Procedural Sedation Clinical Pathway — Emergency Department

Goals and Metrics

Provider Resources

Related Pathways

Child Requiring Procedural Sedation

Pre-sedation Evaluation
- History and physical
- ASA Physical Status Classifications

Determine Level of Sedation Required
- Painless procedure, anxiolysis
- Painful procedure, local/regional anesthesia
- Painful procedure
Obtain verbal consent
Policy: ED Procedural Sedation

Sedation Medication Dosing Guidance

Procedure Preparation and Monitoring

Sedation Procedure
Time out
Monitor child

Recover Child
Phase 1 recovery
Phase 2 recovery

Discharge Criteria and Instructions

Indications for Admission
Sedation related:
- < 28 days (FT)
- < 60 wks post-conceptual age
- Need for further monitoring
Other medical/surgical reason for admission

Anesthesia Consult

ASA 4/5
Known or suspected difficult airway based on exam or syndrome, history of or active airway obstruction (severe OSA, active croup)
Clinical concern for increased intracranial pressure with urgent procedure
Ongoing emesis

Consider Anesthesia Consult

ASA 3
Age less than 1 yr
Chronic lung disease
C-collar in place
Impending OR for other procedure
Status epilepticus or poorly controlled seizure disorder
Acute asthma exacerbation requiring frequent bronchodilators
Severe autism/behavioral issues
Resource requirement
Complexity of procedure, pain, amount of sedation medication required
Impaired GI motility syndromes

Cardiology Consult

Review last Cardiology Clinic note
Examples that are appropriate for ED sedation
- Repaired isolated PDA, ASD, VSD, coarctation with no hemodynamic or electrophysiologic compromise
For all other cardiac patients requiring procedural sedation, consult Cardiology or Cardiac Anesthesia as clinically indicated

Resources for Sedation Emergencies

Posted: July 2020
Last Revised: March 2025

Authors:
- J. Del Pizzo, MD;
- J. Fein, MD, MPH;
- K. Hummel, PharmD;
- H. Huang, PharmD;
- P. Stricker, MD

Editors: Clinical Pathways Team

Evidence

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.