What is the plan for a missed dose in pediatric procedural sedation?

From the Guidelines

For pediatric procedural sedation, I recommend using midazolam as a first-line agent, typically at a dose of 0.05-0.1 mg/kg IV (maximum 5 mg) or 0.5 mg/kg orally (maximum 20 mg), as this approach has been shown to be effective and safe in recent guidelines 1. When selecting a sedation agent, it is crucial to consider the patient's age, medical history, and the type of procedure being performed.

• The goals of sedation in pediatric patients include guarding the patient's safety and welfare, minimizing physical discomfort and pain, controlling anxiety and behavior, and returning the patient to a state in which safe discharge from medical supervision is possible 1.
• The choice of sedation agent should be based on the specific needs of the patient and the procedure, with consideration of the drug's pharmacokinetics, pharmacodynamics, and potential interactions 1.
• For painful procedures, adding an analgesic such as fentanyl at 1-2 mcg/kg IV may be necessary, while for non-painful procedures, sedatives/hypnotics like midazolam are preferred 1.
• It is essential to titrate the sedation agent to effect, rather than administering the full calculated dose at once, and to have resuscitation equipment immediately available, including age-appropriate airway equipment, supplemental oxygen, and reversal agents 1.
• Continuous monitoring of oxygen saturation, heart rate, and respiratory rate is crucial during the procedure, with blood pressure checks every 5 minutes, to ensure the patient's safety and promptly address any potential complications 1.

From the Research

Missed Plan Dose for Paediatric Procedural Sedation

• The combination of midazolam and ketamine has been used for procedural sedation in children, with studies showing its efficacy and safety 2, 3, 4, 5.
• The dosage of midazolam and ketamine used in these studies varied, with midazolam doses ranging from 0.05 to 0.1 mg/kg and ketamine doses ranging from 1 to 2 mg/kg 2, 4, 5.
• In a study comparing the effects of intravenous premedication with midazolam, ketamine, and a combination of both, the combination group showed significantly better behavior and deeper sedation 6.
• The use of oral ketamine and midazolam for procedural sedation in the pediatric emergency department has also been studied, with results showing minimal adverse events and no significant adverse events 3.
• The safety and efficacy of procedural sedation and analgesia using midazolam and ketamine have been demonstrated in various settings, including pediatric hematology-oncology units and intensive care units 4, 5.

Adverse Events and Complications

• Adverse events associated with the use of midazolam and ketamine for procedural sedation in children include transient decrease in oxygen saturation, vomiting, dizziness, and disinhibition with crying spells 2, 4, 5.
• The incidence of adverse events was low in most studies, with no significant adverse events reported in some cases 3, 5.
• The combination of midazolam and ketamine was found to be safe and effective, with minimal complications and no need for additional sedative medications in most cases 2, 4, 5.

Dosage and Administration

• The dosage of midazolam and ketamine used for procedural sedation in children should be titrated to effect, with careful monitoring of vital signs and respiratory status 2, 4, 5.
• The use of oral ketamine and midazolam for procedural sedation in the pediatric emergency department has been shown to be effective, with a dosage of 6 mg/kg of ketamine and 0.5 mg/kg of midazolam used in one study 3.
• The combination of 0.05 mg/kg of intravenous midazolam and 0.5 mg/kg of intravenous ketamine has been found to produce deep sedation and desirable behavior in children 6.