Pediatric Sedation

TABLE – I

Chloral Hydrate in Pediatric sedation

1. Method of Administration.

20 to 75 mg / kg orally or rectally (maximum single dose, 1.0g; if a second dose in given, the maximum total dose in either 100 mg / kg or 2.0 g, whichever is lower).

2. Contraindications
1. Compromised hepatic function.
2. History of obstructive sleep apnea*
3. Previous unfavorable experience with chloral hydrate.
3. Advantages

No specific advantages for sedation and treatment of children with fractures.

 

4. Disadvantages
1. Prolonged time to peak effect (as long as 60 min).
2. Difficult to titrate.
3. Prolonged observation period required.

* Caution is required when using any sedative medication in patients with obstructive sleep apnea.

TABLE – II

Benzidiazepines in Pediatric Sedation

1. Method of Administration.
1. Diazepam: 0.1 to 0.3 mg / kg IV or PO. IM administration should be avoided because it is painful.
2. Midazolam

1.      PO: 0.5 – 0.75 mg / kg.

2.      Nasal: 0.3 – 0.4 mg / kg*

3.      IM: 0.03 – 0.1 mg / kg.

4.      IV: 0.05 – 0.1 mg / kg.

2. Contraindications
1. Previous unfavorable experience with benzodiazepines.
2. (?) Early pregnancy (possible teratogenicity).
3. Altered state of consciousness.
3. Advantages
1. Generally provide excellent sedation and amnesia.

                  B. Reversible if necessary (flumazenil, 10 mg / kg, upto a total dose of 1.0 mg.

4. Disadvantages
1. No analgesic effect.
2. Respiratory depression, especially with parenteral administration.
3. Combination with narcotics may lead to oversadation or respiratory arrest.

* Many children find the intranasal administration of midazolam to be very unpleasant. This    

    method of administering midazolam is not recommended.

TABLE – III

Opioids in Pediatric Sedation

1. Method of Administration.
1. Morphine: 0.05 – 0.1 mg / kg IM or IV.
2. Meperidine: 0.5 – 1.0 mg / kg IM or IV.
3. Fentanyl: In increments of 0.001 mg / kg IV (maximum total dose, 0.004 – 0.005 mg / kg).
4. Nalbuphine: 0.1 mg / kg IM or IV.

    

      Patients younger than 3 months old should be given no more than half of these doses initially. IV titration to desired effect is the ideal way to administer all Sedative medications.

2. Contraindications
1. Altered state of consciousness.
2. Previous unfavorable experience (excludes that medication only).
3. Sedation for non painful procedure.
3. Advantages
1. Provide excellent analgesia.
2. Reversible if necessary (naloxone 0.001 – 0.005 mg / kg IV titrated to effect).
4. Disadvantages
1. Risk of respiratory depression and apnea.
2. Increased risk of respiratory depression and apnea when combined with other sedatives.
3. No amnestic effects.
5. Additional side effects (more likely when used in recurrent doses for treatment of pain).

Nausea, vomiting, pruritus, constipation, decreased gastric motility.

TABLE – IV

Fentanyl and Midazolam in Pediatric Sedation*

1. Method of Administration IV titration to effect.
1. Midazolam: In increments of 0.05 mg / kg to a maximum of 0.1 mg / kg. Wait 5 min between doses.
2. Fentanyl: Begin 5 min after last midazolam dose. Give in increments of 0.001 mg / kg to a maximum of 0.003 mg / kg, wait 2 to 3 min between doses.
2. Contrandications
1. Altered state of consciousness.
2. Previous unfavorable experience with either medication.
3. Specific contraindications to benzodiazepines or opioids (seen Tables 2 and 3).
3. Advantages
1. Provides sedation, amnesia (midazolam), and analgesia (fentanyl).
2. Reversible if necessary (see Tables 2 and 3).
4. Disadvantages
1. Additive respiratory depressant effects.
2. Additive depressant effects on protective airway reflexes with increased risk for regurgitation and aspiration of gastric contents.

* An excellent review of the advantages and problems associated with this drug regimen is provided in Yaster M, Nichols DG, Deshpande JK, Wetzel RC.

Miazolam – fentanyl intravenous sedation in children: case report of respiratory arrest. Pediatrics 1990;86:463-467.

TABLE – V

Ketamine in Pediatric Sedation

1.       Method of Administration and Dosage.

A.     IM: 4 mg / kg.

B.     IV: 1 – 2 mg / kg.

C.     PO: 6 – 10 mg / kg.

D.     Rectal: 5 – 10 mg / kg.

2.       Contraindications

A.     Altered state of consciousness.

B.     Increased intracranial pressure.

C.     Active upper respiratory infections (increased quantity of secretions and possible increased risk of laryngospasm).

D.     Full stomach.

E.      Prior unfavorable experience with ketamine.

F.      Patients older than 16 yrs old (increased incidence of emergence phenomena).

3.       Advantages

A.     Provides Sedation, amnesia, intense analgesia.

B.     Sympathetic-mediated activity may be beneficial for children with asthma.

4.       Disadvantages

A.     Increases production of saliva and tracheobronchial secretions; coadministration of glycopyrrolate 0.01 mg / kg recommended.

B.     Potential for loss of the airway from:

1.      Laryngospasm secondary to increased secretions.

2.      Aspiration from laryngeal incompetence.

3.      Apnea.

C.     Emergence phenomena: Rare in young children. No advantage to quiet  

      environment. Midazolam may help, but may contribute to oversedation.  

TABLE – VI

Dosing Schedules and Formulations for Nonsteroidal Anti-inflammatory Drugs in children.

Agent	Dose	Formulations*
Ibuprofen (oral)	5 -10 mg / kg q6h (pubilished dose is for treatment of fever, not specifically for analgesia).	100 mg / 5 mL suspension Tablets: 200, 300, 400, 600, 800 mg.
Naproxen (oral)	5 – 7.5 mg / kg q12h	125 mg / 5 mL suspension Tablets: 250, 375, 500 mg.
Ketorolac (IM, IV)	0.5 mg / kg q6h	Injectable 30 mg / mL.
Choline Magnesium	50 mg / kg / day	500 mg salicylate / 5 mL solution
Trisalicylate (Trilisate) (oral) @	Divided into 2 or 3 doses (maximum daily dose, 2.25 g)	Tablets: 500, 750, 1000 mg.
Salsalate @ (oral) (Disalcid)	Pediatric dose not published; adult maintenance dose is 2 – 4 g / day.	Tablets: 500, 750 mg.
Acetaminophen $ (oral, rectal)	10 – 15 mg / kg q4 – 6h	80 mg / 0.8 mL drops 80 mg chewable tablets 160 mg / 5 mL solution 325-, 500-mg tablets 120-, 325-, 650-mg suppositories
* An exhaustive listing of available formulations for NSAIDs may be found in AHFS     Drug information 1994. @ Although they are salicylates, choline magnesium trisalicylate, and salsalate do not cross-react with aspirin and may be used in patients allergic to aspirin. As many as 28% of children with asthma may be in this group of patients. Owing to an association with Reye syndrome, salicylates should be avoided in children with flu-like symptoms or chickenpox. $ Acetaminophen is considered a member of this class of medications, even though it mainly acts centrally and it only very weaknly inhibits prostaglandin synthesis. Acetaminophen also does not cross-react with aspirin and may be used in patients allergic to aspirin. Adapted from Nonsteroidal Anti-inflammatory agents. In McEvoy GK, Litvak K, Welsh OH Jr, eds. AHFS Drug Information 1994. Bethesda, MD: American society of Hospital Pharmacists, 1994; Walson PD, Mortensen ME. Pharmacokinetics of common analgesics, anti-inflammatories, and antipyretics in children. Clin Pharmacokinet 1989;17:116-137, with permission.