Paediatric Clinical Guideline
Emergency 1.2
Sedation for scans
Short Title:
Sedation for scans and painless procedures
Full Title:
Guideline for sedation for scans and painful procedures in children and
young people
Date of production/Last revision:
June 2008
Explicit definition of patient group
to which it applies:
This guideline applies to all children and young people under the age of 19
years.
Name of contact author
Drusilla Ferdinand, Paediatric SpR
Dr Damian Wood, Consultant Paediatrician
Ext: 64041
Revision Date
June 2011
This guideline has been registered with the Trust. However, clinical guidelines are 'guidelines' only. The interpretation
and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a
senior colleague or expert. Caution is advised when using guidelines after the review date.
Sedation for scans and painless procedures
Scope of guideline
This guideline is for the sedation of paediatric patients undergoing painless diagnostic or
therapeutic procedures. For these procedures sedation is aimed to reduce fear, anxiety or
stress and induce drowsiness.
This guideline will outline the four steps used to sedate a child for a painless procedure.
Contra-indications to sedation
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Abnormal airway
Severe respiratory disease
Respiratory failure
Raised intracranial pressure
Depressed conscious level
Cardiac failure
Neuromuscular disease
Impaired bulbar reflexes
Bowel obstruction
Allergy to sedative drug / previous adverse reaction
Behavioural problems
Refusal by parent / guardian / child
Significant risk of aspiration including significant cerebral palsy and gastrooesophageal reflux
Situation where caution may be required
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Paediatric Clinical Guideline
Emergency 1.2
Sedation for scans
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Neonates, especially premature or ex-premature
o
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Renal impairment
o
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There will be reduced clearance of drugs so a lower dose may need to be
considered
Hepatic impairment
o
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Those born prematurely or less than 3 months of age should be observed for
4-6 hours post sedation and have tolerated at least one good feed
There may be a prolonged duration of action due to impaired metabolism so
a lower dose may need to be considered
Anticonvulsant therapy
o
o
Sedative drugs may act synergistically to produce profound sedation
Some children will be resistant to conventional doses due to hepatic enzyme
induction
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Gastro-oesophageal reflux
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Children receiving opioids, other sedatives or drugs which potentiate the action of
sedatives e.g. macrolide antibiotics
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Distressed child
Preparation
Consent
Written, informed consent is required prior to the procedure. This should be obtained by a
person who is able to prescribe and give the sedation.
Parents should be informed of the possible side effects of sedation, including respiratory
depression and the need for ventilatory support.
They should be informed that;
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sedation may fail and the procedure may need to be abandoned
the child may require a general anaesthetic at a future date
the effects of the sedating agents may continue for several hours and sometime to
the next day
The nurse must ensure that the patient is compatible with the MRI scanner before giving the
sedation.
The parent / carer must accompany the child to MRI to fill in the safety questionnaire with the
radiographer.
Equipment
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Paediatric Clinical Guideline
Emergency 1.2
Sedation for scans
The following equipment should be available with the patient and through transfers:
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Oxygen with appropriate tubing and mask
Suction with appropriate tubing, Yankaur suction and suction catheters
Pulse oximeter
Bag and mask and oral airways
The following equipment should be available in the department:
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Emergency trolley including airway support and resuscitation drugs
Other equipment to consider:
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ECG monitor
Non-invasive blood pressure monitor
Thermometer
Reversal agents for benzodiazepines (Flumazenil) if appropriate
Fasting
Sedation of children can lead to vomiting which increases the risk of aspiration. The
procedure may also lead to the requirement of general anaesthesia. Therefore patients
should be starved as for a general anaesthetic. A longer time is required for food due to the
unpredictable clearance from the stomach. Unlimited clear fluids can be given up to 2 hours
prior to sedation. These are reliably cleared from the stomach in a short time. Examples of
clear fluids are water and dilute squash. Orange juice is NOT a clear liquid.
The decision to override the fasting guidelines should be undertaken by a doctor and be
documented in the notes.
Food – including cow’s milk and formula milk
Breast milk
Clear fluids
6 hours
4 hours
2 hours
Personnel
Two nurses or one nurse plus another professional who is competent and up to date with
Basic Life Support should be present throughout transfers between departments and one
nurse should remain present throughout the procedure.
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Paediatric Clinical Guideline
Emergency 1.2
Sedation for scans
2. Sedation
Many painless procedures can be accomplished without pharmacological intervention if there
are child-friendly facilities, good preparation of the child and family and a cooperative child.
Babies under 3 months should ideally not require pharmacological sedation. They should be
given a feed and wrapped well in a warm, quiet environment to promote sleep. This is an
exception to the fasting guidelines.
Babies, however, usually require sedation for MRI scans. The MRI scanners are very loud
and the examinations frequently lengthy (30 minutes or more). “Feed and swaddle “is
therefore rarely successful. This should be discussed with the radiologist and the consultant
responsible for the child.
If using sedation agents give these when the nurse caring for the patient is directly instructed
to do so by the radiographer in charge of the scanner, the superintendant radiographer or the
MRI sedation nurse (usually 20 minutes prior to the procedure) and monitor the child in a
quiet environment.
3 months – 1 year
Choral hydrate 50 -100mg/kg orally
Choral hydrate 75 -100mg/kg orally
1-3 years
Maximum dose = 2 grams
Quinalbarbitone 7.5 - 10mg/kg
4-5 years
Maximum dose = 200mg
Please prescribe maximum doses unless medical reason to give lower dose.
If this is unsuccessful after 30 minutes assess the patient. If the child is wide awake and there
are no signs of drowsiness or agitation, give rectal Paraldehyde 0.3ml/kg with equal volume of
olive oil (0.6ml/kg of the ready mixed solution). Maximum dose is 10ml (20ml). This should be
prescribed before the child is transferred. If the child is agitated or restless at 30 minutes,
withhold the paraldehyde for a further 10-20 minutes. If after this the child is not sedated, give
rectal paraldehyde.
If an older child requires sedation their case should be discussed with ambulatory care and
the consultant responsible for the child.
Children over 5 years old do not remain sedated well during MRI scans. They should be
considered for an MRI under general anaesthesia.
If the above has failed on previous occasions then sedation using Midazolam can be
considered. This should be discussed with and ideally supervised by and appropriate
paediatric anaesthetist. However, general anaesthesia is preferable and safer. If Midazolam is
used then appropriate reversal agents (such as Flumazenil) should be to hand.
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Paediatric Clinical Guideline
Emergency 1.2
Sedation for scans
Chloral Hydrate
Contra-indications:
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severe cardiac disease
marked hepatic or renal impairment
gastritis
Cautions:
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Respiratory insufficiency
Avoid contact with skin and mucous membranes
Side effects:
 gastric irritation
 abdominal distension
 flatulence
 drowsiness
 headache
 ataxia
 confusion
 excitement
Administration:
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It is corrosive to mucous membranes unless well diluted with water. It has an
unpleasant taste which can be disguised with sweet juice. Using a syringe may aid
administration.
Quinalbarbitone
Cautions:
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respiratory disease
renal disease
hepatic impairment
Side effects:
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Hangover with drowsiness
Dizziness
Ataxia
respiratory depression
hypersensitivity reactions
Administration:
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Mix with water. Capsules can be opened.
Paraldehyde
Contra-indications:
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Paediatric Clinical Guideline
Emergency 1.2
Sedation for scans
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gastric disorders
Cautions:
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bronchopulmonary disease
hepatic impairment
Side effects:
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drowsiness (increased if barbiturates or other sedatives have been given)
rectal irritation can occur
Administration:
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Mix with an equal volume of olive oil. Give immediately if using a plastic syringe as it
destroys plastic with prolonged contact.
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Paraldehyde decomposes easily. Do not use if it has a brownish colour or odour of
acetic acid.
Note
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Some children become disinhibited by sedative agents and become restless and
unmanageable. It is important to recognise this and avoid additional sedative doses
as this can worsen restlessness or result in deep sedation. If the child becomes
disinhibited consider re-scheduling the procedure with alternative sedation or general
anaesthesia.
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The effects of sedation can last several hours and sometimes until the next day.
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These agents have a sedative effect. They are not analgesics.
3. Monitoring
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Continuous monitoring of the child by a trained member of staff should commence
when the sedation is administrated until the recovery criteria are met (see below).
A pulse oximeter should be attached when sedation is commenced.
Regular measurement of heart rate, respiratory rate, oxygen saturations and
temperature should be noted.
4. Procedure
The child should be transferred between departments with the relevant personnel. The
portering department must not be involved.
5. Post-procedure care
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Paediatric Clinical Guideline
Emergency 1.2
Sedation for scans
The child should be transferred to a recovery area post procedure until the following criteria
are met:
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Airway patent and stable without support
Easily rousable with normal responsiveness for age and mental status
Oxygen saturation 95% or above in air
Haemodynamically stable
Adequate hydration and urine output
No nausea or vomiting (has eaten / drunk)
No pain
If these criteria are not met then the child may need continued observation overnight on a
ward.
On discharge the family should be given contact information to use if there are concerns in
the 24 hours following sedation.
Contact information
Department
CT1
Name
Extension
Number
Sr Jean Crofts
61020 / 61021
Alison Fenwick
CT2 +3
Superintendant Radiographer
SN Sue Nowak
MRI
62219
Annie Martin
Andrew
Cooper
66750 / 64927
–
Superintendant 62230
MRI
Radiographer
63067
Ambulatory Care
Unit
Sr Louise Richardson
66147 / 66936
Drusilla Ferdinand
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June 2008