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Procedural Sedation Pharmacology
Deb Updegraff R.N., P.N.P, C.N.S.
Clinical Nurse Specialist
LPCH Pediatric Intensive Care Unit
Procedural Sedation

The phrase “procedural sedation”
refers to techniques of managing a
patient’s pain and anxiety to
facilitate appropriate medical care
in a safe, effective and humane
fashion.
Sedation Pharmacolgy
Individual responses are dependant on:

Age

Concurrent disease states

Concurrent drug therapy
Chloral Hydrate
Hypnotic“Short term sedative and hypnotic given prior
to nonpainful procedures
Chloral Hydrate

Usually given to Outpatients due to
relative low risk profile. For nonpainful procedures only.
EEGs
MRI/CT Scans
Echocardiograms
Chloral Hydrate
PO/Rectal
Dose: 50mg/kg give 30-60
minutes prior to procedure.
Can repeat x1
25mg/kg
Not to exceed 100mg/kg in a 24 hour
period
Chloral Hydrate



Expect a moderate decrease in
heart rate and blood pressure in
patients ASA I-II
For infants < 6 months there is ↑
risk for apnea and hypoxia.
Age a limiting factor. High failure
rate in children > 4 years.
Pentobarbital : Nembutal®
Barbituate- Non elective central nervous system depressants
primarily used as Hypnotic sedative for non painful procedures.
Nembutal


PO/Rectal/IM/IV
Dose for procedural sedation:
4mg/kg , may repeat 2mg/kg, max
100mg
Nembutal: precautions



Rapid IV injection ie, can cause
respiratory depression, apnea,
laryngospasm, bronchospasm and
hypotension
Recommended to infuse IV dose
over 10-30 minutes.
Can significantly decrease cardiac
output and should be avoided with
CHF
Benzodiazepines


Midazolam- Versed®
Lorazepam - Ativan®
Induce anterograde amnesia (not
retrograde)
May have some opioid sparing
effect by ↓ anticipatory pain
response
Midazolam -® Versed




Most commonly used Benzo for
preoperative and pre-procedural sedation.
Undergoes hepatic metabolism and renal
excretion and prolonged effects seen with
dysfunction of either system
Sedative, amnestic and anxiolytic with no
analgesic properties
Commonly used with an opioid analgesic
such as Fentanly®
Versed®
Onset in 1 to 2 minutes
 Duration 30 min
 Caution for respiratory depression
and hypotension

Dosage for children
having procedures:
PO; 0.5 mg/kg/dose may
repeat once with
0.25mg/kg/dose. Max dose:
20mg.
IV: 0.05-0.1 mg/kg dose.
May repeat over several minutes
to a max dose of 0.1-0.2 mg/kg.
Intranasal: 0.2-0.3
mg/kg. May repeat in 15 min
Adults: 0.5 mg to 2mg slow push
over at least 2 min. Usual dose
needed is 2.5 – 5 mg . > 5mg
generally not needed.
Fentanyl- Sublimaze®






Used in combination with Versed for
many years due to rapid onset and
effectiveness
Synthetic opioid
Metabolized by the liver
Short duration of effect
Pure analgesic (should not be
used alone)
Least histamine release of opiates
Caution:
Chest rigidity with rapid infusion and
hypotension
Fentanyl

Dosage for Pediatrics:
-IM or IV 0.5-1.0 mcg/kg/dose
-onset 1-2 min
-lasts 30 minutes
Etomidate
Classified as a General Anesthetic
Ultra short acting nonbarbiturate
hypnotic used for the induction of Anesthesia
Used for Sedation in Adults
0.2mg/kg IV given over 30-60 seconds
Onset <1minutes Duration 3-5 minutes
Limited data, Action too short for some procedures
Ketamine-Ketalar®
Classified as a general anesthetic
 Rapid acting dissociative anesthetic
that produces a profound analgesic
effect
 Gaining favor in children due to
reliable effects and strong safety
profile

Ketamine
When patients are on ketamine they
may appear awake. Eyes may remain
open, they may have nystagmus.
Ketamine is a potent phencyclidine
deriviative
Produces potent analgesia and rapid
sedation while it preserves
respiratory drive and airway protective
reflexes
Ketamine
IV 1-2 mg/kg/dose
-Onset is 1 minute
-Duration 10-20 minutes

IM 2-4 mg
-onset 5 minutes
-duration 15-45 minutes

Ketamine Caution:
Nystagmus can occur along
with hypersecretions, agitation
Delirium, vomiting , myoclonus
and laryngospasm
PropofolClassified as a general anesthetic
-Lower doses
sedation
hypnosis
 Anmestic, anxiolytic, antiemetic, and
antiepileptic properties
 No Analgesic effects

Propofol
Dosing 2.5 -3.5 mg/kg/ dose over 2030 seconds
 Onset 10-30 seconds
 Duration 10-20 minutes
 For prolonged procedures may
require continuous infusion 125300mcg/kg/minute. (smaller children
may require smaller infusion rates.

Propofol Caution
Profound Respiratory Depression
 Profound Irreversible bradycardia
 Profound Hypotension


Avoid with Soy or Egg allergies