What Drugs Are Used for Sedating Children?

Sedative and analgesic drugs and their doses are primarily based on the child’s weight, but are individualized according to the child’s need. Pediatric sedation is a procedure to relax a child before painful or unpleasant medical procedures.

Pediatric sedation is a procedure to relax a child before painful or unpleasant medical procedures. The doctor administers medications that depress the level of consciousness in the child, relax their muscles and prevent pain.

Depending on the type and dosage of medication, sedation levels may be:

• Minimal sedation: The child is relaxed, awake and responsive.
• Procedural sedation: The child is semi-conscious and responds to stimulation.
• Deep sedation: The child is unconscious and may require assistance with breathing.
• General anesthesia: The child is completely unconscious and unresponsive to pain, and will require mechanical ventilation.

Emergency department procedures are typically performed under procedural sedation, which keeps the child semi-conscious, without affecting lung and heart functions.

The purpose of sedating a child is to relieve pain and fear, and control excessive movement during a procedure. Sedation takes away the child’s distress and makes the child cooperative, resulting in better outcomes from the procedure.

Historically, pain in children has been misunderstood and undertreated. Until comparatively recently, babies too young to verbalize were thought too young to experience fear or pain. Current research shows that even newborn babies experience pain, and sedation is essential before a painful procedure.

Some of the myths surrounding pain in children are:

• Children’s immature central nervous system (CNS) cannot experience pain.
• Children have no memory of pain.
• A given injury elicits an equivalent amount of pain in children as in adults.
• Children easily become addicted to opioids.

The facts are:

• Even newborns exhibit behavioral and hormonal changes in response to painful procedures.
• Children do not have to understand the meaning of pain to experience pain.
• Preemptive sedation and pain relief (analgesia) may decrease postprocedural opioid requirements.
• A child may require deep sedation in many situations where an adult would require minimal or no sedation.

Major pediatric surgeries may require general anesthesia, but procedures in the emergency department are generally performed using procedural sedation. Pediatric sedation may be administered during procedures that include the following

Diagnostic:

• Lumbar puncture
• Arthrocentesis (fluid drainage from a joint)
• Bone marrow biopsy
• Sexual assault examination
• Radiologic evaluation (CT, MRI)

Therapeutic:

• Suturing and wound repair
• Abscess incision and drainage
• Fracture or dislocation reduction
• Foreign body removal
• Burn debridement (removal of burnt tissue and wound cleaning)
• Tube thoracostomy (insertion of a flexible tube into the chest space)
• Multiple procedures at the same time

Procedural sedation is a safe and necessary step before performing any painful procedure on a child. Doctors generally use a minimum possible sedative dosage for the shortest duration required to keep the child relaxed and pain-free during the procedure.

The child’s vital signs are continuously monitored during and after the procedure until they are fully awake and stable. The emergency department is also always prepared with the necessary devices to assist breathing if required, and medications to reverse the anesthesia, if sedation gets deeper than intended.

Preparation

Before sedating a child an emergency department doctor:

• Obtains information on the child’s medical history which may include:
  • Time of last solid and liquid oral intake
  • Recent illness
  • Abnormality with any of the major organ systems
  • Drug allergies
  • Use of current medications
  • Presence of any upper airway infection or disease
  • Prior adverse events with sedation or general anesthesia
• Conducts a physical examination to evaluate the child’s
  • Heart and lung functions
  • Blood pressure and other vital parameters
  • Airway structure and function
  • Neurological and mental status
  • Size and location of injury

In elective procedures, the child cannot have any food or drink for a few hours prior to sedation. This direction varies depending on the age of the child. The American Academy of Pediatrics (AAP), and the American Society of Anesthesiologists (ASA) recommend the following durations for nothing-by-mouth (nil per os [NPO]) status prior to sedation:

• Younger than six months: No solids or nonclear liquids for four to six hours and no clear liquids for two hours.
• Six to 36 months: No solids or nonclear liquids for six hours and no clear liquids for two hours.
• Older than 36 months: No solids or nonclear liquids for six to eight hours and no clear liquids for two hours.

Procedure

The doctor may administer sedative to a child using one of the following routes:

• Oral
• Intranasal
• Intramuscular
• Intravenous
• Rectal

Monitoring

• During the procedure, the physician continuously records and monitors the child’s vital signs including:
• Blood pressure and heart rate every 15 minutes for procedural sedation and every 5 minutes for deep sedation
• Oxygen saturation and airway function
• Level of consciousness and response to physical stimulation
• Some children may also be monitored with
  • Electrocardiography (ECG)
  • Electroencephalography (EEG)
  • Capnography (measure of carbon dioxide concentration)

Post-procedure

The doctor continues to monitor the child’s vital signs until the child responds appropriately to gentle verbal or physical stimulation. The child may be discharged after:

• Their vital signs return close to normal
• They regain their age-appropriate mobility without assistance
• They are able to feed orally

Sedative and analgesic drugs and their doses are primarily based on the child’s weight, but are individualized according to the child’s need.

Response to medication can vary even among children of the same weight, and some children might need a higher dose than others. The doctor typically starts with the lowest dose possible and adjusts based on the child’s response.

Sedatives and analgesics

Following are some of the commonly used drugs for pediatric sedation:

Opioid analgesics for pain relief, such as:

• Morphine sulfate
• Fentanyl

Benzodiazepine class of sedative agents that include:

• Midazolam
• Diazepam

Barbiturate class of drugs such as:

• Pentobarbital
• Methohexital
• Thiopental

Other sedative agents include:

• Nitrous oxide
• Ketamine
• Propofol
• Dexmedetomidine

Adjuvant therapy

Medication doses can be minimized by including some of the following techniques to distract the child during the procedure:

• Providing some visual or auditory distraction
• Having a parent engage the child’s attention with a story

Reversal agents

Reversal agents are used to reverse the effects of the anesthetic drugs after completion of the procedure, or if the child has adverse reactions to the sedative agent.

The two reversal agents used are:

• Naloxone: Reverses opioid analgesic agents
• Flumazenil: Reverses benzodiazepine class of drugs

A child may take up to 24 hours to completely recover from the effects of sedation. The side effects of sedation include:

• Drowsiness and lethargy
• Impaired muscle coordination with certain drugs such as ketamine
• Disorientation and delirium
• Nausea and vomiting
• Headache
• Low blood pressure