Paeds · clinical-pharmacology-and-therapeutics

Procedural sedation medicines

Also known as Paediatric procedural sedation and analgesia · Ketamine sedation in children · Nitrous oxide for procedures · ED procedural sedation medicines · Dissociative sedation

Fellowship guide to the medicines used for procedural sedation and analgesia in children: matching the agent and the depth to the procedure (ketamine, nitrous oxide, midazolam with an opioid, dexmedetomidine, propofol), the pharmacology that decides each choice, how to set up safely (an independent sedationist, ASA depth, capnography, suction and reversal), the preprocedural fasting question and why fasting should not delay emergency sedation, and how to manage the complications that matter (laryngospasm, hypoventilation, emergence agitation, oversedation), with ANZ, UK, US and Canada guidance.

high12 referencesUpdated 17 July 202622 min readVerification in progress

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Red flags

Sedating a child for a painful procedure with a benzodiazepine alone and no analgesic, so the child is paralysed by the stimulus but cannot escape the painGiving a midazolam and opioid together without a dedicated observer, then being surprised by apnoea from their synergistic respiratory depressionUsing pulse oximetry alone and missing hypoventilation, because supplemental oxygen masks desaturation until the child is dangerously hypercapnicDelaying an urgent painful procedure for a fasting window when the PSA evidence shows fasting does not reduce adverse events in the emergency settingProceeding without an independent sedationist whose only job is the airway, because the proceduralist cannot watch the drug and the wound at onceDischarging before the child returns to baseline arousal, protects the airway, and can tolerate oral intake

Life stages

neonateinfanttoddlerpreschoolschool-ageadolescent

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General and Community Paediatrics — procedural sedation and analgesia principles and safetyAcute care — medicines used for procedural sedation in childrenAcute care and emergency paediatrics — selecting and dosing procedural sedation agentsPatient safety — monitoring, fasting, and rescue during procedural sedationPharmacology of ketamine, nitrous oxide, midazolam, dexmedetomidine and propofol for sedationPreprocedural assessment, monitoring including capnography, and discharge criteriaShort case and structured discussion of a child needing fracture reduction or wound repair under sedationDiscussion of a sedation adverse event and its preventionPatient safety and quality improvement: safe sedation and monitoringPharmacology — sedative and analgesic medicines in childrenFoundation of Practice (FOP) — pharmacology of sedation agentsApplied Knowledge in Practice (AKP) — procedural sedation safety and adverse eventsCommunication scenarios — explaining sedation, fasting and risk to a familyHistory taking and management — a child for a painful procedureGeneral Pediatrics Content Outline — sedation pharmacology and safetySystems-based practice — sedation protocols, monitoring and rescuePatient Care — procedural sedation with appropriate monitoring and rescueSystems-Based Practice — sedation safety systems and team rolesMedical Knowledge — pharmacology and adverse effects of sedation agentsMedical Expert — pharmacology and safe conduct of procedural sedation in childrenCollaborator — sedation team roles and the independent sedationistPatient Safety — monitoring, fasting and rescue

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Target exams

RACP General PaediatricsRACP DWERACP DCERCPCH Progress+MRCPCH TheoryMRCPCH ClinicalABP General PediatricsACGME PediatricsRCPSC Pediatrics

Red flags

Life stages

neonateinfanttoddlerpreschoolschool-ageadolescent

Care settings

outpatientwarded-acutenicupicuretrieval

Clinical exam formats

written-only

Board mappings

The fellowship answer

Match the drug and the depth to the procedure, keep one person whose only job is the airway, and never reach for a sedative when what the child needs is analgesia. Procedural sedation and analgesia is a drug-induced state that lets a child tolerate a noxious procedure while protective reflexes and a safe airway are preserved. Ketamine is the workhorse for painful emergency procedures because its NMDA antagonism gives dissociative sedation with preserved airway reflexes and stable circulation, nitrous oxide and dexmedetomidine fill the lighter and the respiratory-sparing niches, and the midazolam-with-opioid combination buys apnoea at the price of every gain. Safety is not a drug effect but a system: a trained independent sedationist, depth matched to the American Society of Anesthesiologists continuum, continuous capnography that catches hypoventilation before oximetry fails, suction and reversal agents within arm's reach, and a fasting decision based on the evidence that fasting does not reduce adverse events in the emergency setting. [3] [4] [11]

Two ideas that get blurred

Sedation — calming the head

Analgesia — relieving the pain

SOAP-ME — the pre-sedation setup the examiner rewards

Suction (Yankauer working) · Oxygen (flow and mask ready) · Airway equipment (appropriately sized adjuncts and supraglottic device) · Pharmacology (drawn-up sedatives and the reversal agents naloxone and flumazenil) · Monitors (pulse oximetry, ECG, blood pressure and capnography) · Emergency drugs and a person skilled in rescue. If any element is missing, the sedation does not start. [3] [11]

Overview & Definition

A six-year-old lands in the emergency department with an angulated forearm fracture that needs reduction, and the question is not whether to sedate her but which drug, at what depth, watched by whom, and with what ready in case her airway is lost. Procedural sedation and analgesia is the controlled, drug-induced depression of consciousness that lets a child tolerate a painful or anxiety-provoking diagnostic or therapeutic procedure while spontaneous ventilation, protective airway reflexes, and cardiovascular stability are preserved. Done well it converts a frightened, restrained child into one who is safe, still, and unharmed; done badly it is one of the commonest sources of serious, preventable airway harm in children. [1] [2]

The discipline rests on a few principles that hold across every agent. The sedationist and the proceduralist are different people, because the person doing the procedure cannot also watch the drug, the airway, and the monitor. The depth of sedation is chosen for the stimulus, not chosen first with a drug bolted on, and the agent's pharmacology is matched to that depth. Monitoring is continuous and includes capnography, which detects the rising carbon dioxide of hypoventilation long before the oxygen saturation falls. And rescue is planned before the first dose is given, with suction, airway equipment, oxygen, reversal agents, and a clinician skilled in advanced airway management all immediately available. [3] [11]

Procedural sedation medicines are the focus of this page, and they divide cleanly by what they do to the brain. Ketamine and the opioids are analgesics that quiet the noxious stimulus; nitrous oxide gives light sedation with analgesia and a rapid recovery; the benzodiazepines, propofol, and dexmedetomidine are chiefly sedatives that calm awareness and produce amnesia. The choice is a matching exercise between the procedure, desired depth, child's physiology, and the recovery time the setting allows. [5] [12]

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References12Show ledger

[1]Borland M, Esson A, Babl F, Krieser D Procedural sedation in children in the emergency department: a PREDICT study Emerg Med Australas, 2009.PMID 19254316
[2]Schofield S, Schutz J, Babl FE Procedural sedation and analgesia for reduction of distal forearm fractures in the paediatric emergency department: a clinical survey Emerg Med Australas, 2013.PMID 23759045
[3]Green SM, Tsze DS, Roback MG Emergency Department Ketamine Sedation: Frequency and Predictors of Critical and High-Risk Adverse Events Ann Emerg Med, 2025.PMID 40481829
[4]Cosgrove P, Krauss BS, Cravero JP, Fleegler EW Predictors of Laryngospasm During 276,832 Episodes of Pediatric Procedural Sedation Ann Emerg Med, 2022.PMID 35752522
[5]Tobias JD Applications of nitrous oxide for procedural sedation in the pediatric population Pediatr Emerg Care, 2013.PMID 23546436
[6]Roback MG, Bajaj L, Wathen JE, Bothner J Preprocedural fasting and adverse events in procedural sedation and analgesia in a pediatric emergency department: are they related? Ann Emerg Med, 2004.PMID 15520704
[7]Bhatt M, Johnson DW, Taljaard M, Chan J, Barrowman N, Farion KJ Association of Preprocedural Fasting With Outcomes of Emergency Department Sedation in Children JAMA Pediatr, 2018.PMID 29800944
[8]Chumpitazi CE, Camp EA, Bhamidipati DR, Montillo AM, Chantal Caviness A, Mayorquin L Shortened preprocedural fasting in the pediatric emergency department Am J Emerg Med, 2018.PMID 29395760
[9]O'Kane A, Quinney SK, Kinney E, Bergstrom RF, Tillman EM A systematic review of dexmedetomidine pharmacology in pediatric patients Clin Transl Sci, 2024.PMID 39644147
[10]Li HP, Liu KP, Yao L Dexmedetomidine in combination with ketamine for pediatric procedural sedation or premedication: A meta-analysis Am J Emerg Med, 2021.PMID 34492589
[11]Langhan ML, Chen L, Marshall C, Santucci KA Detection of hypoventilation by capnography and its association with hypoxia in children undergoing sedation with ketamine Pediatr Emerg Care, 2011.PMID 21494162
[12]Weerink MAS, Struys MMRF, Hannivoort LN, Barends CRM, Absalom AR, Colin P Clinical Pharmacokinetics and Pharmacodynamics of Dexmedetomidine Clin Pharmacokinet, 2017.PMID 28105598

Procedural sedation medicines

Also known as Paediatric procedural sedation and analgesia · Ketamine sedation in children · Nitrous oxide for procedures · ED procedural sedation medicines · Dissociative sedation

high12 referencesUpdated 17 July 202622 min readVerification in progress

Practise this topic

Overview & Definition

Paediatrics Fellowship Pro

You have read the opening of this topic. The complete unit — every section and its primary-source references — is part of the Paediatrics Fellowship fellowship atlas.

References12Show ledger

[1]Borland M, Esson A, Babl F, Krieser D Procedural sedation in children in the emergency department: a PREDICT study Emerg Med Australas, 2009.PMID 19254316
[2]Schofield S, Schutz J, Babl FE Procedural sedation and analgesia for reduction of distal forearm fractures in the paediatric emergency department: a clinical survey Emerg Med Australas, 2013.PMID 23759045
[3]Green SM, Tsze DS, Roback MG Emergency Department Ketamine Sedation: Frequency and Predictors of Critical and High-Risk Adverse Events Ann Emerg Med, 2025.PMID 40481829
[4]Cosgrove P, Krauss BS, Cravero JP, Fleegler EW Predictors of Laryngospasm During 276,832 Episodes of Pediatric Procedural Sedation Ann Emerg Med, 2022.PMID 35752522
[5]Tobias JD Applications of nitrous oxide for procedural sedation in the pediatric population Pediatr Emerg Care, 2013.PMID 23546436
[6]Roback MG, Bajaj L, Wathen JE, Bothner J Preprocedural fasting and adverse events in procedural sedation and analgesia in a pediatric emergency department: are they related? Ann Emerg Med, 2004.PMID 15520704
[7]Bhatt M, Johnson DW, Taljaard M, Chan J, Barrowman N, Farion KJ Association of Preprocedural Fasting With Outcomes of Emergency Department Sedation in Children JAMA Pediatr, 2018.PMID 29800944
[8]Chumpitazi CE, Camp EA, Bhamidipati DR, Montillo AM, Chantal Caviness A, Mayorquin L Shortened preprocedural fasting in the pediatric emergency department Am J Emerg Med, 2018.PMID 29395760
[9]O'Kane A, Quinney SK, Kinney E, Bergstrom RF, Tillman EM A systematic review of dexmedetomidine pharmacology in pediatric patients Clin Transl Sci, 2024.PMID 39644147
[10]Li HP, Liu KP, Yao L Dexmedetomidine in combination with ketamine for pediatric procedural sedation or premedication: A meta-analysis Am J Emerg Med, 2021.PMID 34492589
[11]Langhan ML, Chen L, Marshall C, Santucci KA Detection of hypoventilation by capnography and its association with hypoxia in children undergoing sedation with ketamine Pediatr Emerg Care, 2011.PMID 21494162
[12]Weerink MAS, Struys MMRF, Hannivoort LN, Barends CRM, Absalom AR, Colin P Clinical Pharmacokinetics and Pharmacodynamics of Dexmedetomidine Clin Pharmacokinet, 2017.PMID 28105598