Pediatric Procedural Sedation

Anatomy and Physiology

The most severe complication of pediatric procedural sedation is respiratory failure due to hypoventilation or airway obstruction, often resulting from deeper sedation than intended. Understanding the anatomic characteristics of the pediatric airway and any history of airway anomalies is essential.

Many unique features of the pediatric airway are most pronounced in infancy. Anatomic considerations include a relatively larger head and occiput, a large tongue and smaller mandible, and a more cephalad larynx that appears more anterior compared to adults. The more acute angle for visualization may be improved by extending the neck, unless cervical spine injury is suspected, or by placing a small roll under the shoulders to facilitate extension. The larynx in pediatric patients is funnel-shaped, with the subglottic area being the narrowest part.

Young children have a floppy epiglottis that may obscure the laryngeal view, large adenoids and tonsils that can contribute to upper airway obstruction, and a small cricoid cartilage, making open cricothyrotomy technically challenging. Many skilled laryngoscopists use a straight laryngoscope to lift the floppier epiglottis out of view for better visualization.[6]

Percutaneous cannula cricothyroidotomy is contraindicated in children younger than 6 due to the small cricothyroid membrane and trachea and the risk of injuring the posterior tracheal wall.[7] Surgical cricothyroidotomy or tracheostomy should be performed in this population. Bag-valve-mask (BVM) ventilation is often necessary before intubation and may be sufficient to facilitate oxygenation in cases where rapid recovery is expected, such as deep sedation. The target tidal volume in BVM is 8 mL/kg, and healthcare providers should squeeze the bag only enough to cause visible chest rise to avoid barotrauma or gastric insufflation.[8]

Indications

Pediatric procedural sedation is indicated when a procedure may cause excessive pain or anxiety in a child or when movement could compromise its safe execution. The level of sedation is tailored to the anticipated pain or anxiety caused by the procedure and the need to keep the patient still. For example, a child may require anxiolysis for CT or MRI, whereas deep sedation for more painful procedures such as fracture reduction or complex laceration repair.

For unscheduled procedures, the patient's vital signs and overall stability must be assessed, along with any history of chronic disease or genetic abnormalities such as cardiovascular or respiratory disease, Down syndrome, or cerebral palsy. Medication history and allergies should also be reviewed. The physical status evaluation of the airway is based on the ASA classification system, as follows:

• ASA class I: A normal, healthy patient with no acute or chronic disease and a normal body mass index (BMI) percentile for age.
• ASA class II: A patient with mild systemic disease without substantial functional limitations. Examples include asymptomatic congenital heart disease, well-controlled dysrhythmia, well-controlled epilepsy, asthma without exacerbation, and abnormal BMI percentile for age.
• ASA class III: A patient with severe systemic disease and significant functional limitations without immediate danger of death. Examples include uncorrected stable congenital cardiac abnormality, poorly controlled epilepsy, cystic fibrosis, asthma with exacerbation, morbid obesity, malnutrition, renal failure, metabolic disease, and a history of organ transplantation.
• ASA class IV: A patient with severe systemic disease that represents a constant threat to life, such as symptomatic congenital cardiac abnormality, severe trauma, sepsis, severe respiratory distress, congestive heart failure, and acute hypoxic-ischemic encephalopathy.
• ASA class V: A moribund patient who is not expected to survive without an operation, including massive trauma, a patient requiring extracorporeal membrane oxygenation, intracranial hemorrhage with mass effect, respiratory failure or arrest, decompensated congestive heart failure, and multiple organ system dysfunction.
• ASA class VI: A patient declared brain dead whose organs are being harvested for donor purposes.[9] This classification applies to both adult and pediatric patients, though pediatric cases are rare. ASA class VI is not typically relevant to pediatric procedural sedation, as procedural sedation is not performed on brain-dead patients.

Pediatric procedural sedation in the emergency setting should generally be administered only to children classified as ASA class I or II. Consultation with an anesthesiologist or appropriate subspecialist is recommended for children classified as ASA class III or IV or those with anatomic cervical spine or airway anomalies.[10]

Contraindications

No absolute contraindication exists for pediatric procedural sedation. However, certain conditions and contexts make it inappropriate, including the following:

• Unavailability of appropriate monitoring and resuscitation equipment.
• Healthcare providers who lack PALS certification or the necessary skills to secure an unstable airway, including intubation and emergent cricothyrotomy.
• Known allergies or adverse reactions to pediatric procedural sedation medications.
• Procedures requiring more than brief pain management, which may necessitate general anesthesia in an operating room.
• Patients classified as ASA class III or higher, who may require care from an anesthesiologist or subspecialist.

Published guidelines recommend fasting for 2 hours (clear liquids), 4 hours (breast milk), and 6 hours (solid food) before scheduled procedures. A high aspiration risk was previously considered a contraindication, but limited evidence links noncompliance with increased aspiration or adverse events.

Assessing the risks and benefits of delaying pediatric procedural sedation is essential for patients in whom aspiration is a potential issue, such as infants, young patients with obesity or obstructive sleep apnea, and those undergoing upper endoscopy. Consultation with an anesthesiologist or sedation expert is strongly advised.[11]

Equipment

Before starting pediatric procedural sedation, the healthcare provider should ensure that the following necessary equipment is available, functional, and appropriately sized for the child:

• Suction apparatus and catheter
• Oxygen supply paired with the appropriate administration equipment, such as a nasal cannula or a nonrebreather mask
• Airway equipment, including a BVM, appropriately sized oral and nasal airways, laryngeal mask airway, direct and video-assisted laryngoscope with correctly sized blades, appropriate-size endotracheal tube, and surgical and needle airway
• Pharmacological agents, including anxiolytic, analgesic, dissociative, and reversal agents
• Monitoring devices, including a pulse oximeter, end-tidal carbon dioxide monitor, noninvasive blood pressure cuff, and electrocardiogram leads
• Functional intravenous catheter
• Medications and equipment for cardiac resuscitation
• Defibrillator

Personnel

Ideally, two healthcare providers perform pediatric procedural sedation—one conducting the procedure and the other overseeing sedation and patient monitoring. In emergency settings with unplanned procedures, having two operators may not always be feasible. However, a nurse or another qualified individual should continuously monitor the patient while the healthcare provider performs the procedure. The healthcare provider performing procedural sedation must be able to:

• Screen and select patients for pediatric procedural sedation
• Understand medications and the appropriate use of their reversal agents
• Monitor airway patency, recognize signs of airway obstruction, and differentiate between obstructive and central apnea
• Assess ventilatory adequacy by observing chest wall motion along with pulse oximetry and capnography
• Monitor cardiovascular stability using cardiac rhythm, blood pressure monitoring, and physical signs
• Recognize inadequate or excessive sedation in pediatric patients
• Perform advanced airway management skills
• Intervene for any complications [12][13]

Preparation

Once the need for pediatric procedural sedation is established, a thorough medical evaluation should be conducted to minimize risks during and after the procedure. A standardized checklist should be used. The American Academy of Pediatrics provides key guidelines, including the following:

• Physical status evaluation based on the ASA classification system. Pediatric procedural sedation in the emergency setting should generally be limited to patients classified as ASA class I or II. For children classified as ASA class III or higher or those with anatomic airway or cervical spine anomalies, consultation with an anesthesiologist or another appropriate subspecialist is advised.
• Informed consent obtained from the patient or primary caregiver, with an explanation of the procedure, medications to be administered, and potential adverse effects.
• Comprehensive health evaluation to determine baseline status and identify conditions requiring additional consideration or consultation. This evaluation includes sex, age, weight, current medications, allergies, and relevant personal or family medical history. The history should focus on risk factors such as obstructive sleep apnea, complications during prior sedation or surgery, family history of adverse reactions to sedation or anesthesia, other medical conditions, and recent respiratory infections.[14]
• Consideration of fasting status in relation to the urgency of the procedure.
• Airway assessment, including the Mallampati score, mouth opening, tonsillar hypertrophy, mandibular or lingual anomalies, and cervical spine mobility.
• Verification of equipment availability, ensuring that all necessary items are appropriately sized and functional.[15]

Technique or Treatment

Nonpharmacological Interventions

Nonpharmacological interventions may decrease medication requirements and shorten the duration of sedation in children. In some cases, adequate analgesia combined with nonpharmacological techniques may eliminate the need for procedural sedation. Behavioral and cognitive strategies are the most commonly employed approaches, with child life specialists assisting in their application.

Behavioral treatments include desensitization, distraction, positive reinforcement, coping skills training, and relaxation.[16] Desensitization involves gradually introducing the feared stimulus over time while maintaining low anxiety levels, weakening the learned association between the stimulus and fear or distress. During procedures, distraction techniques engage children with age-appropriate stimuli such as interactive toys, music, bubble-blowing, or pacifiers for neonates. Positive reinforcement involves offering encouraging statements and tangible rewards, such as toys or stickers, following a procedure. Relaxation training teaches children progressive muscle relaxation techniques to ease anxiety. As parental anxiety can contribute to a child's distress, addressing parental concerns plays a key role in reducing a child's fears.[17]

Cognitive treatment approaches include preparation, memory modification, hypnosis, positive self-statements, and thought-stopping. Providing children with procedural information helps establish realistic expectations and lessen anxiety. Hypnosis redirects the child's focus away from the procedure and toward a more enjoyable or comforting experience.[18] Children may be instructed to interrupt anxious thoughts about the procedure and replace them with positive statements. Memory modification involves altering recollections based on information presented after the procedure.

Pharmacological Agents

The ideal agent for pediatric procedural sedation depends on the required level of sedation, considering the anticipated degree of pain or discomfort and the amount of motion permissible. Additional factors such as anxiety level, age, fasting status, and procedure duration should also be evaluated. The selected agent should provide adequate analgesia, sedation, and anesthesia with a rapid onset and short duration to facilitate the procedure while ensuring quick recovery and discharge. Pediatric procedural sedation techniques can range from anxiolysis for nonpainful procedures to deeper sedation for painful interventions, and the chosen agent should align with the sedation goals.

Sedative-hypnotic agents, including propofol, benzodiazepines, dexmedetomidine, etomidate, and barbiturates, are commonly used in pediatric patients. These agents provide sedation and anxiolysis but do not offer analgesia, except for dexmedetomidine. For analgesia, opioids such as fentanyl are used. Ketamine provides sedation, analgesia, and amnesia and is frequently combined with propofol (ketofol). Nitrous oxide, an anesthetic gas, offers sedation, anxiolysis, amnesia, and mild analgesia.

In addition to nonpharmacological interventions, intranasal or sublingual midazolam, intranasal dexmedetomidine, and inhaled nitrous oxide are options for nonpainful procedures. A combination of intranasal ketamine and dexmedetomidine has shown promising results in retrospective observational studies.[19][20]

Local anesthetics, either topically applied or given by direct infiltration, may be used for minor painful procedures, such as wound cleaning or laceration repair. For less painful procedures such as urethral catheterization or nasogastric tube placement, local anesthetics may be combined with inhaled nitrous oxide, oral or intranasal midazolam, or inhaled dexmedetomidine.

For moderately to severely painful procedures, such as fracture or dislocation reduction, a regimen offering sedation, amnesia, and analgesia is often preferred. Intravenous ketamine, ketofol, or propofol with fentanyl may be used. Studies have reported similar sedation efficacy with these combinations compared to the use of opioids and benzodiazepines.[21][22] Airway reflexes remain intact with ketamine sedation, which is linked to fewer respiratory adverse events than combinations of fentanyl with propofol, benzodiazepines, or etomidate. Emergence agitation may occur in the early recovery phase with ketamine.[23] However, combining this drug with propofol has been shown to reduce this incidence.[24] In addition, propofol with fentanyl may allow for a shorter recovery time than ketamine alone or in combination with propofol.[25]

Midazolam: Midazolam provides sedation, anxiolysis, and amnesia. Midazolam solutions are acidic, and intranasal administration is associated with stinging pain and increased secretions. Pretreatment with lidocaine spray can help reduce the pain and nasal irritation.

The dose for oral or rectal administration is 0.25 to 0.5 mg/kg per dose. For intramuscular administration, the dose is 0.05 to 0.15 mg/kg, with a maximum of 10 mg, given 30 to 60 minutes before the procedure. For intravenous administration, the recommended dose is 0.025 to 0.1 mg/kg, with a maximum dose of 6 mg for children younger than 6 and 10 mg for those aged 6 or older. The intranasal dose ranges from 0.2 to 0.8 mg/kg, with a maximum of 10 mg per dose.

The onset of action when this agent is given orally is 10 to 15 minutes. For intravenous administration, the onset is 1 to 5 minutes. For intramuscular injection, the onset is 10 to 20 minutes, whereas the onset for intranasal delivery is 5 to 10 minutes. Oral and rectal administration have a slow onset and are less predictable. The duration of action is 0.5 to 2 hours.[26]

Nitrous oxide: Nitrous oxide provides analgesic, sedative, anxiolytic, and weak anesthetic effects, depending on the concentration administered.[27] This anesthetic gas is contraindicated in cases of pneumothorax, bowel obstruction, and increased intracranial pressure. Nitrous oxide is also associated with nausea, vomiting, dizziness, and confusion. Nitrous oxide is teratogenic and contraindicated in pregnancy. This agent may be used for minor painful procedures such as laceration repair, dental procedures, and lumbar puncture.[28] The inhaled dose is ≤50% for minimal sedation and 51% to 70% for moderate sedation, with a maximum of 70% nitrous oxide (combined with 30% oxygen). The onset of action is within 2 to 4 minutes. The duration is 3 to 5 minutes after discontinuation.

Fentanyl: Fentanyl provides analgesia, but its adverse effects include hypotension, bradycardia, and respiratory depression. A rapid intravenous infusion can cause chest wall rigidity.[29] The dose for intravenous administration is 1 to 2 mcg/kg per dose, with a maximum of 50 mcg per dose. Fentanyl should be administered 3 to 5 minutes before the procedure, and delivery may be repeated at half of the original dose every 3 to 5 minutes as needed. For intranasal administration, the dose is 1.5 to 2 mcg/kg, with a maximum of 100 mcg per dose, given 15 to 20 minutes before the procedure. The onset for intravenous administration is 2 to 4 minutes, whereas intranasal onset is 5 to 10 minutes. The duration of action is 30 to 60 minutes.

Dexmedetomidine: Dexmedetomidine provides sedation and moderate analgesia with a longer onset and duration than other agents. This agent causes no-to-minimal respiratory or hemodynamic compromise.[30] Adverse effects include bradycardia, hypotension, and, rarely, hypertension. Dexmedetomidine should be avoided in patients with cardiac conduction abnormalities or those taking digoxin. The intranasal dose is 2 to 3 mcg/kg, administered 30 to 60 minutes before the procedure. The intravenous dose is 1 to 2 mcg/kg per dose over 10 to 20 minutes, whereas the intramuscular dose ranges from 1 to 4 mcg/kg. The onset for intravenous administration is 5 to 10 minutes, and for intranasal administration, it can range from 10 to 60 minutes based on age. The duration is 60 to 120 minutes.

Propofol: Propofol provides sedation but lacks analgesic properties. This agent has a rapid onset and short duration of action that produces motionless anesthesia. Propofol causes respiratory and cardiovascular depression. Common adverse effects include bradycardia, hypertriglyceridemia, hypotension, and propofol-related infusion syndrome, a condition characterized by dysrhythmia, hypotension, asystole, heart failure, metabolic acidosis, hypertriglyceridemia, rhabdomyolysis. Propofol-related infusion syndrome typically occurs with higher doses given over a prolonged period. Increased dosing requirements for younger patients are due to the large volume of distribution. Propofol also causes burning pain at the injection site.[31]

The intravenous bolus dose is 1 to 2 mg/kg, followed by 0.5 to 1 mg/kg every 3 to 5 minutes as needed. Alternatively, the intravenous bolus may be followed by a continuous intravenous infusion. The initial bolus is dosed at 1 to 2 mg/kg, followed by 50 to 250 mcg/kg/min. The onset of action of propofol is less than 50 seconds, and the duration is 3 to 10 minutes.

Etomidate: Etomidate has hypnotic and sedative properties but does not provide analgesia. Opioids may be needed for painful procedures. Etomidate causes cardiovascular and respiratory depression and should be avoided in patients with increased muscle tone, such as those with cerebral palsy, due to the risk of myoclonic jerks.[32] Etomidate can also cause adrenal insufficiency by suppressing cortisol production by inhibiting 11β-hydroxylase.[33] The intravenous dose is 0.2 to 0.3 mg/kg per dose for patients aged 6 months or older, with a reported maximum dose ranging from 0.3 to 0.6 mg/kg per procedure. The onset is 30 to 60 seconds, and the duration is dose-dependent, lasting from 2 to 5 minutes.

Ketamine: Ketamine acts as a dissociative analgesic, providing motionless anesthesia, sedation, amnesia, and analgesia. This drug has a lower risk of respiratory depression compared to other agents and increases heart rate and blood pressure through sympathetic stimulation.[34]

In addition, ketamine functions as a bronchodilator and does not increase intracranial pressure, making it safe for use in traumatic brain injuries.[35] However, ketamine can cause increased intraocular pressure, diplopia, nystagmus, salivation, and laryngospasm. This agent is relatively contraindicated in infants younger than 3 months due to a higher risk of laryngospasm. Ketamine is also emetogenic, but pretreating with ondansetron or combining it with propofol can reduce the frequency of vomiting. The coadministration of midazolam may reduce the risk of emergence agitation.[36] Ketamine may be used after preprocedural opioids without increasing the risk of adverse events.[37]

For intravenous administration, the dose is 1 to 2 mg/kg, with additional doses given every 5 to 15 minutes if needed. For intramuscular administration, the dose is 4 to 5 mg/kg. The oral dose is 5 mg/kg combined with oral midazolam and should be given 30 to 45 minutes before the procedure. The intranasal dose is 3 to 6 mg/kg, divided and administered in each nostril using a mucosal atomizer device. The onset of action is within 30 seconds for intravenous administration, 3 to 5 minutes for intramuscular administration (with analgesia beginning in 10 to 15 minutes), and 5 to 10 minutes for intranasal administration. Oral administration has an onset of action within 30 minutes. The duration of action is 5 to 10 minutes for intravenous administration, 15 to 25 minutes for intramuscular administration, and up to 1 hour for intranasal administration.

For subdissociative-dose ketamine, the intravenous dose is 0.1 to 0.6 mg/kg.[38] This dose provides analgesia and amnesia without complete dissociation, making it suitable for minor procedures, such as laceration repair or abscess drainage, but not for major painful procedures.[39]

Propofol and ketamine: Combining propofol with ketamine reduces the risk of bradycardia and hypotension compared to using propofol alone. However, this combination may carry a higher risk of apnea, hypotension, and bradycardia than ketamine alone.

For intravenous administration, the initial dose is 0.5 mg/kg of ketamine, followed by 0.5 mg/kg of propofol. Additional doses of ketamine, ranging from 0.5 to 1 mg/kg, may be administered repeatedly every 10 to 15 minutes. Propofol injection, also in doses of 0.5 to 1 mg/kg, may be repeated every 2 to 3 minutes as needed. The onset of action is less than 1 minute, and the effects lasts 15 to 35 minutes.

Reversal agents: Reversal agents are essential in managing the effects of overdoses or excessive sedation caused by opioids and benzodiazepines. Naloxone and flumazenil are commonly used to rapidly counteract the effects of these substances, restoring normal respiratory and neurological function.

Naloxone is used for opiate reversal. For infants and children younger than 5 or weighing 20 kg or less, the intravenous dose is 0.1 mg/kg per dose. The intramuscular or subcutaneous dose is also 0.1 mg/kg per dose, with a maximum of 2 mg per dose. For children older than 5 or weighing more than 20 kg, the dose is 2 mg for both intravenous and intramuscular or subcutaneous administration. Infants, children, and adolescents may receive 4 to 8 mg intranasally or 2 to 3 times the intravenous dose through the endotracheal route. Doses may be repeated every 2 to 3 minutes as needed.

The onset of action is 2 minutes for intravenous administration and 2 to 5 minutes for intramuscular or subcutaneous administration. The duration lasts between 30 minutes and 2 hours, depending on the route of administration. In cases where opioid use lasts longer than naloxone, repeat doses may be required every 20 to 60 minutes. The onset of action is slightly delayed with intranasal administration.[40]

Flumazenil is used for benzodiazepine reversal. The intravenous dose is 0.01 mg/kg, with a maximum dose of 0.2 mg, administered over 15 seconds. This dose may be repeated after 45 seconds, and then every minute, up to a maximum cumulative dose of 0.05 mg/kg or 1 mg. The onset of action of flumazenil is 1 to 2 minutes, and its duration lasts 45 to 60 minutes. This drug should be avoided in chronic benzodiazepine users, as it may induce seizures.

Postprocedure Monitoring and Recovery

After the procedure, the patient must be closely monitored until full recovery is achieved, including the return of protective reflexes and the resumption of baseline consciousness levels. This step ensures the patient's safety and readiness for discharge.

Complications

Each medication used in pediatric procedural sedation has specific potential adverse effects. The goal is to select the most appropriate agent for each patient, tailored to the specific procedure. Ideally, pediatric procedural sedation should only keep the patient sedated for the shortest time necessary to perform the procedure safely. Healthcare providers must always be mindful of the potential adverse events associated with the medications used and consider the patient's risk factors. The most concerning complication in pediatric procedural sedation is airway compromise, often resulting from oversedation. Healthcare providers must be able to recognize signs of airway compromise and be prepared to perform advanced airway management if necessary.

Clinical Significance

When performed correctly, procedural sedation enables pediatric patients to endure brief stressful or painful procedures without significant pain or unpleasant memories. The procedure facilitates diagnostics and interventions while minimizing the child's stress. For elective or unscheduled procedures, pediatric procedural sedation must be conducted in a controlled environment with appropriate staff and equipment. Healthcare providers must anticipate potential complications, such as vomiting and cardiorespiratory depression, and be prepared to intervene when necessary. The incidence of adverse outcomes is lower when administered by skilled healthcare providers, such as pediatric intensivists, outside the operating room.[41]

Enhancing Healthcare Team Outcomes

Pediatric procedural sedation should be performed as a coordinated team effort. In an ideal setting, two clinicians are involved—one performing the procedure and the other administering sedation and monitoring the patient. In emergency departments or resource-constrained environments, a qualified nurse can monitor the patient, whereas the clinician performs the procedure. A nurse or other qualified staff member must continuously monitor the patient during the procedure, necessitating interprofessional teamwork and communication.

Before beginning pediatric procedural sedation, the clinician and nursing staff must ensure that all resuscitative equipment, monitors, medications, and reversal agents are readily available. The healthcare provider may also need to collaborate with the pharmacist to obtain necessary sedation medications or reversal agents. Effective interprofessional communication is essential to ensure patient safety, optimize team performance, and promote patient-centered care.[42]