By Tiffany Tamse
PGY 1
Indications for Pediatric
Procedural Sedation
 LP
 Arthrocentesis
 Suturing
 Wound care
 Abscess I&D
 Fracture reduction
 Dislocation
 Foreign body removal
 Burn debridement
Question 1
 A 12 yo boy presents to the ED with an
uncomplicated forearm fracture. VS: T 37.2,
HR 90, BP 116/72, RR 22, Ht 5’6”, Wt 220lbs.
On physical exam he is holding his arm
close to his chest in flexion and says it is
very painful to move. Ortho decides to set
the fracture and requests procedural
sedation. The ED attending decides to use
ketamine.
. Which of the following is true for
the use of ketamine in this patient?
 A. He has a lower likelihood of developing nausea given
his age and BMI.
 B. He will need co-administration of an analgesic agent
as ketamine does not have analgesic properties.
 C. BP should be monitored closely as hypotension often
occur with ketamine administration.
 D. Ketamine is a non-progressive dissociative anesthetic
and increasing the dose will increase time of sedation
but not the depth of sedation.
Correct Answer
 D. Ketamine is a non-progressive dissociative anesthetic
and increasing the dose will increase time of sedation but
not the depth of sedation.
 Ketamine is dosed 1-2 mg/kg IV or 4-5 mg/kg IM with
a peak onset of 1-2 min IV and 2-5 min IM
 Infusion rate is over 1-2 minutes to reduce the risk for
respiratory depression.
 An additional 0.5-1 mg/kg may be administered for
continued sedation
A. He has a lower likelihood of developing nausea given
his age and BMI.
 Percentage of patients with N/V after ketamine range from
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about 3% to 20%
Studies have shown that BMI > 25 (our patient has a BMI of
35) have an increased likelihood of nausea/vomiting after
use of ketamine
N/V with ketamine administration also peaks around the
age of 12
IM administration and higher doses of ketamine have also
been shown to have increased rated of N/V
Prophylactic Zofran before, during or after the procedure
for our patient would be beneficial.
B. He will need co-administration of an analgesic agent
as ketamine does not have analgesic properties.
 Ketamine dose have analgesic properties in addition to
sedation, anesthesia, and amnesia
 Ketamine is a PCP derivative and can also cause
hallucinations, particularly in older children and adults.
 Midazolam may be used in conjunction with ketamine
to prevent hallucinations.
 Dose: 0.05 mg/kg (max 2 g) over 3 minutes
C. BP should be monitored closely as hypotension often
occur with ketamine administration.
 Ketamine is a sympathomimetic and inhibits
catecholamine uptake:
 Increased HR, BP, CO and coronary perfusion
 May cause transient increase in ICP
 Good for use in patients in shock
 Alternatives should be considered in patients with
cardiac disease, increased ICP, or increased IOP
 Ketamine is also contraindicated in procedures involving
laryngeal stimulation as it exaggerates the protective air
reflexes and can cause laryngospasm.
Question 2
 A 14 yo boy with PMH of Autism with aggressive behavior
presents to the ED with 6 cm laceration extending from
the bottom of the right eye brow to the hairline. Mom says
that he was playing in the park and tripped and fell into a
tree branch sustaining the laceration. Patient lost
consciousness for 30 seconds during the event but is now
back to his baseline up walking and trying to get out of
the room. VS: T 37.6, HR 92, BP 120/76, RR 20. CT is
needed to rule out any head trauma/bleed. And the
patient will need sutures to close the laceration. Sedation
will be needed and the ED attending decided to use
propofol. Which of the following is false about the use of
propofol?
Which of the following is false about the use of
propofol?
 A. Premedication with Lidocaine is injected into the
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vein prior to propofol administration as the injection
of propofol can be painful
B. Sedation with propofol is dose dependent and a
larger dose produces deeper sedation which can
progress to general anesthesia.
C. Hypotension after initial bolus of propofol is
expected and transient .
D. The patient may be cleared for discharge as early as
30 minutes after drip ends.
E. Zofran should be administered before propofol as it
causes a high rate of nausea/vomiting.
Correct Answer
 E. Zofran should be administered before propofol as it
causes a high rate of nausea/vomiting.
 Propofol has antiemetic activity and therefore zofran is
not needed as often as for ketamine·
 Other advantages are the fast onset and short halflife.
A. Propofol can be very painful upon injection and
therefore premedication with lidocaine is very common·
 dose: 0.5mg/kg injected into the vein with a
tourniquet applied for 1 minute
 Ketamine or opioids may also be used prior to propofol
for analgesic effects as propofol does not have any
analgesic effects
 Pain is also less if an antecubital injection site is used
compared to a hand vein
B. Sedation with propofol is dose dependent and a larger
dose produces deeper sedation which can progress to
general anesthesia
 Propofol dosing 0.5-1 mg/kg for the bolus (1-2 mg/kg
for 6mo-12 yr of age) with repeated doses of 0.5-1
mg/kg boluses every 3-5 min (max 3mg/kg)
 Continuous infusion of 25mcg/min titrated up to a
max of 200mcg/min to achieve adequate sedation
 Bolus dosing increased the risk of exceeding desired
level of sedation and has been associated with higher
risk of respiratory depression, bradycardia,
hypotension, or debilitation
C. Hypotension after initial bolus of propofol is expected
and transient .
 Should be used with caution in hemodynamically unstable
patients (depleted intravascular volume) and consider
using an alternate sedation agent
 Other relative contraindications may be patients with
allergy to egg or soybeans, although there is not sufficient
evidence to support this statement
 Other advers effects include respiratory depression and
apnea (total adverse effects with propofol use is 2-5%)
 Prolonged infusions in critically ill patients may cause an
acute bradycardia -> asystole + metabolic acidosis,
rhabdomyolysis, hyperlipidemia or fatty liver.
D. The patient may be cleared for discharge as early as
30 minutes after drip ends.
 Propofol is an ultra short acting soy-based hypnotic
that has lipophillic properties and deposits in the
tissues of neuro lipid membranes to potentiate effects
of GABA and cause rapid sedation
 Effective 10-50 seconds after administration
 T ½ is 9min, making recovery time faster than with
most other anesthetics
 Good for short procedures like CT or other imaging as
random movements under sedation do not occur as
they do with ketamine
Ketofol = Ketamine + Propofol
 Advantages
 Propofol decreases the hallucinations and
nausea/vomiting from ketamine as well as the emergence
phenomenon and helps to produce more stable
hemodynamics
 Ketamine decreases the hypotension from
propofol administration as well as the pain, episodes of
hypoxia (more stable airway) and requires less boluses to
maintain sedation but with similar recovery time
 Dosing:
 1:1 mixed and administered together or ketamine
administered first to decrease pain from propofol
administration
NPO Status Guidelines
 Clears > 2 hours
 Solids
 < 6 months: 4-6 hours
 6-36 months: 6 hourso
 > 36 months: 6-8 hours
*Studies have shown that failure of NPO guidelines may
not increase risk of complications with procedural
sedation .
References
 Up to Date: Selection of medications for pediatric procedural
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sedation outside of the operating room·
Up to Date: Pharmacologic agents for pediatric procedural
sedation outside of the operating room·
Kinder KL, Lehman-Huskamp KL, Gerard JM. Do children with
high body mass indicies have a higher incidence of emesis when
undergoing procedural sedation? Pediatr Emerg Care. 2012
Nov;28(11):1203-5. doi: 10.1097/PEC.0b013e318271be65. ·
Alletag MJ, Aurebach MA, Baum CR. Ketamine, propofol, and
ketofol use for pediatric sedation. Pediatr Emerg Care. 2012
Dec;28(12):1391-5; quiz 1396-8. doi:
10.1097/PEC.0b013e318276fde2 ·
Doctor K, Roback MG, Teach SJ. An update on pediatric hospitalbased sedation. Curr Opin Pediatr. 2013 Jun;25(3):310-6. doi:
10.1097/MOP.0b013e328360bb92