What are the typical doses for procedural sedation in the Emergency Department (ED)?

Typical Doses for Procedural Sedation in the Emergency Department

The most effective and safe doses for procedural sedation in the ED include ketamine 1.5-2 mg/kg IV, midazolam 0.07-0.1 mg/kg IV, propofol 1 mg/kg initial bolus followed by 0.5 mg/kg as needed, and etomidate 0.1-0.2 mg/kg IV. 1

Common Sedative Agents and Dosing

Ketamine

• Initial dose: 1.5-2 mg/kg IV or 4 mg/kg IM 1
• Supplemental dose: 0.5-1 mg/kg IV if needed 1
• Pediatric dosing: 1.5 mg/kg IV has shown 94% efficacy in children 18 months to 8 years 1
• Ketamine provides both sedation and analgesia, making it particularly useful for painful procedures 1

Midazolam

• Initial dose: 0.07-0.1 mg/kg IV (typically 2-5 mg in adults) 1, 2
• Titration: May require increments of approximately 25% of initial dose 2
• Geriatric patients (>55 years): Reduce dose to 0.2-0.25 mg/kg 2
• Patients with severe systemic disease: Consider lower doses of 0.15-0.2 mg/kg 2

Propofol

• Initial dose: 1 mg/kg IV 1, 3
• Supplemental dose: 0.5 mg/kg IV as needed 1, 3
• Recovery time is significantly shorter than midazolam (7.8 vs 30.7 minutes) 4
• Provides deeper sedation with higher procedure success rates (92% vs 81%) compared to midazolam 3

Etomidate

• Initial dose: 0.1-0.2 mg/kg IV 1
• Average dose in studies: 0.19-0.23 mg/kg IV 1
• Particularly useful for brief procedures requiring deep sedation 1
• Higher doses (>0.23 mg/kg) associated with increased risk of respiratory depression in patients >55 years 1

Fentanyl (for analgesia with sedation)

• Dose range: 0.5-2 μg/kg IV 1, 5
• Average dose in studies: 1-3 μg/kg 5, 3
• Often combined with sedatives for procedures requiring both analgesia and sedation 5

Combination Regimens

Midazolam + Ketamine

• Midazolam 0.07 mg/kg IV followed by ketamine 2 mg/kg IV 1, 6
• Provides effective sedation with reduced risk of emergence reactions 1
• 94-100% procedural success rate with this combination 6

Propofol + Fentanyl

• Fentanyl 1-3 μg/kg IV followed by propofol 1 mg/kg IV 5, 3
• Additional propofol doses of 0.5 mg/kg as needed 1
• Provides rapid onset and shorter recovery time compared to midazolam combinations 3, 4

Safety Considerations

• Respiratory depression is the most common adverse effect, particularly with propofol (20% transient apnea) and midazolam (8% oxygen desaturation <90%) 3
• Etomidate may cause myoclonus in up to 21% of patients 1
• Ketamine is associated with emergence reactions in 5-7% of cases and emesis in 12-19% of patients 1
• Older patients (>55 years) and those with higher ASA status require dose reductions to minimize adverse effects 1, 2
• Always have reversal agents available (naloxone for opioids, flumazenil for benzodiazepines) 1

Agent Selection Based on Procedure Type

• Fracture/joint reductions: Propofol + fentanyl or ketamine (alone or with midazolam) 1, 4
• Abscess drainage: Ketamine + midazolam provides excellent conditions 6
• Brief procedures: Etomidate offers rapid onset and recovery 1
• Pediatric procedures: Ketamine is particularly effective and safe 1

Monitoring Requirements

• Continuous pulse oximetry, cardiac monitoring, and frequent blood pressure measurements are essential 1
• Supplemental oxygen should be readily available 3
• Equipment for airway management must be immediately accessible 1
• Dedicated personnel for monitoring sedation separate from those performing the procedure 7

Remember that these doses should be adjusted based on patient factors including age, comorbidities, and concomitant medications, with careful titration to achieve the desired level of sedation while minimizing adverse effects 1, 2.