Which anesthetic drug is commonly used for short procedures in pediatric clients?

Opioid analgesics

Opioid analgesic agents are frequently used to control pain. They may be given either alone or in combination with sedative-anxiolytic agents. In some scenarios, they can be employed as hypnotic agents; however, the risk of respiratory depression is greater in this setting. The analgesic effect occurs at the mu opioid receptor.

Other opioid receptors (eg, kappa, delta) have been implicated in other effects (ie, some sedation and no amnestic properties). These effects are dose-related.

Whenever opioid analgesics are used, a reversal agent should be readily available. Naloxone is an opioid reversal agent that can be administered as 0.1 mg/kg intravenously (IV), intramuscularly (IM), subcutaneously (SC), or endotracheally (ET) every 2-3 minutes until response in children aged 5 years or younger or weighing 20 kg or less. In children older than 5 years or weighing more than 20 kg, the dosage is 2 mg IV, IM, SC, or ET every 2-3 minutes until response. Naloxone’s half-life is 1-2 hours. Rebound sedation and apnea may occur.

Morphine sulfate

Morphine sulfate is indicated for analgesia because of its reliable and predictable effects, good safety profile, and ease of reversibility with naloxone. It elicits analgesia and possesses some sedative effect but has no amnestic properties. Its peak effect is observed 15-30 min after IV administration and 30-60 min after IM administration.

For procedural analgesia and sedation in children, morphine sulfate is given in a dosage of 0.08-0.1 mg/kg/dose IV, IM, or SC before the procedure and every 5-10 minutes as needed.

Fentanyl

Fentanyl is a synthetic opioid that is 75-200 times more potent than morphine sulfate and has a much shorter half-life. It has less hypotensive effects than morphine does and is safer in patients with hyperactive airway disease because there is minimal to no associated histamine release. By itself, fentanyl causes little cardiovascular compromise, although addition of benzodiazepines or other sedatives may result in decreased cardiac output and blood pressure.

Because of its short duration of action (30-60 minutes) and easy titratability, fentanyl is an excellent choice for pain management and sedation. Its onset of action is immediate after IV administration. It is easily and quickly reversed by naloxone.

In children younger than 6 years, fentanyl is given as 0.3-1.5 µg/kg/dose by slow IV push (over 1-2 minutes); this may be repeated every 1-2 hours. In children aged 6 years and older, it is given as 1-5 µg/kg/dose by slow IV push (over 1-2 minutes); the IV dose may be repeated every 1-2 hours (the dose may range from 1 to 10 µg/kg/dose).

Benzodiazepines

Benzodiazepines are used as sedative-hypnotic agents. They have anxiolytic, amnestic, and skeletal muscle relaxant properties. However, they do not have any analgesic properties. They exert effects on gamma-aminobutyric acid (GABA) receptors and potentiate GABA neuron inhibitory actions, as well as result in chlorine channel opening and postsynaptic neuronal hyperpolarization.

Midazolam is commonly used because of its short half-life and prompt onset of action. Diazepam is also used, but it has a long half-life and active metabolites. Lorazepam is a poor choice for procedural sedation, because of its long duration of action.

The benzodiazepine reversal agent is flumazenil; the pediatric dose is 0.01-0.02 mg/kg IV, which may be repeated every minute to a maximum cumulative dose of 1 mg. Flumazenil can precipitate seizures in patients who have ingested tricyclic antidepressants (TCAs) or are long-term benzodiazepine users.

Midazolam

Midazolam is a favored sedative-hypnotic agent for procedural sedation because its water solubility allows it to be administered via several different routes (eg, oral, IV, IM, intranasal, and rectal).

Midazolam has a rapid onset of action when administered IV (2-5 min), is easily titrated, is associated with less pain at the injection site, and has a shorter duration of action than other commonly used benzodiazepines. The dose-response curve is highly variable in children; weight-based dosing produces variable levels of sedation in agitated children of the same weight; this is common with IM and PO dosing.

Dosing in children younger than 6 months has not been established. When midazolam is given IV, 2-3 minutes should be allowed to elapse after a dose before additional doses are administered.

In children aged 6 months to 12 years, midazolam is given as 0.05-0.1 mg/kg IV, titrated to the desired effect. Younger children (ie, < 5 years) may require larger cumulative doses, as high as 0.6 mg/kg or 6 mg.

In children older than 12 years, midazolam is given as 0.01-0.05 mg/kg IV (approximately 0.5-4 mg); the dose may be given slowly or infused over several minutes and may be repeated every 10-15 minutes. Do not exceed a cumulative dose of 10 mg. The oral dose is 0.25-1 mg/kg/dose, not to exceed 20 mg/dose. The IM dose is 0.1-0.15 mg/kg/dose 30-60 minutes before the procedure or operation, not to exceed 10 mg/dose. The intranasal dose is 0.2-0.5 mg/kg.

Diazepam

Diazepam modulates the postsynaptic effects of GABA-A transmission, resulting in an increase in presynaptic inhibition. It appears to act on part of the limbic system, the thalamus, and the hypothalamus to induce a calming effect. The peak effect for rectal administration occurs at 1.5 hours. The negative attributes of diazepam for pediatric sedation are that it has a long half-life, active metabolites, and erratic absorption. Additionally, it causes pain with injection.

IV and IM dosing depend on age. Dosing is not established in neonates younger than 30 days. In children aged 30 days or older, IV or IM dosing is 0.25 mg/kg/dose; the agent should be administered over 3 minutes to avoid respiratory depression. The dose may be repeated after 15-30 minutes, with care taken not to exceed 10 mg/dose.

Rectal gel dosing also depends on age. Dosing is not established in children younger than 2 years. In children aged 2-5 years, the rectal dose is 0.5 mg/kg/dose. In children aged 6-11 years, rectal dosing is 0.3 mg/kg. In children aged 12 years and older, rectal dosing is 0.2 mg/kg.

Barbiturates

Barbiturates elicit action at GABA receptors and hyperpolarize the nerve cell membrane via chlorine channels. They produce sedation and amnesia and reduce anxiety, but they have no analgesic effects. These medications produce a reproducible dose-response effect, based on weight. Additionally, they have neuroprotective properties (derived from their ability to lower intracranial pressure [ICP]) and anticonvulsant properties. Disadvantages include hypotension, hypoventilation, and apnea.

Pentobarbital

Pentobarbital is widely used for procedural sedation. It is a short-acting barbiturate with sedative, hypnotic, and anticonvulsant properties. When administered IV, pentobarbital has a prompt onset of sedation (within 3-5 minutes), and its duration of action is 15-45 min. When administered IM, it produces sedation in 10-20 minutes and has a duration of action of 1-2 hours.

Dosing in children is 2-5 mg/kg/dose by slow IV push, not to exceed 100 mg/dose. IM dosing is 2-6 mg/kg/dose, not to exceed 100 mg/dose.

Methohexital

Methohexital is an ultrashort-acting barbiturate. Its onset of action occurs in less than 1 minute, and its duration of action is about 10 minutes.

Induction dosing is 0.75-1 mg/kg/dose IV. Maintenance dosing is 0.5 mg/kg/dose IV every 2-3 minutes.

Thiopental

Thiopental can be used as an induction agent for endotracheal intubation. It decreases ICP. Its onset of action occurs within 30-40 seconds, and its half-life is 3-8 hours (though it may be prolonged with repeat doses because of accumulation in fatty tissues).

Induction dosing is 2-5 mg/kg/dose IV; no specific initial dose is recommended, because of the great variability of patient response. Age, sex, and body weight all affect dosing. Pediatric patients often need doses that are larger (on a milligram-per-kilogram basis) than those used for adults or elderly persons.

Miscellaneous agents

Induction/hypnotic agents that provide rapid loss of consciousness include nitrous oxide, ketamine, and propofol. Ketamine also provides analgesia and amnestic effects. Etomidate, an ultrashort-acting sedative, is used frequently in adults for rapid sequence induction. It appears to have neuroprotective properties and minimal cardiovascular effects. Although some studies suggest that etomidate may be efficacious in pediatric patients, the utility of this agent in this population has not been fully established.

A small study compared the effects of etomidate plus fentanyl with those of ketamine plus midazolam during orthopedic reductions in a pediatric ED. [15] The results indicated that the incidence of adverse reactions to ketamine, including emergence phenomenon, may be lower than was previously thought.

Nitrous oxide

Nitrous oxide elicits anxiolysis, amnesia, and mild-to-moderate analgesia. However, its analgesic property is variable, typically requiring additional analgesic agents. [16] Nitrous oxide has little effect on the cardiovascular and respiratory systems, with only minimal effect on the airway reflex. The peak onset of action occurs within 30-60 seconds, the maximum effect within 5 minutes. Effects are rapidly lost once inhalation ceases, and recovery occurs within 5 minutes.

A 1:1 mixture of oxygen and nitrous oxide is administered as an inhalant via a handheld mask or mouthpiece. Typically, patients are to maintain the seal to ensure adequate inhalation; once sedation is approached, the patient will lose the seal and allow the mask or mouthpiece to fall.

Ketamine

Ketamine is a dissociative agent that induces catalepsy. It exhibits sedative, analgesic, and amnestic properties. This agent is related to phencyclidine (PCP) and has shown a history of efficacy. It preserves the airway reflexes and has minimal effect on the respiratory drive. Ketamine has bronchodilatory effects and is especially effective with bronchospasms. In addition, it has a good safety profile in children.

After IV administration of ketamine, peak onset of action occurs within 1 minute, and the duration of action is about 10-15 minutes. After IM administration, the peak onset of action occurs in about 5-10 minutes, and the duration of action is 15-30 minutes.

Because of the risk of hypertension, dysphoria, and agitation, ketamine is rarely used in adults. In pediatric patients, ketamine may (rarely) cause laryngospasm. The reaction appears to be idiosyncratic and not to be a function of age, dose, coadministration of anticholinergics, or other clinical variables. [17]

Dosing is 1-1.5 mg/kg by slow IV push (not to exceed 0.5 mg/kg/min). Additional doses may be administered at 0.5 mg/kg IV every 10-15 minutes, depending on the patient’s response and the duration of the procedure. Alternatively, ketamine may be given as 4 mg/kg IM, and additional doses of 2-4 mg/kg may be administered—again, depending on the patient’s response and the duration of the procedure.

A 2013 study demonstrated the benefit of performing sedation with a newly available combination of ketamine and propofol, known as ketofol, rather than with ketamine plus fentanyl for sedation. Switching to the newer combination resulted in a 14% decrease in adverse events overall, a 7% decrease in oxygen desaturation, and a 9% decrease in nausea and vomiting. The decrease in desaturation requiring positive pressure ventilation was 35%. [18]

A retrospective study examined the data that suggested an advantage of sedation with the combination of ketamine and propofol over ketamine alone or propofol alone. The study found that sedation with the combination of ketamine and propofol can be safely performed by a skilled emergency physician. [19]  However, a prospective, multicenter, observational cohort study from 6 pediatric emergency departments that examined 6295 cases of pediatric sedation reported that the use of ketamine alone resulted in the lowest incidence of serious adverse events (17 [0.4%]) and significant interventions (37 [0.9%]) compared to just propofol or a combination of ketamine with propofol or fentanyl. [20]

Propofol

Propofol is a unique medication that has no relation to either of the usual sedative classes (ie, benzodiazepines and barbiturates). It is a purely sedative agent without any analgesic or amnestic properties.

Because of its high lipid solubility, propofol has a rapid onset of action (within 40 seconds). Its duration of action is 1-3 minutes, allowing swift emergence and recovery. Preliminary pediatric studies indicate that propofol is efficacious in terms of providing sedation and is easy to use.

Monitored anesthesia care (MAC) sedation dosing is 0.5-1 mg/kg by IV push, infused over 2 minutes initially. Maintenance dosing is 0.5-1 mg/kg IV every 3-5 minutes as needed or, alternatively, 50-150 µg/kg/min by continuous IV infusion.

Initially, propofol was used as an induction agent in general anesthesia. However, it has also been used for sedation in intubated patients in intensive care units (ICUs) and in patients undergoing diagnostic imaging studies, such as computed tomography (CT) and magnetic resonance imaging (MRI). Propofol is now an important sedation agent among ED physicians. Controversy exists among anesthesiologists and ED physicians regarding optimal use of this drug in patient management. [21]

Procedural sedation policy governing propofol use is typically under the direction of the anesthesiology department. Anesthesiologists have often opposed ED use of propofol because of the potential risk of deep sedation (leading to general anesthesia) and hypoxic/respiratory depression. However, emergency medicine physicians have the technical skills for rapid-sequence intubation and advanced airway management. The ED practice environment is tailor-made for propofol use in a brief controlled setting for procedural sedation. [22]

Increasing numbers of studies describe propofol use in the ED. Patel et al described how propofol provided effective moderate sedation for procedures lasting 30 minutes or longer and outlined effective dosing regimens in different age groups. [23] In this study, the sedation was performed by a pediatric sedation service staffed by nonanesthesiologists.

Dexmedetomidine

Dexmedetomidine is a medication that has the ability to provide sedation without causing respiratory depression. It resembles clonidine in that it is an alpha2 -adrenergic receptor agonist. It has been administered to adults by IM injection for perioperative anxiolysis and sedation. There is some evidence to suggest that dexmedetomidine may be useful for procedural sedation in children, but more and larger controlled studies are needed to evaluate its safety and efficacy in this setting. [24, 25]

Which anesthetic medication is commonly used for short procedures on pediatric clients?

What is the most common sedative drug used for pediatric?

What anesthesia is used for children?

What drugs are used in pediatrics?