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Preprocedure Sedatives in Children

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]