Procedural sedation in paediatrics

Overview

This clinical practice guideline from the Royal Children's Hospital Melbourne, last updated in December 2021 and endorsed by the Paediatric Improvement Collaborative, gives an overview of procedural sedation in children and the main sedative agents. Sedation is commonly used to make painful or distressing procedures and investigations possible and more likely to succeed. The drugs can cause airway compromise, respiratory depression and central nervous system depression, so careful monitoring and skilled staff are essential.

Key principles

Non-pharmacological methods such as play therapy and distraction should be used as alternatives or adjuncts, and topical, local or regional anaesthesia (for example a Bier block) should be used when appropriate. Analgesia must be adequate, with attention to the combined effects of sedation and opioids. Sedative agents should only be used by clinicians who are trained and approved in their use in children and who are experienced in paediatric resuscitation, airway management and monitoring. Resuscitation equipment and competent staff must be ready before sedation starts.

Preparation and risk assessment

Before sedation the need and urgency are reviewed, consent is obtained, fasting times are checked, a sedation checklist with role assignment is used and a 'plan B' for failed sedation is agreed. Senior advice is needed for children at higher risk, including those with severe obstructive airway disease, severe respiratory distress, sleep apnoea, circulatory compromise, congenital heart disease, altered consciousness, unstable epilepsy, neuromuscular disease or a previous sedation failure or anaesthetic reaction.

Choice of agent

The choice depends on the aims of sedation and on child, clinician, environment and procedure factors. For imaging the options are chloral hydrate, midazolam or ketamine, with general anaesthesia as an alternative, and for painful diagnostic procedures topical anaesthetic, nitrous oxide, midazolam or ketamine. For therapeutic procedures such as fracture or dislocation reduction, laceration repair and larger burns dressings the options are nitrous oxide, midazolam, ketamine or propofol, or regional anaesthesia, with extra analgesia such as fentanyl where needed. Ketamine keeps airway reflexes and cardiovascular stability, whereas propofol has a narrow therapeutic window with respiratory and cardiovascular depression. Midazolam and chloral hydrate give no analgesia.

Monitoring and discharge

Pulse oximetry, cardiac monitoring and blood pressure are used, with close observation of the airway and chest movement, and a skilled person stays until recovery is well established. A child can go home once able to walk and talk at their pre-treatment neurological baseline. If sedation fails, an alternative agent can be tried if safe, general anaesthesia may be needed, and transfer should be considered when needs exceed local capability.