17.1 Pediatric Procedural Sedation and Analgesia
Key Takeaways
Assess airway, physiologic reserve, medication exposure, recent intake and procedural urgency. ASA status describes health, while law and privileges govern who can provide sedation.
Apply ASA fasting intervals to healthy elective patients. For time-sensitive procedures, weigh aspiration risk and depth against the harm of delay.
Match the agent to pain and depth. Ketamine provides dissociative analgesia but does not guarantee airway protection. Propofol and midazolam lack analgesia. Check age, setting, route and dose.
Assign a trained monitor, observe the airway and breathing directly, and use capnography according to the setting and intended depth. Prepare equipment and personnel to rescue unintended deeper sedation.
Support ventilation immediately when it fails. Use an indicated antagonist alongside rescue, then monitor until the child has recovered and recurrent sedation is unlikely.
Pediatric Procedural Sedation and Analgesia
Quick Answer: Match sedation and analgesia to the procedure and the child's airway, physiologic reserve and developmental needs. Use elective fasting intervals for healthy scheduled patients. For a time-sensitive procedure, weigh recent intake and aspiration risk against the harm of waiting. Assign a trained monitor, prepare to rescue deeper sedation, and observe the child until airway function, vital signs and responsiveness are back to an appropriate baseline.
Sedation Depth and Rescue Capability
| ASA depth | Response | Airway and ventilation | Cardiovascular function |
|---|---|---|---|
| Minimal | Usual response to verbal commands | Unaffected | Unaffected |
| Moderate | Purposeful response to verbal commands or light touch | Airway support generally unnecessary and ventilation adequate | Usually maintained |
| Deep | Purposeful response after repeated or painful stimulation | Airway support may be needed and ventilation may be inadequate | Usually maintained |
| General anesthesia | No arousal even with painful stimulation | Airway support often needed and ventilation frequently inadequate | May be impaired |
Reflex withdrawal does not count as purposeful movement. Be able to rescue a child whose sedation becomes deeper than intended, including rescue from general anesthesia when providing deep sedation. Ketamine dissociation is a distinct state of analgesia, amnesia and reduced responsiveness. Spontaneous ventilation and airway reflexes are often retained, but obstruction, apnea and laryngospasm remain possible. The University of Michigan Sedation Scale can document observed arousal when the local protocol uses it. It ranges from 0 (alert) to 4 (unarousable). Continue to assess breathing and the airway regardless of the score. ASA depth statement · 2026 unscheduled sedation guideline · UMSS validation
Evaluate the Child and Procedure
- History: Use AMPLE (allergies, medications, past history, last oral intake and events). Ask about prior sedation or difficult airway, anesthetic reactions, obstructive sleep apnea, snoring, prematurity and current respiratory symptoms. Review opioids and other sedatives already given. Recent or active upper respiratory infection may affect the airway plan. Ask about drugs that may delay gastric emptying, including GLP-1 receptor agonists. Assess the symptoms, proposed drug and setting.
- Examination: Obtain weight, baseline vitals and responsiveness when feasible. Assess breathing, circulation, tonsil size, mouth opening, mandibular size and neck mobility. A Mallampati view can supplement a cooperative child's exam. The 2026 unscheduled sedation guideline does not require it. Assess how the team can access the airway during the procedure, including inside an MRI suite.
- Physical status and staffing: ASA I describes a healthy patient, II mild systemic disease, III severe systemic disease, IV a constant threat to life from severe disease, V a moribund patient unlikely to survive without the operation, and VI a patient declared brain dead for organ donation. The E modifier indicates an emergency in which delay significantly increases the threat to life or a body part. ASA I or II is often suitable for routine sedation. Significant systemic disease, an abnormal airway or severe sleep apnea warrants individualized assessment and appropriate consultation. Applicable law, institutional privileges, competencies and available rescue resources determine who can provide sedation.
- Preparation: Discuss risks, benefits and alternatives with the caregiver, obtain consent and involve the child as appropriate. Use local anesthesia, regional blocks or nonpharmacologic support when suitable. Assign procedure and monitoring roles before giving medication. For deep sedation the dedicated observer's sole responsibility is monitoring and rescue support. A moderate sedation monitor may assist with briefly interruptible tasks under the AAP/AAPD guidance.
AAP pediatric guideline, reaffirmed December 2025 · AAPD guideline · 2026 competencies and privileging · Pediatric URI cohort
Elective Fasting and Time-Sensitive Care
| Intake for a healthy elective patient | ASA fasting interval |
|---|---|
| Water, pulp-free juice or other clear liquids | 2 hours |
| Human milk | 4 hours |
| Infant formula, nonhuman milk or a light meal such as plain toast and clear liquids | 6 hours |
| Fried or fatty foods or meat | Additional time may be needed, for example 8 hours or more, depending on amount and type |
The ASA 2023 modular update retained the two-hour clear-liquid interval for healthy elective children. Unscheduled sedation calls for a separate decision. Assess the time, type and amount of intake, aspiration risk factors such as bowel obstruction, expected depth and harm from delay. A painful, threatened limb may need immediate reduction with a trained team and rescue equipment. A child with bowel obstruction or a full stomach and a need for deep sedation may warrant an anesthesia-led protected airway. Ketamine does not guarantee airway protection. A multicenter pediatric ED cohort found no aspiration among 6,183 sedations and no association between fasting duration and the studied adverse outcomes. Most children had ASA I or II status. 2017 ASA fasting guideline · 2023 ASA update · 2026 unscheduled guidance · Pediatric ED fasting cohort
Choose an Agent and Check the Dose
These examples identify the source and setting for each dose. Confirm weight in kilograms, the indication, route, concentration and local limits. Account for other drugs that depress ventilation before adding or redosing an agent.
| Agent | Use and pediatric dose example | Important effects |
|---|---|---|
| Ketamine | Dissociative analgesia for painful procedures. The Texas Children's pathway uses 1–2 mg/kg IV over 60 seconds or 3–5 mg/kg IM. This is a pediatric procedural protocol. The U.S. Ketalar label has not established safety and effectiveness below age 16. A 20-kg child receiving 1.5 mg/kg IV receives 30 mg. | NMDA receptor antagonism. May increase heart rate and BP and cause secretions, emesis or recovery agitation. Laryngospasm and apnea can occur. Routine adjunctive midazolam has no demonstrated recovery benefit in children. |
| Propofol | Rapid IV hypnotic without analgesia. The Texas Children's deep sedation service lists 0.5–1 mg/kg IV bolus as one example. U.S. Diprivan labeling does not recommend pediatric monitored anesthesia care sedation because safety, effectiveness and dosing for that indication have not been established. | Can cause apnea and hypotension. Provide local or other analgesia when the procedure calls for it and account for additive effects. Check the formulation's contraindications. Diprivan lists hypersensitivity to the drug or its components and prior egg or soy anaphylaxis. |
| Midazolam | Anxiolysis and amnesia without analgesia. One U.S. IV label starts at 0.05–0.1 mg/kg from 6 months to 5 years and 0.025–0.05 mg/kg from 6 to 12 years. Give slowly and reassess the peak effect before redosing. | Benzodiazepine that may cause respiratory depression or paradoxical agitation. Concomitant opioids increase sedation and respiratory risk. |
| Fentanyl | IV opioid analgesia. Texas Children's lists 1–2 mcg/kg for infants and children younger than 12 years, with separate neonatal and adolescent dosing and reduced dosing with benzodiazepines. | Can cause bradycardia and respiratory depression. Rapid injection increases the risk of rigidity that can impair ventilation. |
| Dexmedetomidine | IV alpha-2 agonist. U.S. Precedex labeling for non-intubated children during noninvasive procedures uses a loading infusion over 10 minutes of 1.5 mcg/kg from 1 month to less than 2 years or 2 mcg/kg from 2 to less than 18 years. The labeled maintenance range is 0.5–1.5 mcg/kg/hour. | Often permits arousable sedation. Monitor for bradycardia, hypotension and transient hypertension during loading. Respiratory monitoring remains necessary. |
Texas Children's procedural dosing · Ketalar label · Diprivan label · Midazolam label · Fentanyl label · Precedex label
The chart shows observed adverse events in 6,295 pediatric ED sedations, most in ASA I or II patients. The investigators counted desaturation when it prompted an intervention. These cohort rates help anticipate events and plan rescue. They do not give the probability for a specific child or establish a causal ranking of drugs. Multicenter pediatric ED study
Monitor, Rescue and Recover
SOAPME helps check suction, oxygen, age-sized airway supplies, pharmacy and resuscitation drugs, monitors, and emergency equipment. Confirm bag-mask function, appropriate airway adjuncts, advanced-airway and vascular access capability, and a way to summon help. Record the intended and observed depth, drug, dose, route and time, vital signs, and interventions.
| Setting or depth | Ventilation and other monitoring |
|---|---|
| AAP/AAPD moderate sedation | Observe breathing and monitor oxygen saturation and heart rate continuously. Ventilation monitoring is strongly recommended when bidirectional speech is possible and required when it is not. Capnography is preferred, with an audible pretracheal or precordial stethoscope as an alternative under the guideline. Document vital signs about every 10 minutes. |
| AAP/AAPD deep sedation | Use a dedicated observer, pulse oximetry, ECG and capnography, with vital signs documented at least every 5 minutes. Document when capnography is initially impractical and apply it as soon as feasible. Arrange IV access or immediate availability of someone skilled in obtaining it. |
| ACEP 2026 unscheduled sedation | Use capnography routinely when feasible for moderate, deep and dissociative sedation, along with direct observation, continuous pulse oximetry, cardiac rhythm monitoring and serial blood pressure. |
A change in the capnogram may precede oxygen desaturation, particularly with supplemental oxygen. Check chest movement, airway and sampling equipment when a waveform disappears. A flat trace alone cannot identify apnea, obstruction or sampling failure. Respond immediately if ventilation is ineffective. AAP/AAPD guideline · ACEP 2026 guideline
Caution
Stop the procedure and call for help when ventilation fails. Open the airway, give oxygen, suction if needed and provide effective bag-mask ventilation for apnea or inadequate ventilation. If soft tissue still obstructs the airway despite positioning, select an appropriately sized adjunct and reassess ventilation. With laryngospasm, remove the stimulus and use jaw thrust and continuous positive airway pressure with oxygen. Persistent obstruction requires advanced rescue, which may include neuromuscular blockade and intubation by a skilled clinician. A rigid chest and abdomen after rapid IV fentanyl suggest opioid-associated rigidity. Give naloxone when appropriate in parallel with rescue and escalate promptly to paralysis and intubation if ventilation cannot be restored. Do not wait for an antagonist to work in a child who cannot be ventilated. Society for Pediatric Anesthesia crisis checklist · Fentanyl label · Pediatric rigidity case series
Choose the airway adjunct. An oropharyngeal airway (OPA) can keep the tongue off the posterior pharynx in an unresponsive child without a gag reflex. With an intact gag reflex, an OPA can provoke gagging or vomiting. A lubricated nasopharyngeal airway (NPA) may be better tolerated when the gag reflex remains. Avoid the nasal route with a suspected basilar skull fracture or significant midface trauma. An NPA can cause bleeding or fail to bypass the obstruction if poorly sized. For example, if a partially responsive child still has soft-tissue obstruction after jaw thrust and has no nasal-route contraindication, an NPA can support mask ventilation. Check chest rise and the capnogram when available. If mask ventilation remains ineffective, a trained clinician may use a correctly sized supraglottic airway, such as a laryngeal mask airway (LMA), to restore ventilation while the team prepares definitive rescue. Reassess for leak or ineffective ventilation after placement. An LMA can restore ventilation while the team addresses ongoing aspiration risk. Regurgitation and aspiration can still occur. AAP/AAPD sedation rescue · Pediatric airway adjunct technique · RCH pediatric resuscitation · ASA difficult airway guideline · FDA device instructions
Reversal: Titrate naloxone under the appropriate pediatric reversal protocol to restore adequate ventilation. The U.S. label distinguishes small IV increments for postoperative opioid depression from weight-based overdose dosing. For reversal of procedural benzodiazepine sedation in children aged 1–17 years, the flumazenil label starts at 0.01 mg/kg IV over 15 seconds, capped at 0.2 mg per dose. If appropriate, repeat after another 45 seconds, then at 60-second intervals up to four additional doses, with a total cap of 0.05 mg/kg or 1 mg, whichever is lower. Flumazenil can precipitate seizures in benzodiazepine-dependent patients. Contraindications include benzodiazepine treatment of a potentially life-threatening condition such as status epilepticus and signs of serious cyclic antidepressant overdose. Use assisted ventilation and specialist escalation when reversal is unsafe. Naloxone label · Flumazenil label
Recovery: Use a staffed recovery area with airway equipment and continued observation. Before discharge, confirm a stable airway, ventilation, oxygenation and hemodynamics, and return to the child's baseline level of consciousness or as close to usual responsiveness as possible for a very young child or a child with a disability. Observe longer after reversal or a long-acting drug and individualize timing for recurrent sedation risk. Give the responsible caregiver verbal and written instructions and return precautions. AAP/AAPD recovery guidance
A previously healthy 20-kg 6-year-old has a displaced forearm fracture with threatened hand perfusion. The orthopedic team requests immediate reduction. The child drank pulp-free apple juice 2.5 hours ago and ate plain toast five hours ago. Perfusion otherwise is stable, the airway exam is reassuring, and a pediatric sedation team is available. Which plan best addresses recent intake?
The juice meets the elective interval, while the toast does not. Balance aspiration risk against the harm of delay and proceed if indicated with an appropriately staffed sedation and rescue plan.
Wait at least one hour for the toast interval before treating the threatened hand, regardless of the evolving perfusion.
Proceed with deep propofol sedation because the clear liquid interval has elapsed, even if airway rescue personnel and equipment are unavailable.
Use dissociative ketamine and omit ventilation monitoring because the child is otherwise healthy and ketamine preserves airway reflexes.
A 10-year-old becomes apneic after rapid IV fentanyl during abscess drainage. The chest and abdomen become rigid. Despite airway repositioning and a tight bag-mask seal, the chest does not rise, and oxygen saturation is falling rapidly. Which response best addresses the likely cause?
Treat presumed isolated laryngospasm with nebulized racemic epinephrine before restoring ventilation.
Suspect fentanyl-associated rigidity. Activate advanced airway help, continue efforts to oxygenate and ventilate, and give naloxone when appropriate. If ventilation cannot be restored promptly, proceed to skilled neuromuscular blockade and intubation.
Treat presumed tension pneumothorax with immediate needle decompression based solely on the flat capnogram.
Treat presumed paradoxical benzodiazepine reaction with flumazenil and nebulized albuterol.
An 8-year-old with epilepsy on long-term clobazam has shallow respirations and falling oxygen saturation after receiving IV midazolam for urgent imaging. There was no opioid exposure. Which immediate response is appropriate?
Use flumazenil as the first intervention and wait for the respiratory response before assisting ventilation.
Give prophylactic phenytoin, then administer flumazenil to avoid benzodiazepine withdrawal.
Open the airway, provide oxygen and assisted ventilation, and call for help. Avoid routine flumazenil in this benzodiazepine-exposed child at risk of seizures.
Give naloxone because it reverses midazolam-associated respiratory depression.
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