The
following table is a guide to aid the clinician in the selection of the most
appropriate sedative to sedate a child for a procedure. One must also consider:
- Not all patients require sedation. It
is dependent on the procedure and age of the child.
- When sedation is desired, one must
consider the time of onset, the duration of action, and the route of
administration.
- Each of the following drugs is well
absorbed when given by the suggested routes and doses.
- Each drug was assigned an
"intensity" based upon the class of drug, dose, and route.
However, it should be noted that any drug can produce a deeper level of
sedation.
- Practitioners performing a specific
level of sedation must be prepared to manage the patient who slips into
the next deeper level of sedation (eg, when performing moderate sedation,
be prepared to manage deep sedation). This may occur regardless of which
sedation drug is used.
- Those drugs classified as producing
deep sedation require more frequent monitoring postprocedure.
- For painful procedures, an analgesic
agent needs to be administered.
LEVELS OF SEDATION
- Minimal sedation (formerly
anxiolysis): A medically controlled state in which patients respond
appropriately to verbal commands; cognitive and coordination function may
be impaired, but cardiovascular and ventilatory function are not affected.
- Moderate sedation (formerly
conscious sedation): A medically controlled drug-induced depression of
consciousness during which patients respond purposefully to verbal
commands either alone or accompanied by light tactile stimulation. No
interventions are required to maintain a patent airway, and spontaneous
ventilation is adequate. Cardiovascular function is usually maintained.
- Deep sedation: A medically
controlled state of depressed consciousness associated with partial or
complete loss of protective airway reflexes. Patients cannot be easily
aroused, but respond purposefully after repeated verbal or painful
stimulation. Cardiovascular function is usually maintained.
- General anesthesia (Note: This level of sedation is reserved for patients in an operating room setting): A medically controlled state of loss of consciousness during which patients are not arousable, even with painful stimulation. Ventilatory function is usually impaired; patients require assistance with maintaining a patent airway; positive-pressure ventilation may be required. Cardiovascular function may be impaired.
Sedatives Used to Produce Moderate
Sedation
|
||||||
Drug
|
Route
|
Dose
(mg/kg)
|
Onset
(minutes)
|
Duration
(hours)
|
Comments
|
|
Chloral Hydrate
|
PO/PR
|
25
to 100
|
10
to 20
|
4
to 8
|
Maximum
single dose: Infants: 1 g; Children: 2 g
|
|
DiazePAM
(Valium)
|
PO
|
0.2 to 0.3; 45 to
60 minutes prior
|
Rapid
|
15 to 30 minutes
|
Maximum oral
dose: 10 mg
|
|
IV
|
0.05
to 0.1 over 3 to 5 minutes
|
1
to 3
|
15
to 30 minutes
|
Maximum
total dose: 0.25 mg/kg
|
||
FentaNYL
|
Intranasal (using
parenteral formulation)
|
1 to 2 mcg/kg
|
5 to 10
|
Related to blood
level
|
Maximum total
intranasal dose: 3 mcg/kg
|
|
IM
|
1
to 3 mcg/kg
|
7
to 8
|
1
to 2
|
|||
IV
|
1 to 3 mcg/kg
|
Immediate
|
30 to 60 minutes
|
|||
LORazepam
(Ativan)
|
PO
|
0.05
|
60
|
8
to 12
|
||
IM
|
0.05
|
30 to 60
|
8 to 12
|
|||
IV
|
0.01
to 0.05 over 5 to 10 minutes
|
15
to 30
|
8
to 12
|
|||
Meperidine
(Demerol)
|
PO
|
2 to 4; 30 to 90
minutes prior
|
10 to 15
|
2 to 4
|
Maximum dose: 150
mg/dose
|
|
IM
|
0.5
to 1; 30 to 90 minutes prior
|
10
to 15
|
2
to 4
|
|||
IV
|
0.5 to 1; 30 to
90 minutes prior
|
5
|
2 to 3
|
|||
Midazolam
(Versed)
|
PO
|
0.25
to 0.5
|
10
to 20
|
1
to 1.5
|
Maximum
oral dose: 20 mg; patients <6 years may need doses as high as 1 mg/kg
|
|
IM
|
0.1 to 0.15; 30
to 60 minutes prior
|
5
|
2
|
Maximum total
dose: 10 mg
|
||
IV
|
6
months to 5 years:0.05
to 0.1
6
to 12 years:0.025
to 0.05
>12
years to Adult:2.5
to 5 mg (total dose) over 10 to 20 minutes
|
1
to 5
|
23
to 30 minutes
|
Maximum
concentration: 1 mg/mL;
Maximum
IM/IV dose:
6
months to 5 years: 6 mg
6
years to Adult: 10 mg
|
||
PR
|
0.25 to 0.5
|
10 to 30
|
1 to 1.5
|
Dilute injection
in 5 mL NS; administer rectally
|
||
Intranasal
|
0.2
to 0.3
|
5
|
30
to 60 minutes
|
|||
Morphine
|
IV
|
0.05 to 0.1
|
Within 20 minutes
|
3 to 5
|
||
Sedatives Used to Produce Deep
Sedation
|
|||||
Drug
|
Route
|
Dose
(mg/kg)
|
Onset
(minutes)
|
Duration
(hours)
|
Comments
|
Methohexital
(Brevital)
|
IM
|
5
to 10
|
2
to 10
|
1
to 1.5
|
Maximum
concentration for IM/IV: 50 mg/mL; maximum IM/IV dose: 200 mg. Greater
incidence of adverse effects with IV use.
|
IV
|
0.5 to 2
|
1
|
7 to 10 minutes
|
||
PR
|
20
to 35
|
5
to 15
|
1
to 1.5
|
Rectal
given as a 10% solution in sterile water; maximum dose rectal: 500 mg
|
|
PENTobarbital
|
PO/IM/PR
|
1.5 to 6
|
IM: 10 to 15
PO/PR: 15 to 60
|
IM: 1 to 2
PO/PR: 1 to 4
|
Maximum dose: 100
mg
|
IV
|
1
to 2
|
3
to 5
|
15
to 45 minutes
| ||
Sedatives Used to Produce
Dissociative Anesthesia (Monitor as if Deep Sedation)
| |||||
Drug
|
Route
|
Dose
(mg/kg)
|
Onset
(minutes)
|
Duration
|
Comments
|
Ketamine
|
PO
|
6
to 10; 30 min prior
|
30
to 45
|
May
use injectable product orally diluted in a beverage of the patient's choice
| |
IM
|
3 to 7
|
3 to 4
|
12 to 25
| ||
IV
|
0.5
to 2
|
Within
30 seconds
|
5
to 10
| ||
REFERENCES
American
Academy of Pediatrics, American Academy of Pediatric Dentistry, Coté CJ, Wilson
S, Work Group on Sedation. Guidelines for monitoring and management of
pediatric patients during and after sedation for diagnostic and therapeutic
procedures: an update. Pediatrics. 2006;118(6):2587-2602.[PubMed 17142550]
Cramton
RE, Gruchala NE. Managing procedural pain in pediatric patients. Curr
Opin Pediatr. 2012;24(4):530-538.[PubMed 22732639]
Elman
DS, Denson JS. Preanesthetic sedation of children with intramuscular methohexital
sodium. Anesth Analg. 1965;44(5):494-498.[PubMed 5890378]
Hegenbarth
MA, American Academy of Pediatrics Committee on Drugs. Preparing for pediatric
emergencies: drugs to consider. Pediatrics. 2008;121(2):433-443.[PubMed 18245435]
Krauss
B, Green SM. Procedural sedation and analgesia in children. Lancet.
2006;367(9512):766-780.[PubMed 16517277]
Miller
JR, Grayson M, Stoelting VK. Sedation with intramuscular methohexital sodium
for office and clinic ophthalmic procedures in children. Am J
Ophthalmol. 1966;62(1):38-43.[PubMed 5936524]
Zeltzer
LK, Altman A, Cohen D, LeBaron S, Munuksela EL, Schechter NL. American Academy
of Pediatrics Report of the Subcommittee on the Management of Pain Associated
with Procedures in Children with Cancer. Pediatrics. 1990;86(5 Pt
2):826-831.[PubMed 2216645]