Clinical Policy: Evidence-Based Approach to
Pharmacologic Agents Used in Pediatric Sedation
and Analgesia in the Emergency Department
April 19, 2004

I. Is etomidate effective for providing procedural sedation in
children in the ED?

Level C recommendations. Etomidate is an effective agent
for procedural sedation in the pediatric patient population
within the ED.

II. Is etomidate safe for providing procedural sedation in
children in the ED?

Level C recommendations. Etomidate is a safe agent for
procedural sedation in the pediatric patient population
within the ED.

III. Are fentanyl and midazolam effective for providing
procedural sedation in children in the ED?

Level B recommendations. Intravenous use of fentanyl and
midazolam is effective for pediatric sedation during
painful procedures in the ED.

IV. Is the use of fentanyl and midazolam safe for providing
procedural sedation for painful procedures in children in the
ED?

Level B recommendations. The combination of fentanyl
and midazolam appears to result in a greater risk of
respiratory depression; therefore, the clinician should take
particular care to monitor the patient for signs of
respiratory depression and should have appropriate
training and support to treat apnea.

V. Is ketamine effective for providing procedural sedation in
children in the ED?

Level A recommendations. Ketamine is effective either as
a sole agent or in combination with a benzodiazepine for
brief painful procedures in children.

Level A recommendations. Ketamine can be safely used for
procedural sedation in children in the ED, but may
require head positioning, supplemental oxygen, occasional
bag-valve-mask ventilatory support, and measures
to address laryngospasm.

VII. Does the addition of midazolam as an adjunct to ketamine
for procedural sedation for children in the ED reduce recovery
agitation or vomiting?

Level A recommendations. The addition of midazolam as
an adjunct to ketamine for procedural sedation for
children in the ED does not decrease the incidence of
emergent reactions.

Level B recommendations. The addition of midazolam as
an adjunct to ketamine for procedural sedation for
children decreases the incidence of emesis.

VIII. Is methohexital effective for providing procedural
sedation in children in the ED?

Level B recommendations. Methohexital administered by
either the intravenous, intramuscular, or rectal routes can
provide effective sedation for children undergoing painless
diagnostic studies.

IX. Is methohexital safe for providing procedural sedation in
children in the ED?

Level B recommendations. Methohexital can be safely
used for procedural sedation but may require head
positioning, supplemental oxygen, and occasional bagvalve-
mask ventilatory support.

X. Is pentobarbital effective for providing procedural sedation
in children in the ED?

Level B recommendations. Pentobarbital alone is effective
in producing cooperation for painless diagnostic procedures.
Best sedation results are seen in children younger
than 8 years.

XI. Is pentobarbital safe for providing procedural sedation in
children in the ED?

Level B recommendations. Pentobarbital can be safely
used for procedural sedation but may require head
positioning, supplemental oxygen, and occasional bagvalve-
mask ventilatory support.

XII. Is propofol effective for providing procedural sedation in
children in the ED?

Level B recommendations. Propofol combined with opiate
agents is effective in producing cooperation for painful
therapeutic or diagnostic studies.

Level C recommendations. Propofol alone, without the
concomitant use of opiate agents, is likely to be effective in
producing sedation for painless diagnostic studies in ED
patients.

XIII. Is propofol safe for providing procedural sedation in
children in the ED?