| These agents should ONLY be administered by clinicians trained and experienced in pediatric procedural sedation using continuous noninvasive electronic monitoring of oxygenation, heart rate, blood pressure, and, whenever possible, end-tidal carbon dioxide monitoring. Resuscitation equipment, medications, and personnel skilled in advanced pediatric life support and knowledgeable of sedatives and reversal agents must be present. Unstable patients, patients with airway anomalies, and those with life-threatening, severe systemic disease warrant consultation with an anesthesiologist, pediatric critical care specialist, or emergency physician prior to procedural sedation. Please refer to UpToDate topics on procedural sedation in children for more details. |
| Agent | Initial IV dose* | Repeat IV dose (as needed to achieve desired level of sedation) | Onset
(minutes) | Duration
(minutes) | Additional notes |
| Ketamine | 1 to 2 mg/kg; some experts do not exceed 1.5 mg/kg per dose For healthy patients without QT prolongation or receiving medications that prolong the QT interval, premedication with ondansetron 0.15 mg/kg IV (maximum dose 4 mg) is recommended | 0.5 to 1 mg/kg; repeat every 5 to 10 minutes, titrating to desired level of sedation | 1 to 2 | 15 to 30 | - Properties – Provides sedation and analgesia for moderately to severely painful procedures. Less respiratory depression and complications than propofol alone or combinations of opioids with midazolam or with propofol.
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Adverse effects – Vomiting and emergence reaction are common; frequency of vomiting is reduced by premedication with ondansetron (0.15 mg/kg, typical dose 4 mg) or by co-administration of propofol. Laryngospasm and apnea occur rarely, but bag-mask ventilation may be necessary in about 1% of sedations. Co-administration of anticholinergics, propofol, or barbiturates increases risk of serious adverse events. - Relative contraindications and precautions – Age younger than 12 months, active pulmonary infections (including URI), known or suspected cardiac disease, suspected increased intracranial pressure (eg, intracranial mass or obstructive hydrocephalus), glaucoma or acute eye injury (open globe), porphyria, thyroid disease, or seizures.
- Absolute contraindications – Age younger than 3 months or patients with known or suspected psychosis.
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| Ketamine and propofol | Ketamine 0.5 mg/kg bolus followed by propofol 0.5 mg/kg Propofol may reduce the risk of vomiting caused by ketamine; thus premedication with ondansetron may not be required | Propofol 0.5 mg/kg every 2 minutes, as needed or Ketamine 0.5 to 1 mg/kg every 10 minutes, as needed | <1 | 15 to 30 | -
Properties – May be administered simultaneously in the same syringe. Optimal dosing has not been established. Range of reported dosing is ketamine 0.2 to 1 mg/kg IV with propofol 0.5 to 2 mg/kg IV. The higher range of these doses may be indicated in patients with more painful procedures. - Adverse effects and contraindications – As above for ketamine and below for propofol; in addition, combining the two drugs changes the frequency of some adverse effects:
- Risk of apnea, laryngospasm, hypotension, and bradycardia may be higher than for patients receiving ketamine alone
- Risk of vomiting may be lower than for patients receiving ketamine alone
- Risk of bradycardia and hypotension may be lower than for patients receiving propofol alone
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| Propofol¶ | Initiate infusion at 150 mcg/kg per minute and titrate gradually to response (up to 250 mcg/kg per minute)Δ or 6 months to 2 years of age: 2 mg/kg IV bolus dose 2 years of age and older: 1 to 1.5 mg/kg IV bolus dose | Not applicable for continuous IV infusion; titrate infusion rate as needed or Additional IV bolus dose 0.5 mg/kg every 3 to 5 minutes, titrating as needed up to 3 mg/kg. Wait at least 3 to 5 minutes between doses to assess effect. | ≤0.5 | 5 to 15 after single bolus dose, longer after prolonged infusion or when repeated bolus doses are given | -
Properties – Provides deep sedation but can produce general anesthesia, especially with multiple bolus doses or high continuous infusion rate. Provides sedation but no analgesia. For painful procedures, an analgesic agent (eg, ketamine, fentanyl), regional anesthetic, or local anesthetic should be co-administered. Commonly used for diagnostic imaging (CT, MRI). Causes peripheral injection-site pain. Rapid onset of sedation with good neurologic recovery. Reduces intracranial pressure. - Adverse effects – Respiratory depression, oxygen desaturation, apnea, hypotension, and/or rapid transition to deeper levels of sedation, especially with overly rapid administration of bolus injection.
- Absolute contraindications – Porphyria; propofol should be avoided in patients with cardiac compromise.
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| Dexmedetomidine | Loading dose (dexmedetomidine alone): - 1 month to <2 years of age: 1.5 mcg/kg over 10 minutes
- 2 to <18 years of age: 2 mcg/kg over 10 minutes
| Not applicable for continuous infusion; titrate infusion rate as needed | 5 to 10 | 30 to 70 | - Properties – Sedation and modest analgesia with minimal respiratory depression. Commonly used for diagnostic imaging (CT, MRI). When dexmedetomidine is used alone, the IV loading dose necessary to accomplish effective pediatric sedation in some children may be as high as 3 mcg/kg. Administration of midazolam (0.1 mg/kg, maximum dose 2 mg) will decrease the required dosing of dexmedetomidine (eg, initial IV bolus of 0.5 to 1 mcg/kg over 10 minutes followed by a continuous infusion of 0.5 to 1 mcg/kg per hour is often effective).
- Adverse effects – Bradycardia, hypertension, or, especially with loading dose, hypotension. Rarely, upper airway obstruction, including laryngospasm. Self-limited bradycardia is common with IV loading doses >2 mcg/kg but usually does not require intervention.
- Relative contraindications – Children who are inadequately hydrated or have reduced cardiac output.
- Absolute contraindications – Dexmedetomidine should be avoided in patients receiving digoxin or other medications acting on the atrioventricular node or with cardiac conduction abnormalities (eg, sinus node dysfunction) unless provided by physicians with training and expertise in pediatric cardiac anesthesiology.
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| Fentanyl | 1 to 2 mcg/kg Some experts prefer to not exceed 50 mcg per dose | Repeat 0.5 to 1 mcg/kg every 3 to 5 minutes Some experts prefer to not exceed 25 mcg per dose | <3 to 5 | 30 to 60 after a single dose | -
Properties – Opioid analgesia. When combined with propofol, may produce a state of general anesthesia. When combined with midazolam, can produce moderate or deep sedation, but less effective and more adverse respiratory events reported when compared to sedation with ketamine alone. Effects can be reversed by opioid antagonists (eg, naloxone). -
Adverse effects – Respiratory depression, apnea, bradycardia, and hypotension. Chest wall rigidity, especially with rapid IV infusion. - Contraindications – Hypersensitivity to fentanyl or any of its components.
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| Midazolam | 6 months to 5 years of age: 0.05 to 0.1 mg/kg IV, maximum single dose 2 mg 6 to 12 years of age: 0.025 to 0.05 mg/kg IV, maximum single dose 2 mg Over 12 years of age: 1 to 2 mg IV | After initial IV dose, repeat after 2 to 5 minutes, titrating to desired level of sedation as follows: - 6 months to 5 years of age: 0.2 mg/kg per dose (maximum total dose 6 mg)
- 6 to 12 years of age: 0.1 mg/kg (maximum total dose 6 mg)
- Over 12 years of age: 1 to 2 mg (maximum total dose 10 mg)
| 1 to 3 | 15 to 60, depending upon total dose administered | -
Properties – Provides sedation but no analgesia. For painful procedures, an analgesic agent (eg, ketamine, fentanyl) should be co-administered. Provides amnesia, mild anxiolysis, and mild sedation for procedures that do not require full immobility (eg, laceration repair with local topical anesthesia). When combined with fentanyl, can produce moderate or deep sedation, but less effective and more adverse respiratory events reported when compared to sedation with ketamine alone or combined with propofol. Flumazenil can reverse effects but should be avoided in patients with seizure disorder or who are chronically maintained on benzodiazepines. - Adverse effects – Respiratory depression and apnea, especially when combined with opioid medications (eg, fentanyl); paradoxical reactions including hyperactivity, aggressive behavior, and inconsolable crying.
- Contraindications – Hypersensitivity to midazolam or any of its components.
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| Etomidate | 0.1 to 0.3 mg/kg IV Lower dose in children with renal or hepatic insufficiency | 0.05 mg/kg every 3 to 5 minutes; titrate up to 0.6 mg/kg total dose to desired sedation | ≤0.5 | 5 to 15 | -
Properties – Rapid onset and recovery. Commonly used for brief diagnostic imaging (eg, head CT). Reduces intracranial pressure. Hemodynamic and respiratory stability maintained in most patients, making it a good choice if cardiovascular status is unknown or compromised (eg, trauma patient). - Adverse effects – Pain at the injection site, transient nonepileptiform myoclonus, vomiting. Myoclonus and vomiting reduced by premedication with midazolam.
- Relative contraindications – Children with severe illness, such as suspected sepsis due to adrenal suppression.
- Absolute contraindications – Children with congenital or acquired adrenal insufficiency.
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