Paediatric Sedation

1. Painless imaging e.g. MRI
• Typically patient needs to be still enough to ensure adequate image quality
• This may necessitate a GA


2. Painful procedures e.g. suturing of lacerations, manipulation of fractures
• Local anaesthetics should be used where possible
• Patients may additionally need conscious sedation
• Ketamine, with sedative and analgesic properties, may be appropriate


3. GI endoscopy
• E.g. colonoscopy is typically not painful, but may be so if there is distension of the colon


4. Dental procedures
• Local anaesthetics should be used

• Full history and examination, including:
• Psychological and developmental status
• Current surgical and medical problems
• Previous experiences with sedation/anaesthesia
• Airway abnormalities
• Conscious sedation is unlikely to be successful in small children and infants
• Patient and parents should be informed and consented as standard, including providing written information

• Fasting generally not required for minimal sedation or that involving only nitrous oxide
• Standard fasting rules apply for those undergoing conscious sedation

• Patients may benefit from preparation, which may take the form of:
• Written information
• Verbal explanation
• Reassurance from parents/carers

• As standard for adult sedation; NIBP, ECG, SpO₂ and capnography
• Should be continued until no risk of further reduced level of consciousness
• IV access may not be necessary for some modalities of sedation e.g. nitrous oxide, chloral hydrate, IM ketamine

• Suitable for patients <15kg (∽2.5yrs old)
• Typically oral dose of 50mg/kg although can go up to 100mg/kg (max. dose 1g)
• Is metabolised to the active metabolite trichloroethanol, which is presumed to be responsible for its sedative effects
• Causes sleep within 10mins
• Lasts ∽1hr

• ± fentanyl 0.25 - 0.5μg/kg for painful procedures; beware fentanyl may cause respiratory depression as the effect can outlast the duration of pain from the procedure
• Temazepam may be an alternative in older children

• E.g. as Entonox to be self-administered by the patient

• Dissociative sedative effect which typically maintains airway and breathing reflexes


Route	Dose
IV	0.5-1mg/kg ± further 0.5mg/kg
IM	4-5mg/kg ± further 2-4mg/kg
PO	5-10mg/kg



• Onset usually within 20mins
• Recovery usually within 90mins

• Can be used for:
• Pre-operative anxiolysis (IV/intra-nasal)
• Intra-operative procedural sedation (IV)
• Tends to preserve spontaneous ventilation and airway tone, and may allow avoidance of I&V


• Some evidence that dexmedetomidine carries beneficial neurological effects:
• Mimics natural sleep
• Less neurotoxic than other anaesthetic drugs
• Confers a degree of neuroprotection


• Issues include:
• Remains off-license in paediatric patients
• Comparatively more expensive than other sedative agents
• Less familiar to many anaesthetists
• Associated with higher hospital costs and prolonged length of PACU stay (BJA, 2024)


• Clinical side-effects include:
• Bradycardia, although this may just mimic bradycardia which occurs during natural sleep
• Hypotension (dose-dependent during infusion)
• (Rebound) Hypertension, either after a bolus or upon cessation of an infusion
• Tachyphylaxis after 24hrs of infusion
• Not necessarily protective against post-operative agitation or emergence delirium

• The above-linked meta-analysis of needle-free sedation techniques in children <8yrs undergoing MRI found success rates of: