Procedural sedation guideline
Aim:
The aim of the Procedural Sedation Guideline is to provide medical and nursing staff outside of theatre, ICU
and ED with a guide for achieving safe sedation of patients in the clinical area.
This guideline outlines Procedural sedation involving single oral agent, administration of nitrous oxide and
intravenous midazolam.
Deep sedation should only be used in designated areas such as Theatres and ICU's; whereby the patient can
remain in that location for the full duration of the sedation period under direct supervision.
Key principles:
The key principles of procedural sedation to consider are:
Benefit risk ratio:
 The benefits of using procedural sedation should at all times outweigh the risks.
 The use of procedural sedation should be less distressing than the procedure performed without it.
Define need vs. availability:
 Appropriately define patients whom minimal to moderate sedation is indicated for the procedure.
 Adequate appropriately competent/accredited staff are available to administer the sedation agent
and monitor the patient
Consult/ Refer/ Recruit help:
 Clinician's should utilise resources such as consulting a peer or expert colleague before proceeding, if
they are uncertain of the appropriateness of the staff, the patient or the equipment for the proposed
sedation.
Additional measures for analgesia/ anxiolysis:
 Appropriate non pharmacological techniques such as distraction or diversion activities or involvement
of an Educational Play Therapist should be an integral part of the process.
 Appropriate local anaesthesia or other analgesia should be used for procedures whether or not a
sedation agent is used.
Indications
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Lumbar puncture
Plaster care
Electrophysiological studies
Wound dressing care
Diagnostic radiology,
Venepuncture
Intercostal /drain catheter
Skin biopsy
Nasogastric or catheter.
Pin care
Procedure duration <45 minutes
Exclusion Criteria:
Nitrous oxide:
 Bowel obstruction
 Pneumothorax
 Middle ear disease
 Decompression sickness
Use of other drugs:
 Allergies to specific drugs to be considered and risk of failure or increased sedation to be considered
in case of >1 drug use.
 Intoxication
 Other factors for specific drugs – ketamine and head injury etc.
Risk assessment criteria
The purpose of the risk assessment criteria is to assist clinicians to identify conditions, disease groups or agents
that may result in an adverse event such as loss of airway, drug interaction, prolonged sedation or agitation.
 Significant risk of airway compromise leading to obstruction – airway assessment
 Airway infection; increased risk of bronchospasm or laryngospasm
 Increased risk of hypoventilation
 Increased risk of aspiration
 Increased risk of cardiovascular compromise
 Immunosuppression: (nitrous oxide can interfere with Folate and B12 metabolism)
 Severity of illness
 History of sedation failure including adverse event
 Patients < 6 months
 Patient < 2 years for nitrous oxide or IV midazolam
Patient assessment
A thorough patient assessment should be completed prior to a sedation agent being used. This includes:
 AMPLE
 previous sedation experiences and drugs used (including if the child has had a previous reaction to
standard doses of sedation drugs)
 physical examination including:
o current weight
o baseline vital signs (Heart Rate (HR), Respiratory Rate (RR), Oxygen Saturation (Spo2), NonInvasive Blood Pressure (NIBP), Glascow Coma Scale (GCS), and UMSS sedation score
Preparation for administering sedation – CIF SPEND
Consent
 Consent should be obtained prior to the procedure as per local guidelines
 Informed consent for the procedural sedation agent must be obtained by a staff member who has an
understanding of the sedation agent and can explain to the patient/ parent/carer the indications for
its use and possible risks involved.
Time Out" or "Positive Patient Identification"
Fasting
Recommended minimum fasting times for Procedural Sedation are consistent with current clinical practice in
Australian paediatric centres and College of Physician Guidelines.
 For ward patients and outpatients fasting times are:
o Oral agents: 2 hours solids and liquids including breastfeeding
o Nitrous oxide 2 hours solids and liquids including breastfeeding
o IV midazolam: 6 hours solids, 4 hours breastfeed, 2 hours clear fluid
NB: specialised areas such as the Emergency Department, Intensive Care Unit and Department of Anaesthesia
have variation to the fasting guidelines this is based on the specific clinical environment and expertise.
Environment
To minimise procedural anxiety:
 Appropriate lighting and minimal noise.
 Prepare the venue and all necessary equipment (keeping needles out of sight) before the patient
enters.
 Assess department and communicate isolation from other responsibilities until completion of
procedures. Delegate responsibilities.
Child and parent
 Optimising the parent's role reduces the child's anxiety during the procedure; staff should be sensitive
to parents who are not able to provide this support. Children usually cope better with the parent(s) or
guardian present, for adolescents discuss if a parent's presence is preferred. 1
 Non-pharmacological techniques should be planned and employed during procedures to complement
and sometimes prevent the need for sedation agent.
Equipment
In any circumstance where a patient may be sedated the following equipment must be available, turned on
and functioning:
 Standard hospital resuscitation trolley with all age-appropriate equipment
 Functional suction apparatus with attachment.
 Saturation oximeter and blood pressure monitoring equipment.
 An emergency call system to summon additional help if required
 A room and appropriate size bed or trolley to monitor and recover the child appropriately.
Staffing
 Staffing requirements are:
o For oral agents: 2 staff required, 1 competent RN or medical staff member
o For nitrous oxide: 2 staff required, 1 accredited to administer the agent
o For IV agents: 2 staff required, 1 accredited to administer the agent
Procedural sedation agents
 Patient's should not receive sedative drugs prior to arrival at hospital.
 Sedated patients should not be placed in corridor or waiting room areas.
 Sedation drug (s) should be documented on Medication Chart MR52.
o Midazolam
o Chloral Hydrate
o Nitrous oxide
Agent
Pharmacokinetics
Nitrous
oxide (N2O)
Onset : 20 seconds
Peak effect: 3 -5
minutes.
Nitrous oxide has low
blood solubility thus
rapid clearance with
exhalation.
Rapid fall in arterial
concentration once
inhalation stops.
Low fat solubility - does
not significantly
accumulate within the
body.
Complete recovery
usually in approximately
5 minutes.
Midazolam
Short acting
Anxiolytic/sedative
Central nervous system
depressant
No analgesic properties
Oral
Absorption is rapid, but
erratic
Max effect within 15- 60
mins
Duration up to 2 hrs
Nasal
Administration
technique is important.
Common Side
Effects/Adverse
Reactions
Dizziness or lightheadedness
Mild nausea
Vomiting
Adverse reactions:
Expansion of closed
gas filed space.
Respiratory
depression
Apnoea
Pulmonary aspiration
of gastric contents if
protective airway
reflexes impaired
Folate metabolism
and vitamin B12
suppression
Cardiac depression
Apnoea and
respiratory depression
"Paradoxical reaction"
(agitation secondary
to benzodiazepines)
Emergence delirium
Midazolam will
potentate the effects
of other sedative
drugs eg. opioids.
Dose Range
Reversal Agents
N2O delivery
range: a maximum
of 70% N2O and
30% O2.
Maximum dose
70%, less if opioids
are being used.
No reversal agent.
Give 100% O2, full
recovery in
approximately 5
minutes.
Oral
0.5 mg/kg (to
maximum of 15
mg)
Give dose 20 -30
min prior to
treatment.
Nasal
0.2-0.4 mg/kg (to
maximum of 10
mg)
Use 5 mg/mL
midazolam for
injection
Flumazenil
Give 5mcg/ kg every
60 seconds to a
maximum total of 40
mcg/ kg.
Adult dose: 300-600
mcg.
NOT required at
time of
administration,
available on PICU
Resuscitation
Trolley.
Drop dose into
alternating nostrils over
15 secs.
Absorption is rapid
Maximal effect in 10
mins
Duration up to 2 hrs
May be irritating and
should only be used if a
rapid effect is required.
Intravenous
Onset of action 1-5 mins
For the purpose of
procedural sedation,
titrate the dose until
desired level of sedation
achieved.
Chloral
Hydrate
Sedative/Hypnotic
Unpredictable onset
Long duration
Hyperactivity occurs
in 1-2% of patients
Liver failure (rare).
Respiratory
depression is less
common compared
with other sedatives.
Intra-nasal
delivery stings and
should preferably
not be used
Intravenous
0.15mg/kg(
maximum of
7.5mg) diluted in
10mls of Normal
Saline
Give bolus of 0.010.02 mg/kg every
2-3 minutes until
adequate level of
sedation is
achieved
DO NOT exceed
maximum dose.
Oral / Rectal
50 mg/kg (to
maximum of 2g) as
a single dose.
No reversal agent.
Sedation procedure
Prior to the sedation
 Document baseline vital signs immediately prior to commencement including:
o HR
o RR
o NIBP (for intravenous agents)
o SPO2
o GCS
o UMSS sedation score
During sedation period
 Patient must remain in the Line of sight (hyperlink to definition of terms) of a competent clinician
(oral agents) or accredited staff member during the procedure for nitrous oxide and IV agents.
 Continuous pulse oximetry is required during the procedure and if the sedation score is > 1.
 If sedation score is equal to > 2: Observe and record vital signs every 5 minutes.
Post sedation period
 Place child in the "recovery" position.
 The 'Sedation Period" is considered over when the patient meets the following criteria:
o return to baseline sedation score and vital signs are within normal limits for the patient
o easily rousable and have intact protective airway reflex
o can talk if developmentally appropriate
NB: If the patient has not met these criteria continue to reassess and monitor the child in "recovery" lateral
position and keep nil orally.
Transport
It is recommended that patient's who require transportation during the 'sedation period ':
 Are accompanied by a competent or accredited clinician
 Are placed in the "recovery" lateral position
 Require continuous oxygen saturation monitoring
 Require suction, oxygen and an appropriate sized bag and mask available at all times during
transportation
Documentation
 Complete "Record of Sedation for Procedures" (MR56S).
 Medications( including nitrous oxide) must be prescribed on the patient's Hospital Medication Chart
(MR52)
 Docuement observations on MR 77 or MR52B.
 Procedure summary: a summary of the procedure including:
o Procedure event with reference to the equipment, number of attempts, and procedure
assessment.
o Recommendations for future interventions
o Parental consent for both the intervention and pharmacological agents used.
Additional discharge criteria for outpatient
Discharge home may be considered (provided other medical factors permit) when the patient meets the
following discharge criteria:
 The patient can sit up unaided / walk ( developmentally appropriate)
 The patient has returned to pre sedation observations (both vital signs and level of sedation)
 A responsible adult is present to accompany the patient home (for all ages)
 Post sedation care has been discussed with parents/guardians. Safety and injury prevention must be
highlighted.
Occupational health concerns
 Prolonged and repetitive exposure to N2O can suppress liver enzymes involved with vitamin B12 and
folate metabolism and inactivate vitamin B12. Occupational exposure can be kept to a minimum by
ensuring a suitable scavenging system is used and a consistent and adequate mask seal to the
patient's face is maintained. The scavenging system should be connected directly to piped wall
suction only (never portable) and turned to a medium flow.
 Pregnancy and nitrous oxide: Exposure to nitrous oxide should be avoided during pregnancy. It is
recommended that exposure to nitrous oxide not occur in the first trimester of pregnancy. Occasional
brief exposure later in pregnancy is considered 'low risk'
Repeated exposure should be avoided in the 2nd and 3rd trimesters.