Pediatric Sedation Literature Review

Maintained by Joe Cravero, MD and George Blike, MD

1.        Pena BM. Krauss B. Adverse events of procedural sedation and analgesia in a pediatric emergency department. Annals of Emergency Medicine. 34(4 Pt 1):483-91, 1999 Oct. 99429767 Abstract | Complete Reference 

Pediatric sedations were reviewed for over one thousand cases occurring at the Children’s Hospital (Boston).  Cases were collected on a weekly basis and records were reviewed for documentation of any one of a number of possible complications (low oxygen saturation, bronchospasm etc.).  The incidence of complications was found to be 2.7%. No particular sedation medication was associated with a greater incidence of complications than the general group. This study is lacks controls and relies on review of records to determine the presence of complications – still it represents an honest effort to determine an complication rate for a large group of mixed patients receiving sedation in a very capable emergency department.                                  

-Joseph Cravero MD

2.        Campbell RL. Ross GA. Campbell JR. Mourino AP. Comparison of oral chloral hydrate with intramuscular ketamine, meperidine, and promethazine for pediatric sedation--preliminary report. Anesthesia Progress. 45(2):46-50, 1998 Spring. 99284919 Abstract | Complete Reference 

This study looked at just 15 patients who were receiving sedation for dental restoration.  Chloral Hydrate was compared to Ketamine for these procedures. Chloral Hydrate 50mg/kg provided adequate sedation to accomplish these procedures for times over 40 minutes – ketamine 2mg/kg or 3mg/kg required IV medication supplementation to perform procedures longer that 30 minutes.  This study suffers from incredibly small numbers and relative under-dosing of ketamine.  The fact that this stimulating procedure could be accomplished with chloral hydrate is somewhat surprising and speaks to the depth of sedation that must have been present during these procedures.

-Joseph Cravero MD

Comment: This statement reviewed a variety of alternative dosing routes including transdermal, transmucosal, and rectal.  It is included in this review of the literature because most of the drugs that are described are in some way applicable to pain or sedation management for children.

Comment: Statement reviewed issues surrounding pain control in newborns.  A review of the physiologic implications of pain and recommended effective and safe interventions  for pain and stress management are included. 

Comment: Statement reviewed the medical issues of concern to anesthesiologists and surgeons concerning the evaluation and preparation of children in the preoperative period. Guidelines for general pediatricians are also included. The statement is relevant to our current search because it addresses issues concerning anesthesia and sedation that are important for practitioners involved in delivering this care in emergency departments. 

6.    Innes G. Murphy M. Nijssen-Jordan C. Ducharme J. Drummond A. Procedural sedation and analgesia in the emergency department. Canadian Consensus Guidelines. Journal of Emergency Medicine. 17(1):145-56, 1999 Jan-Feb.

Comment: Goals, definitions and responsibilities of pediatric sedation laid out by the Canadian Association of Emergency Physicians. 

Comment: 64 out of 243 sedations performed in one ED over an 18 month period are retrospectively reviewed in this paper. Four minor complications were found and of all the medications given the combination of fentanyl plus propofol was found to have the quickest recovery time and based on this review – is recommended as the medication combination of choice for the ED. 

8.     Ilkhanipour K. Juels CR. Langdorf MI. Pediatric pain control and conscious sedation: a survey of emergency medicine residencies [see comments]. Academic Emergency Medicine. 1(4):368-72, 1994 Jul-Aug.

Comment: A mail/telephone survey of residency directors at 80 U.S. emergency medicine residencies regarding resident experience with pediatric analgesia and sedation for painful procedures conducted during November 1991. Emergency medicine faculty supervised conscious sedation and analgesia in 87% of responding programs, while pediatrics faculty and pediatrics-emergency medicine fellows supervised in the remainder. Thirty-four programs (57%) had formal protocols for the administration of these drugs. Seventy-seven percent of the programs had airway resuscitation equipment at the bedside, while only 63% brought resuscitation drugs. However, 60% of the programs reported complications of sedation, including respiratory depression, prolonged sedation, agitation, and vomiting. The most commonly used agents were midazolam (82%), meperidine alone (68%) and with promethazine and chlorpromazine (67%), and chloral hydrate (67%). Only 25% of the programs used nitrous oxide, and 30% used ketamine 

10.   Joseph MH, Brill J Lonnie KZ. Pediatric Pain Relief in Trauma. Pediatrics in Review 1999;2075-84. 

Comment: A very nice review of the literature and issues surrounding the use of pain control and sedation primarily in the Emergency Department surrounding trauma management in children.  The discussion is much broader and includes a list of medications and indication for their use. 

Comments: Sedations with analgesia were reviewed retrospectively (64 out of 247).  Four minor complications were identified but none with any permanent sequellae.  Fentanyl with propofol infusion was found to have the quickest time to recovery and discharge after the procedure. 

12.   Petrack EM, Christopher NC, Kriwinsky J. Pain Management in the Emergency Department: Patterns of Analgesic Utilization. Pediatrics Vol 99 No. 5 May 1997 pp 711-714.

Comment: 40 charts reviewed from 3 different ED’s with analgesic utilization evaluated in multiple ways.  Overall, pediatric patients were significantly less likely to receive analgesia for painful procedures although there was considerable variation in practice.  Discharge pain meds were not different between the groups. 

13.   Hart LS. Berns SD. Houck CS. Boenning DA. The value of end-tidal CO2 monitoring when comparing three methods of conscious sedation for children undergoing painful procedures in the emergency department. Pediatric Emergency Care. 13(3):189-93, 1997 Jun. 

Comment: This paper looked at 40 patients randomly assigned to receive one of three sedation medication regimens for painful procedures in the ED. Capnography was used along with oxygen saturation to monitor respiratory depression. The study found a surprisingly high rate of respiratory depression when fentanyl was used as part of the medication scheme 20-23% and CO2 end tidal monitoring allowed early detection of respiratory depression. 

15.   Kennedy RM, Porter FL, Miller JP, Jaffe DM: Comparison of fentanyl/midazolam with ketamine/midazolam for pediatric orthopedic emergencies. Pediatrics. 102 (4 pt 1):956-63, 1998 Oct. 

Comment: During emergency orthopedic procedures K/M works better than F/M to relieve anxiety and pain.  Respiratory emergencies occur more often with F/M. Both regimens facilitate reduction, produce amnesia and rarely cause delirium.  Vomiting is more frequent and recovery more prolonged with K/M. 

16.    Schutzman SA. Liebelt E. Wisk M, Burg J: Comparison of oral transmucosal fentanyl citrate and intramuscular meperidine, promethazine, and chlorpromazine for conscious sedation of children undergoing laceration repair. Annals of emergency Medicine. 28(4): 385-90 1996 Oct. 

Comment: Little diference between these meds were found.  OTFC had more O2 desaturation, more vomiting in the OTFC group and more somnolence in the MPC group. 

Comment:  A retrospective study of the effectiveness and complications of this combination Desaturations seen when higher doses of fentanyl are used. 

18.   Dachs RJ. Innes GM. Intravenous ketamine sedation of pediatric patients in the emergency department. Annals of Emergency Medicine. 29(1):146-50, 1997 Jan. 

Comment: Thirty patients given ketamine sedation for painful procedures in the emergency department. One and a half mg/kg was found to be effective in 94% of patients and vomiting occurred in 2 patients while agitation occurred in 4. Parents were pleased with  the sedation method. 

Comment: The objective of this study was to assess complications and risk factors among children undergoing conscious sedation with fentanyl and midazolam for reduction of fractures and dislocations. A 22-month retrospective review was made of an urban pediatric emergency department's records after implementing a protocol for the administration of fentanyl and midazolam. A total of 339 children were enrolled in the study. An alteration in respiratory status occurred in 37 (11.0%) patients: 28 (8.3%) had oxygen saturation < 90%; 16 (4.7%) received oxygen; 12 (3.6%) were given verbal breathing reminders, eight (2.4%) received airway positioning maneuvers, and 2 (0.6%) received naloxone. Four patients (1.2%) vomited. None required assisted ventilation, intubation, or admission resulting from complications of CS. (odds ratio = 2.7). The paper concludes that complications associated with F/M administered by protocol were few, minor, and easily managed. 

21.   Cote CJ. Sedation for the pediatric patient. A review. Pediatric Clinics of North America 1994 Feb;41(1):31-58. 

22.   Morton NS et al. Development of a selection and monitoring protocol for safe sedation of children. Paediatr Anaesth. 1998;8(1):65-8. 

23.   Binder LS et al. Chloral hydrate for emergent pediatric procedural sedation: a new look at an old drug. Am J Emerg Med. 1991 Nov;9(6) 21-6. 

24.   Havel CJ Jr. Strait RT. Hennes H. A clinical trial of propofol vs midazolam for procedural sedation in a pediatric emergency department . Academic Emergency Medicine. 6(10):989-97, 1999 Oct. 

Comment: A prospective blinded study comparing midazolam and propofol as sedative in addition to morphine in the emergency department. Propofol was effective and has a much shorter recovery time than midazolam. Brief periods of O2 desaturation were more common in the propofol group. 

25.   Chudnofsky CR. Safety and efficacy of flumazenil in reversing conscious sedation in the emergency department. Emergency Medicine Conscious Sedation Study Group. Academic Emergency Medicine. 1997 Oct; 4(10):944-50. 

26.   Lowrie L. Weiss AH, Lacombe C: The pediatric sedation unit: a mechanism for pediatric sedation.  Pediatrics. 102(3) E30, 1998 September. 

Comment: A controversial idea of centralized sedation with transport to site of procedure by PICU nurses.  This concept is proposed as a way to make sedation uniform in a large hospital setting.  Experience with 454 cases is reviewed. Cancellation of procedures was required in 2.4% of cases due to decreased pulse oximetry, airway obstruction, or apnea. 

28.   Means LJ. Ferrari L. Mancuso TJ. Davidson P. Hackel A. Deshpande JK. Davis P. Brown R. Bailey A. Cote C. The pediatric sedation unit: a mechanism for safe pediatric sedation      [letter]. Pediatrics. 103(1):199-201, 1999.  

30.   Conte PM Walco Ga. Procedural pain management in pediatric oncology: a review of the literature. Review. Cancer Investigation. 17 (6) 448-59, 1999  Full text. 

31.   Hopkins KL, Davis PC et. al: Sedation for pediatric imaging studies.  Neuroimaging clinics of North America. 9(1)1-10, 1999. 

Comment: This paper comments on the need for protocols. 

32.   Hertzog JH, Campbell JK, et. al.., Propofol anesthesia for invasive procedures in ambulatory and hospitalized children: experience in the pediatric intensive care unit. Pediatrics 103(3) E30, 1990. 

Comment: Propofol used successfully in a variety of procedures by intensivists for ambulatory and inpatient procedures. A retrospective review of 251 procedures performed on 115 children in a university affiliated PICU. Hypotension, respiratory depression, and myoclonus were noted as side effects of propofol usage. No procedural failures were attributed to propofol use.

33.   Sharar SR, Bratton SL et. al.. A Comparison of oral transmucosal fentanyl citrate and oral hydromorphone for inpatient pediatric burn wound care analgesia. Journal of Burn Care and Rehab.  19(6): 516-21, 1998 Nov-Dec.  

Comment: OTFC (10mcg/kg) shown to be slightly better than hydromorphone (60 mcg/kg) for pain and anxiolysis for burn care – in the preprocedural time frame but not superior at other points in the procedure. Considered a safe alternative. 

34.   Slonim AD, Ognibene FP. Sedation for pediatric procedures, using ketamine and midazolam, in a primarily adult intensive care unit: a retrospective evaluation. Critical Care Medicine 26(11):1900-4, 1998.  

Comment: Retrospective review. Nine complications encountered in 247 procedures performed with ketamine and midazolam. No cardiovascular compromise noted and none were admitted to the ICU. Conclusion is that sedation for painful procedures can be performed outside the OR by non-pediatricians. Limited side effects were noted. 

Comment: 10-15 mcg/kg of oral fentanyl gave sedation without vomiting or desaturation preoperatively. 

Comment: 2Y/O child with desaturation given these two meds. 

Comment: Techniques for sedation discussed – 46 references.  

38.   Macpherson CF, Lundblad LA: Conscious sedation of pediatric oncology patients for painful procedures: development and implementation of a clinical practice protocol. Journal of Pediatric Oncology Nursing. 14(1): 33-42: 1997 Jan.  

Comment: Protocol is included. A review of the literature is also included along with 16 references. 

Comment: Survey sent to pediatric centers around the country. Results are presented along with monitoring practices, complications and success rates. Chloral Hydrate remains a widely used sedative. 

Comment: fentanyl infusion by computerized assisted continuous infusion differ between adults and children. Details in this paper. 

41.   Murat I, Billard V, et al. : Pharmacokinetics of propofol after a single dose in children aged 1-3 years with minor burns. Comparison of three data analysis approaches. Anesthesiology. 84(3):526-32, 1996 Mar.  

Comment: The volume of the central compartment and the systemic clearance were both greater than all values reported in older children and adults. This is consistent with the increased requirements seen in this group. 

Comment: A review of various blocks that can be applied to procedures in order to decrease postoperative pain. 

43.   Schechter NL, Allen DA, Hanson K. Status of pediatric pain control: a comparison of hospital analgesic usage in children and adults. Pediatrics 1986 77:11-15. 

44.   Parker RI, Mahan RA, et al. Efficacy and safety of intravenous midazolam and ketamine as sedation for therapeutic and diagnostic procedures in children. Pediatrics 1997 99:427-431. 

45.   Karian VE, et al. Sedation for pediatric radiological procedures: analysis of potential causes of sedation failure and paradoxical reactions. Pediatric Radiology. 1999 Nov;29(11): 869-73. 

46.   Warner TM. Clinical applications for pediatric sedation. CRNA. 1997 Nov;8(4) 144-51. 

47.   Morton NS et al. Development of a selection and monitoring protocol for safe sedation of children. Paediatric Anaesth. 1998;8(1):65-8. 

48.   Green SM et al. What is the optimal dose of intramuscular ketamine for pediatric sedation? Acad Emerg Med. 1999 Jan;6(1):21-6. 

49.   Egelhoff JC et al. Safety and efficacy of sedation in children using a structured sedation program. AJR Am J Roentgenol. 1997 May;168(5):1259-62. 

50.   Schwanda AE, et al. Brief unconscious sedation for painful pediatric oncology procedures. Intravenous methohexital with appropriate monitoring is safe and effective. Am J Pediatr Hematol Oncol. 1993 Nov:15(4):370-6. 

52.   Liebelt EL. Reducing pain during procedures. [Review] [22 refs] Current Opinion in Pediatrics. 8(5):436-41, 1996 Oct. 

53.   Malviya S et al. Adverse events and risk factors associated with the sedation of children by nonanesthesiologists. Anesthesia & Analgesia 1997 Dec;85(6):1207-13. 

54.   D’ Agostino J et al. Comparative review of the adverse effects of sedatives used in children undergoing outpatient procedures. Drug Saf. 1996 Mar; 14(3): 146-57. 

55.   Anghelescu D. Kaplan RF. Defining levels of sedation in pediatric patients [letter; comment]. Anesthesia & Analgesia. 87(6):1454-5, 1998 Dec.  

Comment: Authors comment on the ill-defined nature of deep vs. conscious sedation in children under chloral hydrate sedation. 

57.   Tobias JD. Sedation and anesthesia for pediatric bronchoscopy. [Review] [23 refs] Current Opinion in Pediatrics. 9(3):198-206, 1997 Jun.  

Comment:  A step by step description of the delivery of sedation – starting with the preoperative evaluation and ending with the recovery of the patient.  Various methods and drugs for sedation are described. 

58.   Balsells F. Wyllie R. Kay M. Steffen R. Use of conscious sedation for lower and upper gastrointestinal endoscopic examinations in children, adolescents, and young adults: a twelve-year review. Gastrointestinal Endoscopy. 45(5):375-80, 1997 May.  

Comment: A review of experience with 2711 sedations for endoscopy. The authors review various methods and success rate and complication rate (0.3%). They conclude that sedation is effective and necessary for endoscopy in children.

Revised: February 23, 2000 .