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©2013 UpToDate ® Print Email Commonly used agents for pediatric procedural sedation administered by oral, sublingual, rectal, or intranasal routes Sedation with these agents can result in significant respiratory depression and other adverse effects. Children should receive appropriate monitoring by personnel skilled in pediatric resuscitation until full recovery has occurred. Please refer to UpToDate topics on procedural sedation in children for more details. Agent Dose Onset (minutes) Duration (minutes) Comments Midazolam 0.25 to 0.5 mg/kg PO or SL, maximum 20 mg 0.2 to 0.3 mg/kg IN, maximum 10 mg* Buccal dosing is as for IN 20 to 30 30 to 60 Midazolam has poor oral bioavailability (15 to 35 percent). IN, SL, and buccal has bioavailability approaching 70 to 80 percent during gradual administration. Provides amnesia, mild anxiolysis, and mild sedation for procedures that do not require full immobility (eg, laceration repair with local topical anesthesia) Flumazenil can reverse effects but should be avoided in patients with seizure disorder or who are chronically maintained on benzodiazepines Common adverse effects: Respiratory depression and apnea, especially if combined with opioids or other sedatives; paradoxical reactions, including hyperactivity, aggressive behavior, and inconsolable crying Pentobarbital• Younger than 4 years: 3 to 6 mg/kg PO/PR, maximum 100 mg 4 years and older: 1.5 to 3 mg/kg PO/PR, maximum 100 mg 15 to 45 60 to 240 Short-acting barbiturate option for noninvasive diagnostic procedures. Better efficacy seen in children <8 years old Common adverse effects: Respiratory depression, hypotension, and increased heart rate, especially with intravenous use or combination with opioid or benzodiazepine Relatively contraindicated in patients with cardiac or hepatic insufficiency or hypovolemic shock Absolute contraindications: Porphyria MethohexitalΔ 25 mg/kg PR, maximum 500 mg 5 to 10 30 to 90 Short-acting barbiturate option for noninvasive diagnostic procedures. More adverse events than pentobarbital Common adverse effects: Respiratory depression, hypotension, and myocardial depression Relative contraindications: Patients with cardiac, liver, or renal insufficiency Absolute contraindications: Porphyria or partial seizure disorder (may precipitate seizures) Thiopental◊ 5 to 30 mg/kg PR, maximum 700 mg 10 to 15 30 to 60 Short-acting barbiturate that is less commonly used.

Common adverse effects: Respiratory depression, hypotension, and myocardial depression Relative contraindications: Patients with cardiac, liver, or renal insufficiency Absolute contraindications: Porphyria or partial seizure disorder (may precipitate seizures) Thiopental◊ 5 to 30 mg/kg PR, maximum 700 mg 10 to 15 30 to 60 Short-acting barbiturate that is less commonly used. Common adverse effects: Respiratory depression, Hypotension, and myocardial depression Relative contraindications: Patients with cardiac, liver, or renal insufficiency Absolute contraindications: Porphyria Chloral hydrate§ 50 to 75 mg/kg PO/PR, maximum 1 gram May give repeat dose of 50 mg/kg (maximum 500 mg) 30 minutes after initial dose if needed 10 to 15 60 to 240 Traditional option for noninvasive diagnostic procedures in infants and young children but inferior to other options listed above because of prolonged effect and greater risk for adverse reactions. Also, not available in some countries, due to concern for potential carcinogenicity Less reliable sedation in patients older than 3 years of age Common adverse effects: Gastrointestinal irritation and vomiting with oral use, prolonged sedation, coma, paradoxical agitation, respiratory depression, especially in young term and preterm infants Tachyarrhythmia with excessive dosing Relative contraindications: Patients with cardiac, liver, or renal insufficiency PO: oral; SL: sublingual; IN: intranasal; PR: rectal. * Pretreatment with lidocaine spray (10 mg/puff) one minute prior to intranasal midazolam decreases nasal mucosal irritation. Intranasal preparation is not commercially available in the USA; 5 mg/mL injectable solution may be given IN. • Oral and rectal preparations of pentobarbital are not commercially available in the USA but may be prepared by pharmacy. Δ Rectal preparation of methohexital is not commercially available in the USA. Injection solution may be diluted with water to a maximum concentration of 10 percent for rectal administration. Rectal administration is associated with defecation. Lower concentration solutions (1 to 2 percent) are less irritating. ◊ Thiopental is not available in the USA or Canada but may be available in other countries. § Oral syrup and rectal preparation are not commercially available in the USA but may be prepared by pharmacy. Oral syrup has a bitter taste.