Pediatric Sedation Guidelines

Pre-Sedation Evaluation

• The American Academy of Pediatrics recommends that practitioners 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
• Patients in ASA classes I and II are generally appropriate candidates for minimal, moderate, or deep sedation, while children in ASA classes III and IV, those with special needs, or anatomic airway abnormalities require additional consideration 1

Sedation Procedure

• The American Academy of Pediatrics recommends maintaining continuous monitoring throughout the procedure, having a dedicated individual monitor the patient, and being prepared to rescue from one level deeper than intended sedation 1
• Dedicated monitoring personnel are required for deep sedation, and equipment such as pulse oximetry monitoring, suction equipment, age-appropriate airway management equipment, and resuscitative medications should be available 1
• The initial dose of ketamine for pediatric patients is 1-1.5 mg/kg IV or 3-4 mg/kg IM, with IV administration being preferred when vascular access is available, and the onset of action is 1-2 minutes for IV and 3-5 minutes for IM 2
• Atropine is recommended as premedication (0.02 mg/kg) to reduce secretions when using ketamine for procedural sedation, and midazolam may be used in combination with ketamine, but does not decrease recovery agitation, may decrease incidence of emesis, and increases risk of respiratory depression when combined 3, 2

Monitoring and Safety

• Continuous pulse oximetry, heart rate and blood pressure monitoring every 5 minutes, and close observation of respiratory status and level of consciousness are essential for safe ketamine sedation, with consideration of capnography for early detection of hypoventilation 2
• Pulse oximetry, heart rate, and blood pressure monitoring are recommended for minimal sedation, with additional continuous capnography and ECG for moderate sedation, as suggested by the American Society of Anesthesiologists, and deep sedation requires continuous capnography, ECG, and dedicated monitoring personnel, as recommended by the American Academy of Pediatrics 4, 1
• The following dosages are recommended for different populations:

Potential Complications

• Respiratory depression is the most common serious complication, involving airway compromise or depressed respirations, and unintended deep sedation is a common occurrence in children 1
• Medication interactions can enhance sedative effects, and prolonged sedation can occur with drugs that have a long duration, such as pentobarbital and phenothiazines 1
• Children younger than 6 years, particularly those under 6 months, may be at greatest risk of adverse events, and neonates and former preterm infants require specific management due to immature hepatic and renal function 1
• Laryngospasm is a potential adverse event, occurring in 0.9-1.4% of general ED settings, with a higher risk in children undergoing gastrointestinal procedures, particularly in children <6 years (13.9%) 2
• Tachycardia is a common adverse event with ketamine, and potential hypotension is more common with midazolam, and the combination of midazolam and ketamine has synergistic effects, requiring dose reduction of both agents to minimize the risk of adverse events, such as respiratory depression and hypotension 2

Recovery and Discharge

• Patients should meet specific recovery criteria, including return to baseline consciousness, stable vital signs, and ability to maintain airway independently, before discharge, as recommended by the American Academy of Pediatrics, and patients should be accompanied by a responsible adult and have adequate pain control before discharge, as recommended by the American College of Emergency Physicians 4, 1
• Fasting guidelines are recommended before sedation, including 2 hours for clear liquids, 4 hours for breast milk, 6 hours for formula/non-human milk, 6 hours for light meal, and 8+ hours for fatty foods, as suggested by the European Society of Nuclear Medicine 5

Alternative Approaches

• The American Academy of Pediatrics recommends considering non-pharmacological techniques, such as parental presence, distraction, and guided imagery, to reduce sedation requirements 1
• Local anesthetic use requires calculation of the maximum allowable dose before administration, and frequent aspiration to minimize intravascular injection 1
• Ketamine is indicated for procedural sedation in various medical procedures, including orthopedic procedures, wound management, laceration repair, burn care, and lumbar puncture, with a high efficacy rate approaching 100% in clinical studies 2
• Contraindications for ketamine use include history of airway instability, active pulmonary infection or disease, increased intracranial pressure, and psychosis, and etomidate should be avoided in pediatric septic shock due to its association with increased mortality 3