Procedural Sedation — Sedation Medication Guidance — Clinical Pathway: Emergency Department

Procedural Sedation Clinical Pathway — Emergency Department

Sedation Medication Dosing Guidance

Medications have adverse effects, which may be more likely in certain patient scenarios and clinical decision making is required for specific children.

Medications Providing Both Sedation and Pain Control

In the event of laryngospasm or upper airway obstruction, initiate airway maneuvers and call for ED Succinylcholine Stat Bag.

Medication/Route Dosing Max Initial Dose Onset Duration Considerations
Ketamine IV
  • 1.5 mg/kg
  • Additional 0.5 mg/kg
    PRN q 5-15 min
 100 mg < 1 min 10 min
  • Ketamine does not achieve motionless sedation
  • Avoid fast IV push, infuse over 1-2 min
  • Rapid administration may cause respiratory depression
  • Consider using lower opioid doses before sedation to decrease risk of respiratory depression
  • Additional doses of IV or IM administration prolong recovery and are associated with agitation and nausea/vomiting
  • If administering IM, consider need for emergency IV access as indicated
  • Avoid co-administration of anticholinergic medications
Ketamine IM
Administration of Intramuscular Injections Procedure
  • 4 mg/kg
    1 additional 2 mg/kg in
    10-15 min as indicated
  • Use 100 mg/mL concentration only
 200 mg 5 min 20-30 min
Ketamine PO 6 mg/kg 200 mg 20-30 min 15-20 min
  • Frequently co-administered with a one-time dose of Midazolam PO 0.5 mg/kg, max 15 mg once
  • Use this regimen for children in which moderate sedation without an IV is the goal

Medications Providing Anxiolysis Only

If anxiolysis inadequate after initial dose and child requires additional doses, assess child's response and be prepared to monitor according to moderate sedation guidelines.

Medication/Route Dosing Max Initial Dose Onset Duration of Effect Considerations
Midazolam PO 0.5 mg/kg 15 mg 10-20 min 60 min Paradoxical reaction is rare but is more common in infants and toddlers
Midazolam IN 0.4 mg/kg 10 mg 5 min
Max effect: 10 min		 20-30 min
Midazolam IV 0.035 mg/kg 2 mg 1-5 min
Max effect: 5-7 min		 30-60 min

Medications Providing Sedation Only, No Pain Control

Medication/Route Dosing Max Initial Dose Onset Duration
of Effect		 Considerations
Dexmedetomidine IN
  • 3 mcg/kg
  • 1 additional dose of
    1 mcg/kg PRN
 200 mcg 10-20 min
(max effect ~30 min)		 85 min
  • Dexmedetomidine achieves an
    arousable sleep
  • Use with PO midazolam can facilitate moderate sedation
  • Total doses cannot exceed 4 mcg/kg or 250 mcg total for procedural sedation
Midazolam IV
  • 0.1 mg/kg
  • May repeat after
    2 to 3 mins
 2.5 mg 1-5 min
(max effect 5-7 min)		 30-60 min Achieving moderate or deep sedation with midazolam alone requires high doses, increasing the risk of respiratory depression and should be done with caution
Pentobarbital PO
  • ≤ 6 mos: 4 mg/kg
  • > 6 mos: 6 mg/kg
  • 2 additional doses
    • 2 mg/kg PRN
  • 8 mg/kg
    Including initial dose
  • or
  • 120 mg
 15-60 min 1-4 hrs
  • Use of the oral form requires prolonged recovery
  • Mix with flavored syrup before administration to improve palatability
Pentobarbital IV
  • 2 mg/kg, max 100 mg
  • Repeat 2 mg/kg x 2,
    max 6 mg/kg
  • 6 mg/kg
  • or
  • 100 mg
 3-5 min 15-45 min
  • Administer over 2 mins, not to exceed rate of 1 mg/kg/min
  • Rapid injection may cause respiratory depression, apnea, laryngospasm, hypotension
  • Do not dilute medication or run with other medications/fluids as it can cause precipitation; check compatibility before use
  • Monitor for paradoxical reaction in emergence phase
Propofol IV Bolus
  • 1-2 mg/kg
  • Additional 0.5 mg/kg
    every 1 min PRN
 100 mg 30 secs 5-15 min
after single bolus
  • Painful when injected, push bolus doses over 20-30 secs
  • Avoid use in children with or at risk for hemodynamic instability
  • Contraindicated if anaphylaxis to egg or soy
  • Consider higher initial bolus dose in toddlers
  • Co-administration of opioids increases risk of respiratory depression
Propofol IV Infusion
  • Loading dose: 1-2 mg/kg
  • Continuous Infusion initial dose: 200 mcg/kg/min
  • Additional bolus doses of
    0.5-1 mg/kg may
    be used
 100 mg 30 secs Continuous

Medications Providing Pain Control Only

Achieving moderate or deep sedation with opioids alone requires high doses, increasing the risk of respiratory depression and should be avoided

Medication and Route Dosing Max Initial Dose Onset Duration Considerations
Fentanyl IN
  • 1-2 mcg/kg
 100 mcg 5-10 min 30-60 min
  • Greater risk of respiratory depression when combined with benzodiazepines
  • Rapid IV administration may cause chest
    wall rigidity
Fentanyl IV
  • 1 mcg/kg
  • May repeat as needed
    for effect
 50 mcg Immediate 30-60 min
Morphine IV
  • 0.05-0.1 mg/kg
 4 mg
May require higher initial doses in chronic opioid users		 5-10 min 3-5 hrs
  • Itching due to histamine release
    (worse with IV)