The depth and type of sedation required in children depends on the procedure to be carried out. With the exception of procedures expected to cause pain most procedures in the Paediatric Emergency Department will not require pharmacological agents.

Painful procedures preformed for children in the ED are usually done with Ketamine Sedation for which there is a separate pathway – Ketamine Sedation

 

Minimal and Moderate Sedation

Minimal – Drug induced calm, the patient is awake and responds to verbal commands but may have impairment of cognition and coordination.

Moderate – Drug induced depression of consciousness but patients respond purposefully to verbal commands or tactile stimulation.

Prior to consideration of drugs for painless procedures please consider consider alternative strategies. There are playspecialists at both sites between 8am and 8pm most days! If play therapists aren’t available consider the use of favourite songs, distraction toys, and of course the modern day all-in-one fix of a phone/tablet with the child’s favourite show!

The help of an experienced nurse and capable parent cannot be underestimated. You should consider the use of intranasal fentanyl (see guideline) on presentation for more painful conditions, as well as paracetamol and ibuprofen.

You might diminish the pain on infiltration of (warmed) local anaesthetics by injecting slowly and using a fine gauge needle. If oral sedation is to be considered oral Chloral Hydrate or Buccal Midazolam should be considered, neither of these require cannulation.

Who can preform minimal/moderate sedation?

• Senior medical staff (ST3+) with paediatric life support training
• Must have done at least 6 months of anaesthetics/ICU
• Familiar with giving medication of choice
• Must have at least 2 staff members – someone to perform sedation, someone to monitor the patient
• Department must be safe – Senior ED Clinician in charge (Consultant or Senior Registrar when Consultant not present in department has final say over if it is appropriate to perform at any given time

Benzodiazepine and chloral both have very variable effects in children and careful consideration of an alternative plan should be made. Can imaging be delayed until a play-therapist is present? Could they be bought into PAU for their imaging requirements? Can a specialist attend to clean and suture a wound under ketamine instead of just cleaning the wound and dressing?

Contraindications

Any of the following comorbidities / contraindications require discussion with an anaesthetist / senior paediatrician:

• Abnormal airway – including large tonsils or craniofacial anomalies e.g. receding jaw, stiff neck, restricted mouth opening, very large head
• Raised intra cranial pressure or depressed conscious level
• History of obstructive sleep apnoea
• Major organ dysfunction including congenital cardiac anomalies
• Moderate to severe gastro oesophageal reflux disease
• Neuromuscular disorders
• Bowel obstruction
• Intercurrent respiratory tract infection
• Known allergy to sedative drug / previous adverse reaction
• Multiple trauma
• Refusal by parent / guardian / child
• Corrected age < 1 year because of severe prematurity
• ASA 3 or more

Fasting

• For an emergency procedure in a child or young person who has not fasted, balance the risks and benefits of the decision to proceed with sedation before fasting criteria are achieved, on the urgency of the procedure and the target depth of sedation. Consider discussing this child with an anaesthetist.
• Apply the 2-4-6 fasting rule for sedation in the ED unless child in significant distress and all other distraction and environmental alterations have been attempted.
  • 2 hours for clear fluids
  • 4 hours for breast milk
  • 6 hours for solids and formula milk

Medications

Chloral Hydrate

Oral – give 45-60 minutes before procedure, it has an unpleasant taste but can be mixed with blackcurrant squash

Dose: –

Minimal Sedation: 30-50 mg/kg Maximum 1g

Moderate Sedation: 100mg/kg Maximum 2g

Side Effects

Gastric irritation including nausea and vomiting reported.

Beware cardiac arrhythmias and respiratory depression with loss of airway reflexes at high doses.

There is NO reversal agent available

Buccal Midazolam

Buccal: Give 15 minutes pre-procedure and give half the dose into each side of the mouth

Dose: –

1-9 years:  0.2mg – 0.3mg/kg; Maximum 5mg

10-18 years:  6mg – 7mg; Maximum 8mg if 70kg or over

Side Effects

Short acting benzodiazepine causing sedation, hypnosis, anxiolysis, anterograde amnesia

Beware respiratory depression / hypotension / loss of airway reflexes at high doses.

Can lead to a distressing paradoxical excitement in children

Reversal agent: Flumazenil

Flumazenil dose: 10 microgram/kg [Max 200 microgram], repeat at 1 minute intervals up to 5 times.

 

Post sedation care

• Observe for 1-2 hours until:

• • Conscious and responding appropriately
  • Able to walk unassisted (older children)
  • Vital signs are within normal limits
  • Respiratory status not compromised
  • Pain and discomfort addressed
• Supervise child closely for 24 hours no driving for older children
• Give advice leaflet to parents/carer
• Ensure that sedation documented on EPR and drugs are signed for in CD book

Full trust policy is available on intranet here