What are the dosing guidelines for pediatric procedural sedation and analgesia (PSA)?

Updated: Sep 21, 2020
  • Author: Alma N Juels, MD; Chief Editor: Erik D Schraga, MD  more...
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Answer

Answer

  Table 2. Commonly Used Drugs for Procedural Sedation and Analgesia in Pediatric Patients (Open Table in a new window)

Drug

Pediatric Dose

Comments

Midazolam

Intravenous: 0.05-0.1 mg/kg IV 3 min before procedure; not to exceed a total cumulative dose of 0.4 mg/kg or 6 mg

Intramuscular: 0.1-0.2 mg/kg IM 30-45 min before procedure

Oral: 0.25-0.5 mg/kg PO 30-45 min before procedure

Intranasal: 0.2-0.6 mg/kg/dose inhaled intranasally 10 min before procedure

Rectal: 0.3-0.5 mg/kg/dose PR 30-45 min before procedure

Reduce dose by 30-50% if combined with opioid analgesic (eg, fentanyl); younger children (ie, < 5 y) may require higher doses up to 0.6 mg/kg/dose

Dexmedetomidine

(precedex) 

1mcg/kg and/or infusion  0.2-1mcg/kg/h,

IM 1-4mcg/kg  

 Intranasal 1-2 mcg/kg

Good sedation without taking away respiratory drive, short acting

Can cause severe bradycardia

Methohexital

25 mg/kg/dose PR 15 min before procedure; not to exceed 500 mg/dose

Ultra–short-acting barbiturate providing good immobilization and hypnosis; paradoxical excitation may occur; no reversal agent exists

Fentanyl

1 mcg/kg/dose IV; if needed, may repeat by 1-mcg/kg increments; not to exceed total cumulative dose of 4 mcg/kg

Provides analgesia for painful procedures; increased risk of respiratory depression when combined with sedatives (reduce sedative dose); chest wall rigidity associated with rapid IV push

Ketamine

Intravenous: 1-2 mg/kg loading dose IV; 0.25-1 mg/kg IV q10-15min; administer slowly, not to exceed 0.5 mg/kg/min

Intramuscular: 2-5 mg/kg/dose IM

Oral: 6-10 mg/kg/dose PO mixed in cola or other beverage 30 min before procedure

Provides excellent sedation and analgesia; elicits dissociative state; increases bronchial and salivary secretions; increases heart rate, blood pressure, and intracranial pressure; emergence hallucinations observed in older children (>15 years) and adults; pharmacologic effects NOT reversible

Propofol

Data limited: 1-1.5 mg/kg IV loading dose; 0.25-0.5 mg/kg IV q3-5min or 50-150 mcg/kg/min continuous IV infusion

Provides rapid anesthesia; apnea occurs upon induction and unpredictably causes loss of airway reflexes (even at sedative doses); irritation and burning with IV administration; effect NOT reversible

Chloral hydrate

25-75 mg/kg/dose PO/PR; not to exceed 1 g/dose (infants) or 2 g/dose (children); administer 30 min before procedure

No longer recommended, see comments

 

No longer recommended since much safer and more effective alternatives exist; unpredictable effect; paradoxical hyperactivity may occur; may cause nausea and vomiting; decrease dose if combined with opioid analgesic (eg, fentanyl); deaths and permanent neurologic injury from respiratory compromise have been reported, particularly in those with risk factors (eg, ASA class III, Leigh encephalopathy, tonsillar and adenoidal hypertrophy, obstructive sleep apnea); active metabolite has prolonged half-life