Bottom Line Recommendations: Summary of Pediatric Emergency Care Information for Healthcare Providers

Procedural Sedation

Last Updated
Dec 2024

Summary

Performing safe and effective procedural sedation in children requires the same foundational elements as other age groups—skilled personnel, an equipped setting, and an ability to manage patients across the sedation continuum. However, children have unique developmental and physiologic factors that require special consideration.

Children are often fearful during the pre-sedation period:

Provide a calm, quiet environment
Provide a simple explanation, distraction (games, music, video/TV), and/or visual imagery
Allow a caregiver to stay at the bedside with the child as they are being sedated, and, if possible, during the procedure

Pre-Sedation Risk Assessment

The sedating team should be ready to perform patient rescue at any time.^1,4 Perform a focused pre-sedation screening history. All of the following risk factors are associated with airway adverse events, unless otherwise indicated.

Infants <12 months of age; strongly consider pre-procedure discussion with Pediatric Referral Centre
Obesity (body mass index ≥95th percentile)
Active asthma or an upper respiratory tract infection (URTI) within the past 2 weeks
Snoring or sleep apnea
Procedures that involve the posterior pharynx
Opioid administration within 30 minutes prior to procedural sedation is associated with oxygen desaturation and vomiting

AVOID procedural sedation if ASA classification ≥3, has high-risk airway/craniofacial abnormalities on examination, and/or is undergoing an upper airway procedure.² Consult Anesthesia and/or Pediatric Referral Centre if a patient has risk factors for pulmonary aspiration (e.g., age <12 months, obesity ≥95th percentile, ASA ≥3, upper airway procedure).

DO NOT delay sedation based solely on fasting time. Large ED cohorts show no association between preprocedural fasting duration and sedation-related adverse events.³

Preparation for Sedation

Obtain informed consent to address the risks, benefits, and alternatives
Perform consistent room set-up every time: capnography, pulse oximetry, heart rate, and blood pressure monitoring
Ensure availability of appropriately-sized equipment: oral/nasopharyngeal airways, endotracheal tubes, and rescue medications
Connect AND test airway bag with mask and suction prior to the start of sedation
Ensure personnel present are skilled to detect/rescue patients from adverse events (e.g., oxygen desaturation, apnea, airway obstruction, laryngospasm, and progression to a deeper sedation level than intended)
Review age-based norms for heart rate, respiratory rate, and blood pressure
Place patient in a neutral sniffing position (+/- roll under shoulders)
Perform a timeout immediately prior to the procedure (e.g., confirm patient identity, weight, procedure site, planned procedure, and gather all medications and supplies/equipment needed during the procedure)

During Sedation

One healthcare provider is responsible for patient monitoring/rescue and a second provider performs procedure
Monitoring:
- Minimal sedation: continuous pulse oximetry and heart rate; blood pressure documented every 15 minutes
- Moderate sedation: continuous capnography and pulse oximetry; heart rate, respiratory rate and blood pressure documented every 5 minutes
Administer weight-based dosing (in kilograms) of sedation medications
Recognize and treat adverse events early to prevent more serious events that require significant intervention

Medications

Ketamine is the most common and most recommended agent used in pediatric procedural sedation in the emergency department.

Provides the best procedural conditions with fewest adverse events (safest medication)
Lowest risk of needing positive pressure ventilation compared to any other parenteral drug or drug combination

Dissociative/Deep Sedation for Major Painful Procedures (e.g., orthopedic reduction, burn debridement)
Drug(s)	Dose	Comments/Cautions
Ketamine	IV: 1-2 mg/kg/dose, slow push (MAX dose 50 mg). May repeat 0.5-1 mg/kg/dose, q5-15min PRN (risk of adverse events increased >3 mg/kg). IM: 4-5 mg/kg/dose (MAX dose 200 mg). May repeat 2-2.5 mg/kg/dose (MAX 100 mg) after 5-10 min PRN x 1.	Do not use in infants <3 months or if known/suspected psychosis Increased risk of laryngospasm with active asthma, URTI and/or posterior pharynx procedures Vomiting is common; consider ondansetron preprocedure in children ≥5 years Significant recovery agitation is rare (<1%) May have prolonged recovery with IM ketamine
Ketamine + Propofol	Ketamine – IV: 0.5 mg/kg/dose, slow push (MAX dose 50 mg). May repeat 0.5 mg/kg/dose, q5–15min PRN. Usual total MAX 2 mg/kg or 100 mg, whichever is less. Propofol – IV: 0.5–1 mg/kg/dose, slow push (MAX dose 100 mg). May repeat 0.5–1 mg/kg/dose, q3min PRN. Usual total MAX 5 mg/kg.	Requires advanced airway skills; protective airway reflexes not maintained, consider patient and procedure risk factors when assessing aspiration risk Less vomiting compared to ketamine alone
FentaNYL + Propofol	FentaNYL - IV: 1 mcg/kg/dose, slow push (MAX dose 50 mcg). May repeat 0.5–1 mcg/kg/dose, q5min PRN. Usual total MAX 2 mcg/kg or 200 mcg, whichever is less. Propofol – IV: 1 mg/kg/dose, slow push (MAX dose 100 mg). May repeat 0.5 mg/kg/dose, q3min PRN. Usual total MAX 5 mg/kg.	Requires advanced airway skills; protective airway reflexes not maintained, consider patient and procedure risk factors when assessing aspiration risk
Minimal/Moderate Sedation for Minor Painful Procedures (e.g., laceration repair)
Midazolam +/- FentaNYL	Midazolam – IntraNASAL: 0.3-0.5 mg/kg/dose, (MAX 10 mg or 1 mL/nostril). Fentanyl - IntraNASAL: 1.5 mcg/kg/dose, (MAX 100 mcg, or 1 mL/nostril).	Intranasal route preferred For intranasal administration, give 50% of dose in each nostril and use atomizer for increased absorption (MAX 1 mL/nostril) Use concentrated midazolam (5 mg/mL) Intranasal midazolam burns. If using fentanyl, administer it first
DexmedeTOMidine	IntraNASAL: 2–4 mcg/kg/dose (MAX 200 mcg).	Do not use if patient has heart block, renal or hepatic impairment, or on beta blockers Give 50% of dose in each nostril and use atomizer for increased absorption (MAX 1 mL/nostril) Onset 30 min, duration 60-90 min For lacerations, wash wound at time of intranasal administration; allow topical anesthetic enough time for peak effect prior to repair
Nitrous Oxide	Minimum 50–70% with oxygen; administer via continuous flow or demand valve.	Do not use if asthma exacerbation, cystic fibrosis, trapped air (e.g., bowel obstruction, pneumothorax), altered level of consciousness, first trimester pregnancy
Moderate/Deep Sedation for Non-Painful Procedures (e.g., diagnostic imaging)
Propofol	IV: 0.5 mg/kg/dose q3 min PRN, slow push (MAX dose 100 mg). Usual total MAX 5 mg/kg.	Requires advanced airway skills; protective airway reflexes not maintained, consider patient and procedure risk factors when assessing aspiration risk
Midazolam	IntraNASAL: 0.3–0.5 mg/kg/dose (MAX 10 mg or 1 mL/nostril) x 1. IV: 0.05–0.1 mg/kg/dose, (MAX 5mg) x 1.	For intranasal administration, give 50% of dose in each nostril and use atomizer for increased absorption. (MAX 1 mL/nostril) Use concentrated midazolam (5 mg/mL) If using midazolam alone, limited evidence suggests pretreatment with lidocaine 2% or 4% 0.2 mL in each nostril 5 min prior to administering midazolam may lessen irritation Does not produce complete motion control; administer on bed where imaging test will be performed as movement can rouse the patient

Post-Sedation Care

Monitor until patient is able to perform their baseline activities as developmentally appropriate
Pain may persist after sedation wears off. Consider early administration of oral analgesics and/or topical adjuncts, refer to TREKK/EIIC Procedural Pain Recommendations.

Information on drug dosing & administration is current as of the writing of this document. Please refer to your hospital formulary/ protocols and jurisdictional regulations for more detailed information. For a full list of references and development team members, please see the following page.

Development Team

Thank you to the following content advisors who led the development of the Procedural Sedation Bottom Line Recommendations Resource.

Maala Bhatt, MD, MSc, FRCPC Director of Emergency Research, Children’s Hospital of Eastern Ontario (CHEO); Associate Professor of Pediatrics, University of Ottawa

Corrie Chumpitazi, MD, MS, FAAP, FACEP Chief, Pediatric Emergency Medicine; Professor of Pediatrics Duke University School of Medicine; Member Duke Clinical Research Institute

Danica Irwin, BSc.Phm Pharmacist, Children’s Hospital of Eastern Ontario (CHEO)

Tracy Furst Pharmacist, HSC Children’s Hospital Winnipeg

Thank you to the TREKK Editorial Committee, editor Dr. Sarah Reid (CHEO), and those in the EIIC PEAK Program who provided editorial support and expertise in the development of this resource. Thank you to the following people who coordinated and oversaw the development process:

Robin Goodman, MSN, RN, CPEN Project Manager, EIIC Knowledge Management Domain

Mona Jabbour, MD, MEd, FRCPC TREKK Co-Director, Associate Professor, Pediatrics and Emergency Medicine, University of Ottawa; Children’s Hospital of Eastern Ontario (CHEO)

Mary Anne Nurmi, Ms TREKK Knowledge Broker

Mark Vasquez, MHA/MBA, PMP EIIC Knowledge Broker

Key References

(as cited in the Procedural Sedation Bottom Line Recommendations:)

Bhatt M, Johnson DW, Chan J, et al. Risk factors for adverse events in emergency department procedural sedation for children. JAMA Pediatr. 2017;171(10):957-964.
Green SM, Leroy PL, Roback MG, et al. An international multidisciplinary consensus statement on fasting before procedural sedation in adults and children. Anaesthesia. 2020;75(3):374-385.
Green SM, Roback MG, Krauss BS, et al. Unscheduled procedural sedation: A multidisciplinary consensus practice guideline. Ann Emerg Med. 2019 May;73(5):e51-e65.
Coté, C. J., & Wilson, S. (2019). Guidelines for monitoring and management of pediatric patients before, during, and after sedation for diagnostic and therapeutic procedures. Pediatrics, 143(6).

Evidence Repository

For a complete list of the evidence that informed the creation of the Procedural Sedation Bottom Line Recommendations see the Evidence Repository here.

Disclaimer

The purpose of this document is to provide healthcare professionals with key facts and recommendations for the diagnosis and treatment of community acquired pneumonia in children in the emergency department. The TREKK Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. THIS DOCUMENT IS SUBJECT TO FULL DISCLAIMER HERE: trekk.ca/terms-of-use