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, such as play therapy and distraction techniques, as alternatives or adjuncts 
2. Topical agents, local or regional anaesthesia should be used if appropriate (eg Bier block)
3. Ensure adequate analgesia and 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

# 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

* 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