These agents should ONLY be administered by clinicians trained and experienced in pediatric procedural sedation using continuous noninvasive electronic monitoring of oxygenation, heart rate, blood pressure, and, whenever possible, end-tidal carbon dioxide monitoring. Resuscitation equipment, medications, and personnel skilled in advanced pediatric life support and knowledgeable of sedatives and reversal agents must be present. Unstable patients, patients with airway anomalies, and those with life-threatening, severe systemic disease warrant consultation with an anesthesiologist, pediatric critical care specialist, or emergency physician prior to procedural sedation. Please refer to UpToDate topics on procedural sedation in children for more details. | |||||
Agent | Initial IV dose* | Repeat IV dose (as needed to achieve desired level of sedation) | Onset (minutes) | Duration (minutes) | Additional notes |
Ketamine | 1 to 2 mg/kg; some experts do not exceed 1.5 mg/kg per dose For healthy patients without QT prolongation or receiving medications that prolong the QT interval, premedication with ondansetron 0.15 mg/kg IV (maximum dose 4 mg) is recommended | 0.5 to 1 mg/kg; repeat every 5 to 10 minutes, titrating to desired level of sedation | 1 to 2 | 15 to 30 |
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Ketamine and propofol | Ketamine 0.5 mg/kg bolus followed by propofol 0.5 mg/kg Propofol may reduce the risk of vomiting caused by ketamine; thus premedication with ondansetron may not be required | Propofol 0.5 mg/kg every 2 minutes, as needed or Ketamine 0.5 to 1 mg/kg every 10 minutes, as needed | <1 | 15 to 30 |
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Propofol¶ | Initiate infusion at 150 mcg/kg per minute and titrate gradually to response (up to 250 mcg/kg per minute)Δ or 6 months to 2 years of age: 2 mg/kg IV bolus dose 2 years of age and older: 1 to 1.5 mg/kg IV bolus dose | Not applicable for continuous IV infusion; titrate infusion rate as needed or Additional IV bolus dose 0.5 mg/kg every 3 to 5 minutes, titrating as needed up to 3 mg/kg. Wait at least 3 to 5 minutes between doses to assess effect. | ≤0.5 | 5 to 15 after single bolus dose, longer after prolonged infusion or when repeated bolus doses are given |
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Dexmedetomidine | Loading dose (dexmedetomidine alone): Maintenance continuous infusion (dexmedetomidine alone): 1 to 2 mcg/kg/hour | Repeat loading dose: 0.5 to 1 mcg/kg over 10 minutes. Not applicable for continuous infusion; titrate infusion rate as needed to achieve clinical effect | 5 to 10 | 30 to 70 |
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Fentanyl | 1 to 2 mcg/kg Some experts prefer to not exceed 50 mcg per dose | Repeat 0.5 to 1 mcg/kg every 3 to 5 minutes Some experts prefer to not exceed 25 mcg per dose | <3 to 5 | 30 to 60 after a single dose |
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Midazolam | 6 months to 5 years of age: 0.05 to 0.1 mg/kg IV, maximum single dose 2 mg 6 to 12 years of age: 0.025 to 0.05 mg/kg IV, maximum single dose 2 mg Over 12 years of age: 1 to 2 mg IV | After initial IV dose, repeat after 2 to 5 minutes, titrating to desired level of sedation as follows:
| 1 to 3 | 15 to 60, depending upon total dose administered |
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Etomidate | 0.1 to 0.3 mg/kg IV Lower dose in children with renal or hepatic insufficiency | 0.05 mg/kg every 3 to 5 minutes; titrate up to 0.6 mg/kg total dose to desired sedation | ≤0.5 | 5 to 15 |
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CT: computed tomography; IV: intravenous; MRI: magnetic resonance imaging; URI: upper respiratory tract infection.
* Doses are given as a suggested range for the initial dose. Children may differ markedly with respect to efficacy of any single dose, and careful titration to effect by using repetitive dosing to achieve the desired depth and duration of sedation is necessary for any individual patient.
¶ In some institutions, propofol is ONLY approved for use by anesthesiologists or others with specialized pediatric procedural sedation training. Check local recommendations.
Δ Administering dexmedetomidine 0.5 to 1 mg/kg IV bolus prior to propofol infusion may reduce the total amount of propofol needed for sedation and has been associated with fewer adverse effects.Do you want to add Medilib to your home screen?