Procedural Sedation and Analgesia
Goals of procedural sedation and analgesia General and supportive measures Medicine treatment Children in hospital are exposed to a variety of painful diagnostic and therapeutic procedures. The aim of procedural pain management is to minimise physical discomfort, pain, movement, and psychological disturbance, without compromising patient safety. Failure to provide adequate preventative pain measu
Goals of procedural sedation and analgesia
General and supportive measures
Medicine treatment
Children in hospital are exposed to a variety of painful diagnostic and therapeutic procedures. The aim of procedural pain management is to minimise physical discomfort, pain, movement, and psychological disturbance, without compromising patient safety. Failure to provide adequate preventative pain measures increases anxiety in both the child and parent/caregiver, making repeat procedures more challenging.
GOALS OF PROCEDURAL SEDATION AND ANALGESIA
- Provide a safe environment for the patient.
- Effectively control pain, anxiety and movement.
- Decreased awareness and amnesia are also advantageous.
GENERAL AND SUPPORTIVE MEASURES
Non-medication measures are as important as medication measures in the management of procedural pain. These include adequate preparation /explanation to the child and parent/caregiver, correct positioning, and the use of distraction. For a comprehensive list see above.*
Note:
- It is the sedation team’s responsibility to familiarise themselves with local guidelines for procedural sedation and analgesia. Important safety aspects must be adhered to including fasting, availability of equipment and the appropriate monitoring recommendations followed. All clinicians providing sedation need to have the necessary skills to manage a compromised airway, and haemodynamic compromise that may occur.
- Each case should be individualised. This table does not supersede clinical judgement.
- Timing of medications in relation to the procedure is essential.
- Always use simple analgesia in combination with other agents.
MEDICINE TREATMENT
Selection of medication and routes of administration should be guided by:
- Drug choice – specifically onset/peak and duration of action, and side effect profile.
- Child’s age and level of cognitive development.
- Child’s condition, comorbid diseases.
- Severity of pain associated with the procedure.
- Duration of the procedure.
- Level of immobility required to complete the procedure.
Providing safe and effective procedural sedation and analgesia can be a challenging undertaking, particularly in inexperienced hands. Some children are difficult to sedate with recommended dosing, and may require multiple agents or general anaesthesia to facilitate successful completion of the procedure. If so, refer the child to an experienced seditionist, or for general anaesthesia. Do not cause the child undue distress and emotional trauma.
Some children are at higher risk for morbidity (and even mortality), and should also be referred to an experienced seditionist, or for general anaesthesia. This includes children with severe systemic illness, life-threatening conditions, raised intracranial pressure, anticipated difficult airway, obesity, congenital syndromes, advanced respiratory disease, cardiac dysfunction, and a depressed level of consciousness. Refer to Chapter: Intensive Care and Anaesthetics for recommendations.
The intranasal route of administration is a relatively painless, fast-acting, effective means of providing analgosedation. To maximise delivery, maximise concentration and minimise the volume. To further minimise the volume per nostril, divide the dose in half, and each half is administered into each nostril.
- Fentanyl:
Fentanyl provides analgesia and sedation. It should never be used as a sole agent. Combine with paracetamol ± NSAID. If used in combination with other respiratory depressant medicines, use lower doses and titrate to effect. The most frequent side effects include an itchy nose and dizziness
| Route | Dose (mcg/kg) | Onset (minutes) | Peak (minutes) | Duration (minutes) |
| Intranasal* | 1–2 | 10 | 15 | 60–120 |
| IV | 0.25 | 1 | 5–6 | 30 |
*Intranasal route is preferred.
A ‘top up’ dose can be considered if satisfactory analgesia is not reached with the initial dose.
- Ketamine:
Ketamine provides analgesia, anxiolysis and sedation. It is bitter tasting, and should be mixed with a sweet-tasting substance, e.g. paracetamol or ibuprofen. It may burn when given via the intranasal (IN) route. To decrease burning, administer 0.25 mL of 2% lignocaine prior to medication. The most frequent side effects include nausea and dizziness. For children who are hypotensive or in situations where opioids should be avoided for airway concerns, IN ketamine could be an alternative option.
| Route | Dose (mg/kg) | Onset (minutes) | Peak (minutes) | Duration (minutes) |
| Oral | 6–10 | > 5 | 30 | 4–6 hours |
| Intranasal | 5 | 5–10 | 20 | 20–120 minutes |
| IV (bolus) | 0.25–1 | < 1 | 3–5 | 10–15 minutes |
| IV (infusion) | 0.5–1 mg/kg/hr | < 1 | 3–5 | 10–15 minutes |
| Intramuscular* | 2–4 | 2–5 | 20 | 30–120 minutes |
*IM injections are painful and distressing, and should not be utilised as a first option.
- Midazolam:
Midazolam provides anxiolysis and sedation ONLY. It does not have any analgesic effect. It is bitter tasting, and should be mixed with a sweet-tasting substance, e.g. sucrose, paracetamol or ibuprofen.
| Route | Dose (mg/kg) | Max. dose | Peak (minutes) | Duration (minutes) |
| Oral | 0.25–0.5 | 15 mg | 10–30 | 60 |
| Sublingual | 0.25–0.3 | 0.3mg/kg | 10–15 | 20–60 |
| Intranasal | 0.2–0.3 | 0.3mg/kg | 10–15 | 60–120 |
| IV | 0.025– 0.1 | 1 | 3–5 | 20–60 |
Table: Procedural Sedation and Analgesia
| Procedures associated with mild pain | Procedures associated with moderate to severe pain | |
| Examples |
Blood taking. Heel prick. IM injection. Nasogastric tube insertion. Urethral catheterisation. Peripheral cannulation. |
Arterial line, central venous catheter. Simple laceration. Intercostal drain insertion/removal. Dressing change for burns. Lumbar puncture. Fracture reduction/manipulation. Bone marrow aspirate and trephine. |
| ANALGESIA | ||
| Local anaesthesia* |
- Topical lidocaine (lignocaine)/prilocaine 1 hour before procedure) covered with occlusive dressing. - Lidocaine (lignocaine) infiltration 0.5, 1 or 2% (lower concentrations burn less). - Consider regional anaesthesia (e.g. digit blocks, wrist block). |
|
| Systemic |
- Sucrose 24% solution (up to 12 months). - Breastfeed - Paracetamol - ± Ibuprofen
|
- Paracetamol ± ibuprofen AND one of the following medicines: - Ketamine OR - Fentanyl |
*Local anaesthetics are used in combination with systemic agents corresponding with the severity of pain associated with the procedure.
Standard Treatment Guidelines and Essential Medicines List for South Africa Paediatric Hospital _2023, 5th edition_Updated July 2024
Chapter 20: Pain Control, 20.1.2 Procedural Sedation And Analgesia