral dexmedetomidine for procedural and anesthetic premedication. Paediatr Anaesth 2005; 15:932.
  40. Sakurai Y, Obata T, Odaka A, et al. Buccal administration of dexmedetomidine as a preanesthetic in children. J Anesth 2010; 24:49.
  41. Neville DN, Hayes KR, Ivan Y, et al. Double-blind Randomized Controlled Trial of Intranasal Dexmedetomidine Versus Intranasal Midazolam as Anxiolysis Prior to Pediatric Laceration Repair in the Emergency Department. Acad Emerg Med 2016; 23:910.
  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. 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.
  45. 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.
  46. 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.
  47. 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.
  48. Tsze DS, Mallory MD, Cravero JP. Practice Patterns and Adverse Events of Nitrous Oxide Sedation and Analgesia: A Report from the Pediatric Sedation Research Consortium. J Pediatr 2016; 169:260.
  49. Babl FE, Grindlay J, Barrett MJ. Laryngospasm With Apparent Aspiration During Sedation With Nitrous Oxide. Ann Emerg Med 2015; 66:475.
  50. Annequin D, Carbajal R, Chauvin P, et al. Fixed 50% nitrous oxide oxygen mixture for painful procedures: A French survey. Pediatrics 2000; 105:E47.
  51. Reynolds J, Rogers A, Medellin E, et al. A prospective, randomized, double-blind trial of intranasal dexmedetomidine and oral chloral hydrate for sedated auditory brainstem response (ABR) testing. Paediatr Anaesth 2016; 26:286.
  52. Gumus H, Bayram AK, Poyrazoglu HG, et al. Comparison of Effects of Different Dexmedetomidine and Chloral Hydrate Doses Used in Sedation on Electroencephalography in Pediatric Patients. J Child Neurol 2015; 30:983.
  53. Surendar MN, Pandey RK, Saksena AK, et al. A comparative evaluation of intranasal dexmedetomidine, midazolam and ketamine for their sedative and analgesic properties: a triple blind randomized study. J Clin Pediatr Dent 2014; 38:255.
  54. 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.
  55. Wang SS, Zhang MZ, Sun Y, et al. The sedative effects and the attenuation of cardiovascular and arousal responses during anesthesia induction and intubation in pediatric patients: a randomized comparison between two different doses of preoperative intranasal dexmedetomidine. Paediatr Anaesth 2014; 24:275.
  56. Talon MD, Woodson LC, Sherwood ER, et al. Intranasal dexmedetomidine premedication is comparable with midazolam in burn children undergoing reconstructive surgery. J Burn Care Res 2009; 30:599.
  57. 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.
  58. 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.
  59. Kennedy RM, Porter FL, Miller JP, Jaffe DM. Comparison of fentanyl/midazolam with ketamine/midazolam for pediatric orthopedic emergencies. Pediatrics 1998; 102:956.
  60. 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.
  61. 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.
  62. Mandt MJ, Roback MG, Bajaj L, et al. Etomidate for short pediatric procedures in the emergency department. Pediatr Emerg Care 2012; 28:898.
  63. Mallory MD, Baxter AL, Yanosky DJ, et al. Emergency physician-administered propofol sedation: a report on 25,433 sedations from the pediatric sedation research consortium. Ann Emerg Med 2011; 57:462.
  64. Green SM, Roback MG, Krauss B, et al. Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children. Ann Emerg Med 2009; 54:158.
  65. 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.
  66. 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.
Topic 85542 Version 17.0

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