| Sedation with these agents can result in significant respiratory depression and other adverse effects. Children should receive appropriate monitoring by personnel skilled in pediatric resuscitation until full recovery has occurred. Please refer to UpToDate topics on procedural sedation in children for more details. |
| Agent | Dose | Onset (minutes) | Duration (minutes) | Comments |
| Nitrous oxide (N2O) | 50 to 70% N2O administered with oxygen typically delivered through a demand valve system with scavenging capability | <0.5 | Recovery typically within 3 to 5 minutes of cessation of N2O delivery | - Primarily used in children older than 4 years of age.
- Provides amnesia, mild to moderate anxiolysis, mild to moderate sedation, and mild analgesia.
- Common adverse effects: Vomiting and dysphoria.
- Clinicians must know how to test and use the equipment in use in their facility. In addition, equipment must be carefully maintained and periodically tested to ensure adequate safety.
- Relatively contraindications and precautions: Nausea and vomiting.
- Absolute contraindications: Pregnancy and conditions with trapped gas within body cavities (eg, bowel obstruction, pneumothorax, middle ear infection).
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| Midazolam | 0.25 to 0.5 mg/kg PO or SL (maximum single dose: 20 mg) 0.2 to 0.3 mg/kg IN* (maximum single dose: 10 mg) Buccal dosing is as for IN | 20 to 30 | 30 to 60 | - Midazolam has poor oral bioavailability (15 to 35%). IN, SL, and buccal has bioavailability approaching 70 to 80% during gradual administration.
- Provides amnesia, mild anxiolysis, and mild sedation for procedures that do not require full immobility (eg, laceration repair with local topical anesthesia).
- Flumazenil can reverse effects but should be avoided in patients with seizure disorder or who are chronically maintained on benzodiazepines.
- Common adverse effects: Respiratory depression and apnea, especially if combined with opioids or other sedatives; paradoxical reactions including hyperactivity, aggressive behavior, and inconsolable crying.
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| Dexmedetomidine | 2.5 to 4 mcg/kg IN (maximum single dose: 200 mcg) | 20 to 30 | 30 to 45 | - Provides mild anxiolysis and mild sedation for nonpainful and minimally invasive procedures.
- Common adverse events: Bradycardia or hypertension with IV administration, uncommon with IN use.
- Relative contraindications and precautions: Children with dehydration or reduced cardiac output.
- Absolute contraindications: Patients receiving digoxin or other medications acting on sinus node or with sinus node dysfunction unless it is provided by clinicians with training and expertise in cardiac anesthesia.
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| Ketamine | 4 to 5 mg/kg IM | 5 to 10 | 30 to 60 | - Provides sedation AND analgesia for moderately to severely painful procedures.
- Common adverse events: Vomiting, emergence reaction; frequency of vomiting is reduced by premedication with ondansetron (0.15 mg/kg, typical dose 4 mg) or by co-administration of propofol.
- Compared with IV administration, IM ketamine increases the risk of vomiting and the duration of sedation and recovery.
- Laryngospasm and apnea occur rarely, but bag-mask ventilation may be needed in about 1% of sedated patients.
- Relative contraindications and precautions: Age younger than 12 months, active pulmonary infections (including URI), known or suspected cardiac disease, suspected increased intracranial pressure (eg, head trauma with signs or symptoms, intracranial mass, or 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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