What is the recommended protocol for pediatric sedation?

Recommended Protocol for Pediatric Sedation

The recommended pediatric sedation protocol requires practitioners to have the skills to rescue patients from a deeper level of sedation than intended, with immediate availability of age-appropriate resuscitation equipment and personnel trained in airway management. 1

Goals of Pediatric Sedation

The primary goals of pediatric sedation are:

1. Guarding patient safety and welfare
2. Minimizing physical discomfort and pain
3. Controlling anxiety and minimizing psychological trauma
4. Providing appropriate cardiopulmonary support if needed 1

Pre-Sedation Assessment

• Evaluate ASA classification: Patients in ASA classes I and II are generally appropriate candidates for minimal, moderate, or deep sedation
• Children in ASA classes III and IV, those with special needs, or anatomic airway abnormalities require additional consideration 1
• Assess for contraindications: history of airway instability, active pulmonary disease, increased intracranial pressure 2
• Document fasting status: 2 hours for clear liquids, 4 hours for breast milk, 6 hours for formula/non-human milk 2

Personnel and Equipment Requirements

Required for All Sedation Levels:

• Pulse oximetry monitoring
• Suction equipment
• Age-appropriate airway management equipment
• Resuscitative medications
• Dedicated monitoring personnel for deep sedation 1, 2

Monitoring Parameters:

• Continuous pulse oximetry
• Heart rate and blood pressure every 5 minutes
• Respiratory status and level of consciousness
• Consider capnography for moderate to deep sedation 2

Medication Selection and Dosing

Ketamine:

• Initial dose: 1-1.5 mg/kg IV or 3-4 mg/kg IM
• Onset: 1-2 minutes (IV), 3-5 minutes (IM)
• Consider atropine premedication (0.02 mg/kg) to reduce secretions 2, 3
• Lower doses (0.5-1.0 mg/kg IV) may be effective for many procedures 3

Midazolam:

• IV: 0.05-0.1 mg/kg titrated slowly (administer over at least 2 minutes)
• Maximum initial dose: 2.5 mg
• Oral: 0.25-0.5 mg/kg (maximum 15 mg) for minimal/moderate sedation 4, 5
• Wait 2-3 minutes between doses to evaluate sedative effect 4

Combination Regimens:

• Ketamine (1 mg/kg IV) with midazolam (0.1 mg/kg IV) provides effective sedation for minor procedures 6
• For needle-free sedation: oral ketamine 6 mg/kg (max 200 mg) with oral midazolam 0.5 mg/kg (max 15 mg) 7
• Note: Combined use increases risk of respiratory depression 2

Procedural Protocol

1. Preparation Phase:

   • Ensure appropriate monitoring equipment is functional
   • Confirm availability of resuscitation equipment and reversal agents
   • Document pre-sedation vital signs and assessment

2. Administration Phase:

   • Titrate medications slowly to desired effect
   • Allow adequate time between doses to assess effect (2-3 minutes)
   • Continuously monitor vital signs and sedation level

3. Procedure Phase:

   • Maintain continuous monitoring throughout
   • Have a dedicated individual monitor the patient (separate from the person performing the procedure) 1
   • Be prepared to rescue from one level deeper than intended sedation

4. Recovery Phase:

   • Continue monitoring until discharge criteria are met
   • Document vital signs and recovery parameters

Discharge Criteria

Patients may be discharged when they:

• Return to baseline consciousness
• Have stable vital signs
• Can maintain airway independently
• Are accompanied by a responsible adult 2

Common Pitfalls and Safety Considerations

• Respiratory depression: Most common serious complication involves airway compromise or depressed respirations 1
• Unintended deep sedation: Children commonly pass from intended level to deeper unintended level of sedation 1
• Medication interactions: Enhanced sedative effects when local anesthetics are used with other sedatives 1
• Prolonged sedation: Drugs with long duration (e.g., pentobarbital, phenothiazines) may cause unpredictable responses and prolonged recovery 1
• Age-specific risks: Children younger than 6 years (particularly those under 6 months) may be at greatest risk of adverse events 1

Special Considerations

• Neonates and former preterm infants: Require specific management due to immature hepatic and renal function 1
• Local anesthetic use: Calculate maximum allowable dose before administration; aspirate frequently to minimize intravascular injection 1
• Alternative approaches: Consider non-pharmacological techniques (parental presence, distraction, guided imagery) to reduce sedation requirements 1

Remember that the practitioner must be able to rescue the patient from a deeper level of sedation than intended for the procedure, making the concept of rescue essential to safe sedation practice.