Pediatric Sedation Management

Sean Barnes, MD, MBA,* Myron Yaster, MD,† Sapna R. Kudchadkar, MD‡
*Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Charlotte R. Bloomberg Children’s
Center, Baltimore, MD.
†
Departments of Anesthesiology & Critical Care Medicine, Pediatrics, and Neurosurgery, Johns Hopkins University School of Medicine, Charlotte R. Bloomberg
Children’s Center, Baltimore, MD.
‡
Departments of Anesthesiology & Critical Care Medicine and Pediatrics, Johns Hopkins University School of Medicine, Charlotte R. Bloomberg Children’s
Center, Baltimore, MD.

Practice Gap
The differences between deep sedation and general anesthesia in the
practice of pediatric procedural sedation are often underemphasized and
must be a key part of clinician education to optimize patient selection and
safety.

Objectives After completing this article, the reader should be able to:

1. Define the various levels of procedural sedation.

2. Know how to prepare for adverse events associated with procedural
sedation.
3. Identify special patient populations that pose challenges to performing
safe procedural sedation.
4. Understand basics of pediatric intensive care unit (PICU) sedation
assessment and management.
5. Know common pharmacologic agents used for sedation in the PICU
and best practices for weaning of sedative medications.

INTRODUCTION

AUTHOR DISCLOSURE Dr Barnes has Historically, children have been undertreated for pain and painful procedures.
disclosed no financial relationships relevant to Many practitioners believed that children neither remembered nor experienced
this article. Dr Yaster has disclosed that he has pain to the same degree that adults did. Fortunately, the past 25 years has seen an
received research support from the National
Institutes of Health (DA033390) and is a
explosion in research and interest in pediatric pain and sedation management.
consultant for the Data Safety Monitoring Indeed, the provision of sedation and analgesia for children undergoing proce-
Boards of Purdue Pharma and Endo dures and mechanical ventilation is now routine and the standard of care. Due to a
International. Dr Kudchadkar has disclosed
wide spectrum of ages and developmental levels, sedation of infants and children
that she was supported by the Johns Hopkins
CTSA Award Number 5KL2RR025006 from the is associated with unique challenges for even the most seasoned practitioner.
National Center for Advancing Translational Therefore, understanding the optimal level of sedation for each child’s circum-
Sciences of the National Institutes of Health.
stance and how to safely administer a given sedation plan is the focus of this
This commentary does contain discussion of
an unapproved/investigative use of a review. We discuss who provides this care, how patients should be assessed and
commercial product or device. prepared for sedation, the drugs and techniques used, and the surroundings in

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 which sedation and recovery from care should occur. Finally, should begin with an overall assessment and move to
we discuss the special consideration of critically ill children specific systems.
being cared for in the pediatric intensive care unit (PICU).
General
PROCEDURAL SEDATION The first step is to evaluate the patient’s underlying health,
such as with the 5-point Physical Status Classification System
Procedural sedation for painful procedures involves the use of the ASA (Table 1). Procedural sedation is often performed
of one or more pharmacologic agents to relieve anxiety and only in patients whose status is Class I (a normal, healthy
pain while also producing immobility to optimize condi- patient) or Class II (a patient with mild systemic disease),
tions for the procedure. In the past, procedural sedation was except in urgent or special situations. (2) Current medications
referred to as “conscious sedation,” with loose definitions and allergies must be verified, and clinicians should
and varying interpretations. In 2002, the terminology of the inquire about the patient’s or family members’ previous
American Society of Anesthesiologists (ASA) “Practice Guide- adverse experiences with procedural sedation or anesthe-
lines for Sedation and Analgesia for Non-Anesthesiologists” sia. Prematurity or a postconceptual age of less than
was adopted: (1) 60 weeks is not a strict contraindication, but this population
• Mild sedation (anxiolysis): Intent is anxiolysis with is at higher risk for respiratory adverse events, including
maintenance of consciousness. apnea and airway obstruction. Therefore, general anes-
• Moderate sedation: Formerly known as conscious seda- thesia with a controlled airway should be strongly con-
tion. A controlled state of depressed consciousness during sidered for these infants.
which airway reflexes and airway patency are maintained.
Patient responds appropriately to age-appropriate com- Airway and Respiratory System
mands (“Open your eyes.”) and light touch. The airway and respiratory tract requires special attention.
• Deep sedation: A controlled state of depressed conscious-
Craniofacial abnormalities, such as Pfeiffer, Crouzon, Apert,
ness during which airway reflexes and airway patency and Pierre Robin syndromes, involve airway anomalies and
may not be maintained, and the ability to independently present potential difficult scenarios that may lead to intu-
maintain ventilatory function may be impaired. The child bation challenges. The airway examination should focus on
cannot be easily aroused but responds purposefully fol- the upper airway, ascertaining the Mallampati classification
lowing repeated or painful stimulation. (3) (Figure), facial symmetry, mouth opening, mandibular
• General Anesthesia: Loss of consciousness occurs.
size, and neck size and flexion. Clinicians should evaluate
Patients likely have impaired airway reflexes, airway the patient’s dentition, inspecting for loose or missing teeth.
patency, and ventilatory function. Children are not Pathology affecting the respiratory tract, such as asthma,
arousable, even by painful stimulation. acute respiratory disease, and reactive airway disease,
Sedation is often described as a continuum, ranging
from lighter to deeper and finally to general anesthesia.
Dissociative sedation is a unique state of sedation achieved
with ketamine that results in a deep level of depressed TABLE 1. American Society of Anesthesiologists
consciousness while generally maintaining airway reflexes Physical Status Classification
and patency. Dissociative sedation is not part of this
Class I A normal, healthy patient
continuum, but conceptualizing sedation as a continuum
illustrates how easily a patient can go from moderate Class II A patient with mild systemic disease (eg, controlled
reactive airway disease)
sedation to deep sedation or even cross the line to general
anesthesia. Class III A patient with severe systemic disease (eg, a child who is
actively wheezing)
Class IV A patient with severe systemic disease that is a constant
PATIENT ASSESSMENT threat to life (eg, a child with status asthmaticus)
Class V A moribund patient who is not expected to survive
Not every patient is a suitable candidate for sedation. Clini- without the operation (eg, a patient with severe
cians must carefully evaluate each child, starting with a cardiomyopathy requiring heart transplantation)
focused history and physical examination, to determine
Modified from: http://www.asahq.org/resources/clinical-information/asa-
whether sedation, rather than general anesthesia, is the physical-status-classification-system
best option. Pertinent history and physical examination

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 thorough history and physical examination looking for evi-
dence of heart failure. A child’s baseline activity and ability to
“keep up” with other children his or her age can serve as a
subjective but important method of understanding a child’s
cardiovascular status. The physical examination includes
careful auscultation of the heart to identify murmurs, gallop
rhythms, crackles (rales), and rhonchi. This is especially
important in children with known cardiovascular disease.
When assessing children with known cardiovascular dis-
ease, clinicians must define the nature of the disease and
underlying anatomy as well as cardiac function and degree
of hemodynamic reserve. All children with known uncor-
rected significant congenital heart disease should undergo
recent (within 6 months) echocardiography because seda-
tive hypnotics affect breathing and oxygenation and shunt
flow direction can acutely and dangerously change.

Gastrointestinal System
Aspiration of gastric contents is a concern when performing
deep sedation. It is imperative to identify what and when the
patient last ate or drank, which is termed the NPO (nil per
os) time. The length of time a patient should be NPO before
Figure. Mallampati Scoring System used to predict ease of intubation. sedation depends on the type of solids or liquids ingested
• Class I: Full visibility of tonsils, uvula, and soft palate
• Class II: Visibility of hard and soft palate, upper portion of tonsils and (Table 2). (5) Even when patients fast, certain conditions
uvula increase the risk of aspiration during sedation, including
• Class III: Soft and hard palate and base of uvula are visible
• Class IV: Only hard palate is visible pregnancy, intraabdominal pathology (eg, bowel obstruc-
Chris Gralapp. tion, peritonitis), esophageal disease or history of previous
esophageal surgery, neuromuscular disease, altered mental
status, trauma, and morbid obesity. Pregnant women in the
increases the risk of bronchospasm. The respiratory exam- second or third trimester or any patient who has suffered
ination should include auscultation of the lungs to rule trauma (eg, motor vehicle collision, fall) are in the same risk
out any active wheezing or evidence of pneumonia, as stratification for aspiration as those who have just eaten. If a
demonstrated by crackles or rales. In addition, a reported procedure needs to be performed emergently, which is not
history of recent upper respiratory tract infection increases uncommon, these at-risk patients require rapid sequence
the risk of laryngospasm and bronchospasm as well as the induction and tracheal intubation to protect their airways.
need for supplemental oxygen. (4) Asking if a patient has
airway obstruction (snoring), mediastinal mass, or a history
of noisy breathing or has been formally diagnosed with TABLE 2. Fasting Recommendations for
obstructive or central sleep apnea is especially important. Sedation and Anesthesia
Patients who suffer from sleep-disordered breathing are at
FOOD TYPE MINIMUM FASTING PERIOD (HR)
increased risk of apnea and desaturation during sedation and
in the recovery period and should be considered for general Clear liquids 2

anesthesia with a protected airway. (1) Breast milk 4

Nonhuman milk, formula 6
Cardiovascular System Solids 8
Defining a patient’s cardiovascular status and hemodynamic
This modified table was published in Barnes S. Analgesia and
reserve is essential because most of the pharmacologic agents
procedural sedation. The Harriet Lane Handbook. 20th ed. Pages
used for procedural sedation can cause vasodilatation, hypo- 111–126. Copyright Elsevier 2015.
tension, and dysrhythmias. At a minimum, children require a

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 Hepatic and Renal Systems I[INTRAVENOUS ACCESS and FLUIDS: Every patient
Many of the pharmacologic agents used for sedation are requires adequate intravenous access for safe admin-
dependent on hepatic and/or renal metabolism and excre- istration of pharmacologic agents. Moderate or deep
tion. Accordingly, patients with hepatic and/or renal condi- sedation should never be performed without intrave-
tions are always at risk for prolonged drug effects, even nous access.
when the administered drugs are titrated to effect. M[MONITORS: The patient’s vital signs and airway
must be continuously monitored by a second individual
who is not performing the procedure and who is skilled
PREPARATION
in resuscitation. It is important to obtain baseline vital
Preparation is a key aspect of safely providing procedural signs (including pulse oximetry) before initiation of
sedation. After completing the patient assessment, clini- sedation. Clinicians must then continuously monitor
cians must obtain informed consent for sedation. This heart rate, respiratory rate, and oxygen saturation,
includes discussing the risks (aspiration, apnea, need for while intermittently monitoring blood pressure (recom-
tracheal intubation), benefits (providing amnesia, analgesia, mended every 3 minutes). Increasingly, capnography
and producing immobility), and alternatives (distraction, is used and recommended, particularly if the patient
restraining the child, general anesthesia) with the parent or cannot be seen during the procedure. Capnography
guardian and with the patient (if capable). To ensure patient measures end-tidal carbon dioxide levels, thereby not
safety, it is imperative to have an emergency plan in place. only measuring the adequacy of ventilation but also
The clinician providing sedation must ensure that qualified respiratory rate, which can immediately alert the clini-
backup personnel and equipment are easily accessible. cian if apnea occurs. Vital signs should be recorded
SOAP IM is an acronym used by many anesthesiologists at least every 5 minutes until the patient returns to a
to remember the essential components of a setup requiring presedation level of consciousness. Complications most
management of an airway: often occur 5 to 10 minutes after administration of
S[SUCTION: If a patient has excessive secretions or it intravenous medication or immediately after a pro-
becomes necessary to intubate. cedure is completed (when stimuli associated with the
O[OXYGEN: A source of oxygen that can be provided procedure are removed).
passively (nasal cannula or face mask) or actively (bag- Unlike out-of-the-hospital cardiovascular arrests, the over-
mask). whelming majority of complications related to sedation are
A[AIRWAY: Although the goal of procedural sedation is caused by respiratory depression. (6) Because all of the
to maintain spontaneous ventilation, clinicians must sedatives, hypnotics, and most of the analgesics used in
always be prepared to intubate, deliver oxygen, or support sedation cause respiratory depression, monitoring the ade-
a patient who develops obstruction with ventilation. quacy of ventilation and oxygenation is imperative.
Airway/intubation equipment that should be available
includes: a method of delivering oxygen (bag, mask, and
PHARMACOLOGIC AGENTS
valve resuscitation device as well as endotracheal tubes
and supralaryngeal airways), airway adjuvants (appropriate- The goal of sedation is to provide the conditions necessary to
sized oral/nasal airway), and a functioning laryngoscope. perform a procedure whether it is painful, such as burn
P[PHARMACY: This includes pharmacologic agents to debridement or fracture reduction, or nonpainful, such as
achieve sedation and address pain management. How- diagnostic imaging studies. Pharmacologic agents used in
ever, most importantly, this portion of the acronym is a procedural sedation generally fall into 5 classes: opioids
reminder to have emergency medications and the per- for analgesia, sedatives for anxiety reduction and sedation,
sonnel who know how to use them immediately avail- dissociative agents for analgesia and sedation, inhala-
able. For rapid induction of unconsciousness, hypnotic tional gases for mild analgesia and sedation, and opioid
agents such as propofol, ketamine, and/or etomidate are and benzodiazepine antagonists to reverse the effects of
required. Succinylcholine, vecuronium, and/or rocuro- these agents, when necessary. These agents can be ad-
nium are commonly administered for paralysis. Emer- ministered through multiple routes, including oral, intra-
gency antidotes for hypotension or bradycardia should nasal, rectal, intramuscular, intravenous, and inhalational
be readily available. These include epinephrine, atropine, (Tables 3 and 4). Central nervous system, cardiovascular,
and phenylephrine. Finally, reversal agents (eg, naloxone, and respiratory depression are potentiated by combining
flumazenil) must also be available. sedative drugs and opioids and by rapid drug infusion.

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Many procedures require repeat dosing to achieve and drive and can facilitate cooperation during a procedure
maintain the chosen sedation end point, and drugs must while still providing anxiolysis.
be titrated to effect.
The chosen pharmacologic agents for procedural seda-
DISCHARGE CRITERIA
tion vary, based on the needs of the child, the procedure, the
comfort and experience of the clinician providing the seda- After the procedure is completed, monitoring should be
tion, and the qualities of the agents. Examples of commonly continued until the patient returns to the age-appropriate
used combinations of sedative and analgesic agents as well baseline state. The airway should be patent, with intact
as a quick dosage reference are listed in Tables 5 and 6. protective reflexes (swallow and cough, gag reflex) and
Dexmedetomidine, an a-2 agonist with properties similar to cardiovascular function stable. The child should be alert
clonidine, has recently emerged as an option for procedural or easily arousable and return to appropriate developmen-
sedation. Dexmedetomidine maintains a child’s respiratory tal baseline. It is important to ensure that the patient can

TABLE 3. Commonly Used Opioids

ROUTE: EQUIANALGESIC
DRUG DOSES (MG/KG/DOSE) ONSET (MIN) DURATION (HR) ADVERSE EFFECTS COMMENTS

Codeine PO: 1.2 30–60 3–4 • Can cause severe No longer recommended in
nausea and vomiting pediatrics; 3%–5% of
• Histamine release population overmetabolize,
potentially leading to
catastrophic overdose.
Converted in liver to
morphine (10%). Newborns
and 10% of US population
cannot make this conversion.
Fentanyl IV: 0.001 1–2 0.5–1 • Pruritus Rarely causes cardiovascular
Transdermal: 0.001 12 2–3 • Bradycardia instability (relatively safer in
Transmucosal: 0.01 15 • Chest wall rigidity with hypovolemia, congenital heart
doses >5 mg/kg (but can disease, or head trauma).
occur at all doses); treat Respiratory depressant effect
with naloxone or much longer (4 hr) than
neuromuscular blockade analgesic effect. Levels of
unbound drug are higher in
newborns. Most commonly
used opioid for short, painful
procedures, but transdermal
route is more effective in
chronic pain situations.
Hydromorphone IV/SQ: 0.015 5–10 3–4 Less sedation, nausea, and
PO: 0.02–0.1 30–60 pruritus than morphine.
Methadone IV: 0.1 5–10 4–24 Initial dose may produce
PO: 0.1 30–60 4–24 analgesia for 3–4 hr; duration
of action is increased with
repeated dosing.
Morphine IV: 0.1 5–10 3–4 • Seizures in neonates The gold standard against
IM/SQ: 0.1–0.2 10–30 4–5 • Can cause significant which all other opioids are
PO: 0.3–0.5 30–60 4–5 histamine release compared. Available in
sustained-release form for
chronic pain.
Oxycodone PO: 0.1 30–60 3–4 Available in sustained-release
form for chronic pain. Much
less nauseating than codeine.

IM¼intramuscular, IV¼intravenous, PO¼oral, SQ¼subcutaneous

This modified table was published in Barnes S. Analgesia and procedural sedation. The Harriet Lane Handbook. 20th ed. Pages 111-126. Copyright
Elsevier 2015.

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 TABLE 4. Commonly Used Benzodiazepines
DRUG CLASS DURATION OF ACTION DRUG ROUTE ONSET (MIN) DURATION (HR) COMMENTS

Benzodiazepines Short Midazolam IV 1–3 1–2 • Has rapid and predictable onset
of action, short recovery time
IM/IN 5–10 • Causes amnesia
PO/PR 10–30 • Results in mild depression of
hypoxic ventilatory drive
Intermediate Diazepam IV (painful) 1–3 0.25–1 • Poor choice for procedural
sedation
PR 7–15 2–3 • Excellent for muscle relaxation or
prolonged sedation
PO 30–60 2–3 • Painful on IV injection
• Faster onset than midazolam
Long Lorazepam IV 1–5 3–4 • Poor choice for procedural
sedation
IM 10–20 3–6 • Ideal for prolonged anxiolysis,
PO 30–60 3–6 seizure treatment

IM¼intramuscular, IN¼intranasal, IV¼intravenous, PO¼oral, PR¼rectal

This modified table was published in Barnes S. Analgesia and procedural sedation. The Harriet Lane Handbook. 20th ed. Pages 111-126. Copyright Elsevier
2015.

maintain hydration and does not suffer known adverse Sedation Assessment
effects of sedation such as nausea or vomiting. Recovery Whenever sedation is administered, substantial patient
time after sedation protocols varies but typically ranges from morbidity and mortality is a possibility. Optimal sedation
60 to 120 minutes. Any decision for admission to the management requires assessing a child’s level of sedation
hospital should be made on a multidisciplinary level with at regular intervals to guide the clinician in titration of sub-
the team performing the procedure and based on the child’s sequent therapy to avoid over- or undersedation. The most
medical history and risk for postprocedure complications. commonly used sedation assessment tools are the State
For example, a child who receives 10 minutes of sedation Behavioral Scale (SBS) and the COMFORT Scale. Both the
for incision and drainage of an abscess on the thigh may be SBS and COMFORT Scale have been validated in critically
able to go home after an appropriate period of observation, ill children. (8)(9) The SBS defines the sedation-agitation
but a child who has reduction of a supracondylar fracture continuum to guide goal-directed therapy using a patient’s
in the emergency department may need to be admitted for response to voice, gentle touch, and noxious stimuli such as
ongoing pain management and determination of surgical suctioning. The COMFORT Scale measures 5 behavioral
disposition. variables (alertness, facial tension, muscle tone, agitation,
and movement) and 3 physiologic variables (heart rate, re-
SEDATION IN THE PEDIATRIC INTENSIVE CARE UNIT spiration, and blood pressure). These tools provide a con-
sistent but modifiable goal for PICU clinicians to titrate
Sedation is not limited to children undergoing procedures; sedation to the level necessary for each individual child.
another important area in which sedation is used is for the Sedatives can be increased or decreased by the nurses or
mechanically ventilated child in the PICU. The ideal seda- physicians based on the goal sedation score, as shown in the
tion management plan for any patient who is mechanically recently published RESTORE trial. (10)
ventilated encompasses analgesia to treat pain from the
noxious stimuli of the endotracheal tube and sedation to Sedatives and Analgesics
provide adequate comfort and safety as required for the Most recommendations regarding sedation management
child’s critical illness, while optimizing patient-ventilator in the pediatric intensive care population are based on expe-
synchrony and minimizing the risk of delirium and sleep rience and best practice rather than evidence-based medicine.
disturbances. (7) For the purposes of this review, we focus on Very few studies have evaluated the pharmacokinetic and
sedation of the critically ill child in the PICU. Given the pharmacodynamic properties of analgesic and sedative drugs
unique physiology, environment, and pharmacologic man- in critically ill patients.
agement of neonates, sedation in the neonatal intensive care Sedation and analgesia in the PICU is often needed for
unit is beyond the scope of this review. prolonged periods of time, and optimal agents for long-term

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TABLE 5. Examples of Sedation Protocols*
PROTOCOL/DOSES COMMENTS

Ketamine (1 mg/kg/dose IV  1–3 doses) Lowest rates of adverse events when ketamine used alone‡
Ketamine þ midazolam þ atropine (“ketazolam”) Atropine ¼ antisialogogue
IV route: Midazolam ¼ counter emergence delirium
• Ketamine 1 mg/kg/dose  1–3 doses
• Midazolam 0.05 mg/kg  1 dose
• Atropine 0.02 mg/kg  1 dose
IM route: combine (use smallest volume possible)
• Ketamine 1.5–2 mg/kg
• Midazolam 0.15–0.2 mg/kg
• Atropine 0.02 mg/kg
• Midazolam þ fentanyl High likelihood of respiratory depression
 Midazolam 0.1 mg/kg IV  3 doses PRN
 Fentanyl 1 mg/kg IV  3 doses PRN Infuse fentanyl no more frequently than every 3 min

IM¼intramuscular, IV¼intravenous, PRN¼as needed

*These examples reflect commonly used current protocols at the Johns Hopkins Children’s Center; variations are found at other institutions.
‡
Green, SM, Roback MG, Krauss B, et al. Predictors of emesis and recovery agitation with emergency department ketamine sedation: an individual-patient
data meta-analysis of 8,282 children. Ann Emerg Med. 2009;54(2):171-180.
Modified from Yaster M, Cote C, Tone E, et al. Pediatric Pain Management and Sedation Handbook. St Louis, MO: Mosby; 1997.
This modified table was published in Barnes S. Analgesia and procedural sedation. The Harriet Lane Handbook. 20th ed. Pages 111-126. Copyright Elsevier
2015.

sedation differ from those used for procedural sedation. Benzodiazepines are potent amnestics, hypnotics, and
For example, propofol infusions are rarely prescribed for skeletal muscle relaxants. However, most sedatives, specif-
longer than 4 hours in critically ill children requiring ically benzodiazepines, chloral hydrate, and the barbiturates,
sedation due to a concern for the development of propofol have no analgesic properties. Benzodiazepines are also inde-
infusion syndrome, which is characterized by cardiac pendent risk factors for development of delirium.
failure, rhabdomyolysis, metabolic acidosis, renal failure, a-Agonists such as clonidine and dexmedetomidine are
and death. The most commonly used agents for long-term useful adjuvants because they cause very little respiratory
sedation in the PICU are benzodiazepines, opioids, and depression and are not deleterious to natural sleep when
a-agonists. (7) compared to opioids and benzodiazepines.
Opioids commonly used in pain management are m-opioid
receptor agonists. All of the m-opioid receptor agonists have Neuromuscular Blockade
similar pharmacodynamic effects at equianalgesic doses In clinical scenarios in which sedation and analgesia are
(the equivalent dose of analgesic required to achieve the adequate, immobility may be necessary to facilitate recovery
same amount of analgesia). These pharmacodynamic from the child’s illness. Therefore, in rare instances, long-
effects include analgesia, respiratory depression, sedation, term neuromuscular blockade (NMB) may be used. NMB
nausea and vomiting, pruritus, constipation, miosis, toler- has no analgesic or sedating qualities, and the level of NMB
ance, and physical dependence. Fentanyl is the most must be constantly monitored to prevent prolonged block-
commonly used analgesic for procedures and pain con- ade. Commonly used NMB agents in the PICU include
trol in the PICU. (7) Ironically, fentanyl has the least rocuronium, vecuronium, and cisatracurium. Cisatracu-
sedating quality of all of the opioids, but it is short-acting rium is commonly used as a continuous infusion in chil-
following single doses. Of note, fentanyl can be long- dren requiring long-term NMB and is the preferred agent
acting following infusions due to its “context-sensitive for children with renal dysfunction due to an organ-
half-life” or the time needed for blood plasma concen- independent metabolic pathway called “Hofmann elimi-
trations of a drug to decline by one-half after discontinu- nation.” Clearance of drugs through Hofmann elimination
ing the infusion once the infusion achieves a constant is best described as spontaneous nonenzymatic degrada-
plasma concentration. tion at normal pH and body temperature.

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 TABLE 6. Analgesics and Sedative-Hypnotic Drugs Quick Reference
DRUG ROUTE DOSE

Sedative-Hypnotic
Diazepam PO 0.25–0.3 mg/kg
IV (painful) 0.1 mg/kg; maximum 0.6 mg/kg within 8 hours
Dexmedetomidine IN 1–2 mg/kg
IV 0.5–2 mg/kg over 10 min, followed by 0.2–1 mg/kg/hr
Diphenhydramine PO, IV, IM 1 mg/kg; maximum 50 mg/dose
Hydroxyzine PO 2 mg/kg/day divided every 6–8 hr; maximum 600 mg/24 hr
IM 0.5–1 mg/kg/dose every 4–6 hr; maximum 600 mg/24 hr
Lorazepam PO, IV, IM 0.05 mg/kg; maximum 2 mg/dose
Midazolam PO 0.5–0.8 mg/kg; maximum 20 mg/dose
PR 0.5–1 mg/kg
IN 0.2–0.3 mg/kg
IM 0.15–0.2 mg/kg
IV sedation 0.1 mg/kg; maximum 10 mg/total dose
Analgesic
Acetaminophen PO, PR, IV 10–15 mg/kg every 4–6 hr (if >50 kg, 650–1000 mg every 4–6 hr)
Fentanyl IV 1 mg/kg
IV infusion 1–5 mg/kg/hr
PO oralet 10–15 mg/kg; maximum 400 mg
IN 1 mg/kg
Hydrocodone* PO 0.135 mg/kg every 4–6 hr; maximum 2 mg/dose
Hydromorphone IV 0.015 mg/kg; maximum 2 mg/dose
IV infusion 2–4 mg/kg/hr
Ketorolac IV, IM 0.5 mg/kg every 6 hr; maximum 30 mg/dose
Methadone PO, IV, IM, SQ 0.1 mg/kg every 8–12 hr; maximum 10 mg/dose
Morphine IV 0.05–0.2 mg/kg; maximum 15 mg/dose
IV infusion 10–40 mg/kg/hr
Oxycodone PO 0.1 mg/kg every 4–6 hr; maximum 5 mg/dose
Other
Ketamine PO 5 mg/kg
IV 0.25–2 mg/kg
IM 2–5 mg/kg

*Commonly with acetaminophen.

IM¼intramuscular; IN¼intranasal, IV¼intravenous, PO¼oral, PR¼rectal, SQ¼subcutaneous
Data from Fishier QA. Pediatric Anesthesia Pearls. Baltimore, MD: Johns Hopkins Department of Anesthesia and Critical Care Medicine; 2000.
This modified table was published in Barnes S. Analgesia and procedural sedation. The Harriet Lane Handbook. 20th ed. Pages 111–126. Copyright Elsevier 2015.

Weaning of Sedatives/Analgesics The length of exposure should correlate with the weaning
Tolerance and physical dependence are unavoidable conse- strategy. (11)
quences of prolonged use and high quantities of opioids and Weaning sedatives and analgesics requires thoughtful
sedatives administered to the critically ill patient. Tolerance planning. To simplify the weaning process, clinicians should
develops following opioid and benzodiazepine use to some make every effort to convert the patient from intravenous
degree following 3 to 5 days of usage. At this point, the risk to oral therapy and from continuous infusions to inter-
for withdrawal symptoms is increased, and patients should mittent bolus therapy. This substantially eases patient care
be weaned at the appropriate time from their opioids and can allow for final tapering and weaning in an out-
and sedatives rather than abruptly discontinuing therapy. patient setting. Changing from one opioid to another may

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be necessary because of ease of administration, duration of management of the critically ill child. Delirium is known
action, and ability to taper the dose. However, equianal- to increase morbidity and mortality in critically ill patients,
gesic dosing is mandatory. and validated screening tools are available to screen for this
a-2 Adrenergic agents such as clonidine or dexmedeto- important clinical entity in children. (15)(16)
midine are often used as adjuvants when weaning sedatives
or analgesics. The addition of these agents has been dem-
onstrated to prevent or mitigate drug withdrawal syndrome
Summary
symptomatology regardless of the drug causing addiction or
• On the basis of expert opinion/consensus, pediatric sedation
dependence. However, high doses of dexmedetomidine for
management can be divided into procedural sedation and
long durations also have the potential for inducing a with- sedation in the pediatric intensive care unit.
drawal syndrome with discontinuation, necessitating close • On the basis of some research evidence as well as consensus,
attention to dose and duration of administration. (12) Drug procedural sedation is necessary to provide a safe and painless
withdrawal syndrome and symptomatology varies, depend- experience for infants or children undergoing diagnostic or
ing on the class of drug to which the patient has developed therapeutic procedures. It is both effective and safe when
performed by appropriately trained clinicians. (1)(2)(7)
dependence. Some symptoms may include vomiting, diar-
rhea, tachycardia, hypertension, diaphoresis, and restlessness. • On the basis of some research evidence as well as consensus,
clinicians should consider sedation as a continuum and must
understand that the patient can go from a state of mild sedation
Sleep Promotion and Delirium Screening to general anesthesia in seconds. Providing safe care is
The PICU is a chaotic environment for the critically ill child, paramount and hinges on targeted assessments and thoughtful
who has multiple risk factors for sleep disturbances. preparation. (1)(2)(7)
Although the administration of sedation and analgesia is • On the basis of some research evidence as well as consensus,
an important part of the care of the mechanically ventilated critically ill children in the pediatric intensive care unit (PICU) may
child, sleep promotion is also crucial. Unfortunately, all need pharmacologically induced sedation to facilitate
mechanical ventilation, invasive procedures, and treatment of
sedatives, with the exception of dexmedetomidine, are det-
multiorgan system dysfunction. Regardless of the methods used,
rimental to experiencing restorative sleep. (7) Benzodiaze- the goals of sedation in the PICU are to provide anxiolysis and
pines are particularly deleterious to sleep-wake homeostasis comfort while maintaining safety to prevent inadvertent removal
and an independent risk factor for delirium. Sedation of life-sustaining medical equipment.
during mechanical ventilation leads to a behavioral state of- • On the basis of some research evidence as well as consensus,
ten assumed to be sleep in which a child is at rest with eyes unlike with procedural sedation, the long-term effects of
closed. However, mechanically ventilated patients receiv- pharmacologic agents administered in the PICU must be
addressed, including potential toxicities, tolerance and physical
ing sedatives have no circadian rhythmicity, and rapid-eye
dependence, sleep disturbances, and delirium. The process of
movement and slow-wave sleep are severely decreased or weaning patients from these agents must be thoughtful and
absent. (13)(14) Therefore, sedatives and analgesics are often include a multidisciplinary approach. (8)(9)(10)(14)
increased in dose and frequency to improve sleep. However,
these drugs may contribute to a vicious cycle of sleep dis-
ruption that progressively leads to agitation.
Optimizing the sleep-wake cycle through simple non- Note. The content of this article is solely the responsibility of
pharmacologic interventions such as sunlight exposure the authors and does not necessarily represent the official views of
during the day and noise reduction at night can decrease the National Institutes of Health.
the amount of sedatives and analgesics to which a child is
exposed. Understanding the interplay between sleep, seda- CME quiz, References, and Suggested Readings for this article
tion, and delirium is imperative in the comprehensive are at http://pedsinreview.aappublications.org/content/37/5/203.

Vol. 37 No. 5 MAY 2016 211

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 PIR Quiz
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1. You use a combination of fentanyl and midazolam to provide procedural sedation to a REQUIREMENTS: Learners
child undergoing reduction of a fractured radius in your emergency department. After the can take Pediatrics in
medications are infused intravenously, the child cannot be easily aroused but does cry out Review quizzes and claim
softly and withdraw his arm on the initial attempts at reduction. Of the following, which credit online only at:
best describes the level of procedural sedation that has been achieved for this child? http://pedsinreview.org.
A. Conscious sedation.
B. Deep sedation. To successfully complete
C. General anesthesia. 2016 Pediatrics in Review
D. Mild sedation. articles for AMA PRA
E. Moderate sedation. Category 1 CreditTM,
2. Which of the following statements is true regarding complications during procedural learners must
sedation? demonstrate a minimum
A. Most complications are due to frequent measurement of end-tidal carbon dioxide performance level of 60%
levels. or higher on this
B. Complications most often occur 5 to 10 minutes after administration of intravenous assessment, which
medications. measures achievement of
C. Complications rarely occur after the procedure is completed. the educational purpose
D. Most complications are due to cardiovascular effects of the medications used. and/or objectives of this
E. Complications most often occur within the first minute of sedation. activity. If you score less
than 60% on the
3. A 4-year-old critically ill child is intubated and under heavy sedation in the pediatric
assessment, you will be
intensive care unit. Which of the following tools is most helpful in avoiding either over- or
given additional
undersedation?
opportunities to answer
A. American Society of Anesthesiology Scale. questions until an overall
B. Glasgow Coma Scale. 60% or greater score is
C. Mallampati Score. achieved.
D. State Behavioral Scale.
E. Trauma Score.
This journal-based CME
4. A 6-year-old child requires prolonged sedation in the pediatric intensive care unit after
activity is available
multisystem trauma. The surgeon estimates that the child will require this sedation for at
through Dec. 31, 2018,
least 3 to 4 days. Prolonged use of which of the following medications is most likely to lead
however, credit will be
to the development of delirium in this child?
recorded in the year in
A. Clonidine. which the learner
B. Dexmedetomidine. completes the quiz.
C. Midazolam.
D. Morphine.
E. Propofol.
5. A patient in the emergency department is in need of procedural sedation for complex
laceration repair. The child has a history of asthma and is actively wheezing. After 3
albuterol treatments and a dose of systemic corticosteroids, the wheezing is much
improved but still present. According to the 5-point Physical Status Classification System of
the American Society of Anesthesiologists (ASA), what is the ASA class for this patient?
A. Class I.
B. Class II.
C. Class III.
D. Class IV.
E. Class V.

212 Pediatrics in Review

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 Pediatric Sedation Management
Sean Barnes, Myron Yaster and Sapna R. Kudchadkar
Pediatrics in Review 2016;37;203
DOI: 10.1542/pir.2014-0116

Updated Information & including high resolution figures, can be found at:
Services http://pedsinreview.aappublications.org/content/37/5/203
References This article cites 19 articles, 3 of which you can access for free at:
http://pedsinreview.aappublications.org/content/37/5/203#BIBL
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 Pediatric Sedation Management
Sean Barnes, Myron Yaster and Sapna R. Kudchadkar
Pediatrics in Review 2016;37;203
DOI: 10.1542/pir.2014-0116

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pedsinreview.aappublications.org/content/37/5/203

Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1979. Pediatrics in Review is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2016 by the American Academy of
Pediatrics. All rights reserved. Print ISSN: 0191-9601.

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