Stay informed with the latest updates on coronavirus (COVID-19). Find out more >>

Procedural sedation

  • See also

    Ketamine use for procedural sedation
    Nitrous Oxide – oxygen mix
    Emergency Airway Management
    Acute Pain Management
    Communicating procedures to children

    Key points

    1. Use non-pharmacological methods as alternatives or adjuncts, such as play therapy and distraction techniques
    2. Topical agents, local or regional anaesthesia should be used if appropriate (eg Bier block)
    3. Ensure adequate analgesia, monitor for combined effects of sedation and opiate analgesia
    4. Choice of sedative agent depends on child factors, the experience of the clinical team and location where the sedation is to be administered
    5. Sedation agents should only be used by clinicians who are trained and approved in their use in children and who have experience in paediatric resuscitation, airway management and monitoring 

    Background

    • This guideline provides an overview of procedural sedation in paediatrics and potential sedation agents. See individual agent guidelines for more details
    • Procedural sedation is commonly used to facilitate painful and distressing procedures and investigations
    • Medications used in procedural sedation may cause a wide range of side-effects, including airway compromise and respiratory depression, as well as depression of the central nervous system, requiring careful monitoring and skilled response
    • Appropriately trained staff skilled in airway management are essential

    Indications

    • Diagnostic and therapeutic interventions where there is a need for sedation to assist with performing and improving the success of the procedure

    Contraindications

    Unsafe to proceed with sedation and/or procedure due to any of the following:

    • Child factors (see ‘Medical assessment of the child’ below)
    • Clinician factors (see ‘Choice of sedative agent’ below)
    • Environment/location factors (see ‘Choice of sedative agent’ below)

    * See specific agent CPGs for relevant contraindications

    Procedure

    Pre-sedation

    • Review the need for procedural sedation and its urgency
    • Review patient risk factors and contraindications relevant to that child and the drug being used (see below)
    • Obtain consent from the child (if appropriate) and their parent(s)/carer(s)
    • Fasting times (see local fasting guidelines)
    • Maximise the use of non-pharmacological methods such as play therapy, distraction and other non-pharmacological strategies
    • Provide analgesia for potentially painful procedures
    • Use a sedation checklist and role assignment (see additional notes for interstate resources)
    • Prepare equipment and environment
    • Discuss a ‘plan B’ in the event of sedation failure

    Resuscitation equipment and staff competent in paediatric resuscitation and airway management and monitoring must be readily available prior to commencing procedural sedation

    Medical Assessment of the child

    The following conditions are associated with increased risk of severe adverse effects of procedural sedation. Consultation with senior clinician/specialist advice is essential to discuss the risk versus benefit of performing procedural sedation in these children:

    Airway

    • Acute: severe obstructive airway disease, eg croup, foreign body, head and facial trauma
    • Past history: previous airway surgery, laryngomalacia, craniofacial abnormalities

    Breathing

    • Acute: severe respiratory distress, eg pneumonia, bronchiolitis, exacerbation of asthma
    • Past History: sleep apnoea

    Circulation

    • Acute: circulatory compromise, eg shock
    • Past history: congenital cardiac disease

    Neurological

    • Acute: altered level of consciousness, seizure, meningitis, trauma, space occupying lesion
    • Past history: unstable epilepsy, neuromuscular disease

    Other

    • Acute: unstable psychiatric disorder
    • Past history: previous sedation failure or anaesthetic reaction, history of anaesthetic reaction

    Choice of sedative agent

    Choice of agent depends on the aims of sedation (eg reduce movement, analgesia, anxiolysis, amnesia) and the following factors:  

    Child factors

    • Age, compliance, developmental stage

    Clinician factors

    • Adequate experience with using the chosen agent and understanding of the side effect profile
    • Appropriately skilled airway clinicians should be available

    Environment/location factors

    • Time of the day, staff availability, departmental load and acuity, availability of other options (eg general anaesthesia)
    • Minimum skilled staffing requirements should be considered, follow agent-specific CPGs and local protocols
    • Appropriate airway and resuscitation equipment

    Procedural factors

    • Emergency (joint relocation) vs planned (laceration repair)
    • Length of procedure time
    • Complexity, intensity of the stimulus of the procedure

    Advantages and Disadvantages of sedation agents

    Medication

    Advantages

    Disadvantages

    Chloral hydrate #

    Oral

     Narrow therapeutic index
     No analgesic effect

    Midazolam #

    Oral, intranasal, buccal, IM or IV
    Amnestic and anxiolytic effect
    Quick onset
    Short acting

    Can produce paradoxical effect after discharge
    Agent failure
    No analgesic effect

    Intranasal fentanyl

    Synergistic with nitrous oxide
    Reduces need for IV access

    No sedative effect

    Nitrous oxide

    Quick onset and offset
    Anxiolysis and amnesia

    Vomiting is common
    Limited analgesic effect

    Ketamine*

    Airway reflexes maintained
    Cardiovascular stability
    IM or IV
    Provides excellent analgesia and sedation and thus can be used as a sole procedural agent

    Side effects include agitation and emesis during recovery
    Rarely can cause laryngospasm

    Propofol #*

    Ultrashort acting sedative anaesthetic agent
    Effective for muscle relaxation
    (eg reduction of ankle dislocation)

    Narrow therapeutic window
    Respiratory and cardiovascular depression
    Lack of analgesic property

    # Extra analgesia eg fentanyl may be required for painful procedures when using these drugs
    * Ketamine and propofol should only be used by clinicians who are trained and approved in their use and who have experience in paediatric resuscitation, advanced airway management and monitoring

    Sedation choice by procedure type

    Procedure type

    Example

    Goals

    Agent of Choice

    Alternatives

    Diagnostic imaging

    CT
    USS
    MRI

    Reduce movement
    Anxiolysis

    Chloral hydrate
    Midazolam
    Ketamine*

    General
    anaesthetic

    Diagnostic (painful)

    IV insertion
    LP
    Port access
    Urinary catheter insertion

    Reduce movement
    Sedation
    Anxiolysis
    Analgesia

    Topical local anaesthetic
    Nitrous oxide
    Midazolam
    Ketamine*

    Extra analgesia eg fentanyl may be required

     

    Therapeutic

    Laceration repair
    Fracture reduction
    Dislocation reduction
    Larger burns dressings
    Foreign body removal
    Dressing changes
    Simple burns dressings
    Foreign body removal
    Abscess incision and drainage

    Reduce movement
    Sedation
    Anxiolysis
    Analgesia

    Nitrous
    Midazolam
    Ketamine*
    Propofol

    Extra analgesia eg fentanyl may be required

    Regional anaesthesia

    * Ketamine and propofol should only be used by clinicians who are trained and approved in their use and who have experience in paediatric resuscitation, advanced airway management and monitoring

    Monitoring

    • Pulse oximetry, cardiac monitoring and blood pressure
    • Close observation of the airway and chest movements is necessary
    • Appropriately skilled staff in attendance until recovery is well established

    Post-Procedure Care and Discharge instructions

    The child should not be discharged home until they have returned to their premorbid neurological baseline

    Alternatives if sedation not successful

    Trial of alternative sedation choice, if safe and appropriate to do so

    Consider consultation with local paediatric team when

    Sedation failure and general anaesthetic required
    Consider consultation for optimal procedural sedation approach

    Consider transfer when

    Sedation and analgesia requirements exceed local capabilities

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval services

    Consider discharge when

    Child is able to ambulate and verbalise at a level consistent with their pre-treatment neurological baseline

    Parent information

    Sedation for procedures

    Additional Resources

    Society for Pediatric Sedation
    Australian and New Zealand College of Anaesthetists (ANZCA):Guideline on procedural sedation in paediatrics
    Royal Children’s Hospital Comfort Kids

    New South Wales
    Paediatric Procedural Sedation - Guide for Emergency Departments, Wards, Clinics and Imaging
    (Please see pages 32 and 33 of the policy for procedural sedation checklist) 

    Victoria
    Royal Children’s Hospital Procedural Sedation Procedure

    Last updated December 2021

  • Reference List

    1. Australian and New Zealand College of Anaesthetists (ANZCA). Guideline on sedation and/or analgesia for diagnostic and interventional medical, dental or surgical procedures. (viewed June 2021)
    2. Krieser, D et al.  Paediatric procedural sedation within the emergency department. Journal of Paediatrics and Child Health. 2016. 52, 197– 203.
    3. Roh, G et al.  Modelling of the Sedative Effects of Propofol in Patients undergoing Spinal Anaesthesia: A Pharmacodynamic Analysis. Basic & Clinical Pharmacology & Toxicology. 2010. 107(1), 531-559
    4. Starship Child Health. Sedation in children . (viewed May 2021)