Paediatric sedation guidelines 17011.pdf - East Cheshire NHS Trust

Policy Title: Guidelines for the Sedation Of Children and Young People on 

the paediatric ward and in A&E 

Executive Summary: The purpose of the paediatric sedation guideline is to support 

nurses and medical staff in ensuring the safety of children 

requiring sedation. Procedures for which children require 

sedation are included, with preference of medication to be 

prescribed. In the event of an adverse reaction, or a dosage 

error, instructions are provided to manage the situation. 

Supersedes: Guidelines for the Sedation Of Children and Young People 

2005, 2010 and A&E guidelines for the sedation of young 

Description of 

Amendment(s): 

people and use of ketamine guidelines 

Re –written to amalgamate both the Paediatric unit and A&E 

guidelines. 

This policy will impact on: The Children’s Ward, Emergency Dept. X-ray dept 

Financial Implications: Non Known 

Policy Area: Children’s Services Document 

Reference: 

Version Number: 3 Effective Date: June 2012 

Issued By: 

Authors: 

Families and Well 

Being 

Amalgamated by J 

Shippey 

Review Date: June 2014 

Impact Assessment 

Date: 

Consultation Phase: 

Received for information: 

APPROVAL RECORD 

Committees / Group 

Paediatricians, Children’s 

Nurses, Radiographer, 

Associate Director W&CBU, 

Consultant & Practice 

Development Nurse in A&E, 

Pharmacy 

Date 

November 2011- 

May 2012

Guidelines for the Sedation 

Of Children and Young People 

On the Paediatric Ward and in A&E 

2 

Paediatric Sedation Guidelines amalgamated by J Shippey June 2011, for review May 2014 

Paediatric Ward Sedation Guidelines writtenby HH, Glover, S. Darbyshire July 2010 

Paediatric A&E Sedation Guidelines written by Dr M Nichol August 2011

Introduction 

This guideline is in two parts. Part A provides guidance for the sedation 

of children and young people on the paediatric ward and part B 

provides guidance for children and young people providing sedation in 

the Accident and Emergency department. It has been split like this 

because children need sedation for different reasons in the different 

departments. In A&E, children need sedation for pain relief for 

procedures such as stitching wounds and orthopaedic reductions. 

However, sedation is used more commonly on the paediatric ward for 

procedures which could cause anxiety such as MRI scanning and 

invasive non painful procedures such as MCUGs. 

INDEX: 

PART A: Page 4 

Guidelines for nurses and doctors in the management of children 

requiring sedation on the paediatric ward. 

PART B: Page 10 

3 




PART A 

GUIDELINES FOR NURSES AND DOCTORS IN THE MANAGEMENT 

OF CHILDREN REQUIRING SEDATION ON THE PAEDIATRIC 

WARD 

INDEX 

PAGE 

1 Introduction 2 

2 Procedures requiring sedation 2-3 

3 Preferred medicines for sedation 3-4 

4 Guidelines for sedation: Flow chart 5 

5 Sedative Drugs 6-7 

6 Training and competence of staff 8 

7 Safety of patients and management of risk 8-9 

8 Appendix 1 - Sedation checklist 10 

9 Appendix 2 - Paediatric sedation assessment tool 11 

10 Appendix 3 - Paediatric sedation audit tool 12 

11 Appendix 4 - General comments 13 

12 Appendix 5 – Adapted Neurological observation chart 14 

13 Appendix 6 – Patients at risk from the effects of sedation 15 

14 Appendix 7 – Discharge information leaflet 16 

15 References 17 

1 




Section 1: 

INTRODUCTION 

 

 

 

The purpose of the paediatric sedation guideline is to support nurses and medical 

staff in ensuring the safety of children requiring sedation. 

The Consultant Paediatrician/speciality Paediatrician makes the decision that a 

child needs sedation for a procedure. It may be necessary for an acutely ill child 

already admitted to the ward to have sedation for investigations. 

Procedures for which children require sedation are included, with preference of 

medication to be prescribed. In the event of an adverse reaction, or a dosage 

error, instructions are provided to manage the situation. 

 

Children are not required to be starved for a period of time prior to sedation but it 

is advised that they only have light diet 2 hours before and clear fluids 1 hour 

before sedation. If sedating infants they can have milk 2 hours prior to sedation. 

Section 2: 

PROCEDURES REQUIRING SEDATION 

The following procedures may require sedation depending upon the age and 

compliance of the child: 

 

Invasive non-painful procedures 

Such as: 

Micturating Cystogram (MCG) and enema administration will normally only require 

Minimal Sedation. The child will then attend the children’s ward as a day case 

patient. 

Please refer to the guidelines for sedation flow chart for guidance on drug choice 

(page 6) 

 

Potentially painful procedures 

Such as: 

Insertion of intravenous long line, insertion and/or removal of sutures and minor 

surgical procedures and dressings will normally require Moderate Sedation with 

analgesia. 

Please refer to the guidelines for sedation flow chart for guidance on drug choice. For 

procedural sedation in A&E, staff should liaise with the A&E Consultant and if 

applicable the relevant ketamine procedural sedation guidelines. 

2 




Non-invasive and non-Painful procedures 

Such as: 

Magnetic resonance imaging (MRI) scan, CT scan or Electroencephalagram will 

require Moderate Sedation in order to achieve ultimate compliance from the child; 

rendering him/her completely still for the purpose of the procedure. However, the 

child would not require analgesia for these investigations. 

Please refer to the guidelines for sedation flow chart for guidance on drug choice 

(page 6). 

Section 3: 

PREFERRED METHODS FOR SEDATION 

PLEASE NOTE: East Cheshire NHS Trusts' Policy and Procedures for the safe and 

secure Handling of Medicines must be adhered to at all times 

 

Oral Chloral Hydrate – see flow chart for doses. 

It is an effective sedative and hypnotic agent that has been successfully used for 

patients pre-operatively to allay anxiety, prior to minor surgical procedures and 

diagnostic procedures (Bhatt-Mehta & Rosen, 1998). It has also been used prior to 

EEG evaluations to produce sleep (American Society of Health System Pharmacists 

Inc, 2002). This preparation is prepared as a special and therefore an unlicensed 

medicine. 

Buccal / oral, Intravenous (IV) or Intranasal Midazolam – see flow chart for 

doses (page 6) 

It provides sedation without loss of consciousness, and relieves anxiety. When 

administered prior to minor surgical procedures, diagnostic, therapeutic or 

endoscopic procedures, anterograde amnesia is also induced (Lloyd, 2000) and 

(American Society of Health System Pharmacists Inc, 2002). It is important to be 

aware that there is occasional distressing paradoxical excitation when midazolam is 

used with children (CSM 2001) 

Oral Morphine – see flow chart for doses (page 6) 

In the instance where a single dose of midazolam is ineffective, due to continued 

agitation and lack of co-operation, morphine may be administered orally or 

intravenously (Only by an experienced member of staff followed by close monitoring) 

(Henderson, 1988). 

3 




Informed consent for the procedure is obtained from the parents on the trust 

consent form 'Parental agreement to investigation or treatment for a child or young 

person.' The East Cheshire NHS Trust Policy for Consent to Examination or 

Treatment is followed. 

It is the responsibility of the Consultant / Doctor performing the procedure to: 

1. Provide the parents with information and the top copy of the consent form 

(completed by the consultant) prior to the procedure. 

2. Check the level of understanding and knowledge the parents have regarding the 

procedure, upon admission to the paediatric unit. Queries to be answered by 

doctor undertaking procedure (or healthcare professional assessed as competent 

to give this information). 

3. Obtain parental signature on Page 3 of the consent form. 

It is the responsibility of the nurse in charge of the patient's care to: 

1. Obtain accurate patient history prior to sedation, using the sedation checklist 

(appendix 1) 

2. Use care and good judgement to obtain this information. Use existing case 

notes to confirm information available. 

3. Ensure that the Doctor completes the Paediatric sedation assessment and 

audit tool prior to sedation (appendix 2). 

4. The named nurse to attend pre, per, and post the procedure in order to 

monitor patient wellbeing throughout. 

4 




Section 4 

GUIDELINES FOR SEDATION: Flow Chart 

Contraindications to sedation: 

Support Facilities which must be available: 

Abnormality of upper airway Resus equipment & paed. Defibrillator 

Abnormality of respiratory centre Suction equipment 

Renal or hepatic dysfunction Oxygen, airway & mask 

Gestational age

Section 4b 

Sedative Drugs 

Please note MAXIMUM drug dosages 

See Children’s British National Formulary (current edition) for further 

prescribing information 

Route Drug Dose Max. Dose When to give Antidote 

Oral Morphine 2years 

500mcg/kg 

15mg 

90mins before 

procedure 

Oral Midazolam 500mcg/kg 15mg 30 - 60mins before 

procedure 

6 



Paediatric A&E Sedation Guidelines written by Dr M Nichol August 2011 

Naloxone 

1 month 

- 12 

years 

10mcg/kg 

with 

subsequent 

doses of 

100mcg/kg 

if no 

response. 

12-18 

years 

0.4-2mg 

repeated at 

2-3 min 

intervals to 

a max. of 

10mg 

Flumazenil 

1 month - 

12 years 

10mcg/kg 

(max single 

dose 

200mcg) 

repeated at 

1-minute 

intervals to 

a max. total 

dose of 

40mcg/kg or 

1g 

12 - 18 

years 

200mcg 

repeated at 

1-minute 

intervals if 

required to

Route Drug Dose Max 

dose 

Oral Chloral 25-50mg/kg 1g or 

Hydrate 

100mg / kg 

(2g max) if 

respiratory 

monitoring 

in place 

When to give 

45-60mins before 

procedure 

Nasal Midazolam 200-300mcg/kg 300mcg/kg 5-10 mins before 

procedure 

IV Midazolam 1month - 6 years 300mcg/kg Immediately before 

50-100mcg/kg or 6mg procedure 

6 -12 years 

25 -50mcg/kg 10mg 

12-18 years 

2-2.5mg; increase in 3.5-7.5mg 

steps of 0.5-1mg if 

necessary 

IV 

(injectio 

n over 5 

min.) 

Morphine 1-6 month 

100 - 200mcg/kg - 6 

hourly. 

6 months - 12 

years 

100 - 200mcg/kg - 4 

hourly. 

12 - 18 year 

2.5 - 10mg - 4 

hourly 

Immediately before 

procedure 

a max. total 

dose of 1g 

Antidote 

None 

Flumazenil 

Flumazenil 

Naloxone 

NOTE 

IV (Intravenous) sedation only to be given by a Doctor or an appropriately trained nurse 

Mcg = Micrograms 

Children do not require a period of starving prior to sedation. However, it is 

recommended for any of the drugs above that the child has: 

Light diet up to 2 hours 

Clear fluid up to 1 hour prior to sedation. 

Infants may have milk 2 hours prior to sedation. 

7 




Section 5: 

TRAINING AND COMPETENCE 

 

Nurses caring for patients requiring sedation on the Paediatric Unit will be 

qualified children’s nurses, registered with the NMC. 

 

Doctors conducting sedation must be of middle grade experience or above 

 

Mandatory training in basic life support and anaphylaxis are essential 

requirements and must be updated yearly. 

 

Adherence to the East Cheshire NHS Trust Policy for the safe and secure 

handling of medicines, and the Policy for consent to examination or 

treatment is imperative. 

 

Relevant issues encompass: 

- Understanding and safe use of equipment (see flow chart) 

- Understanding the possible complications and hazards of the 

procedure of sedation (see appendix 3 and 4) 

- Completion of all the relevant documentation in accordance with 

ECNHS trusts' policy 

Section 6: 

Safety of Patients and Management of Risks 

 

Adherence to the East Cheshire NHS Trust Policy for the safe and secure 

handling of medicines, and the Policy for consent to examination or 

treatment is imperative. 

 

Immediate action is to seek medical advice. 

 

Ensure patient safety, maintaining airway. 

 

In the event of respiratory arrest, call 2222 and administer basic life support. 

8 




Medicines other than those referred to in these guidelines may be proposed for 

use. Sometimes this is necessary in order to achieve the desired result. The 

Consultant in charge of the child's care, following discussion with a pharmacist 

takes this decision. The medicines dosage and route of administration must 

remain within the guidelines of the British National Formulary for Children 

The information within these guidelines has been gleaned from sedation guidelines 

implemented in other NHS trusts. It is therefore courteous to acknowledge Alder 

Hey children’s Hospital and North Staffordshire Hospital trusts in their contribution. 

Audit 

These guidelines will be audited in line with the KPI’s identified below on an annual 

basis by paediatric nursing staff. The findings will be reported to the Paediatric Unit 

and the Paediatric Audit Group and Clinical Governance. Any action plans 

developed from this audit will be agreed by the Paediatric Audit group with a 6 

monthly review of progress. 

Key Performance Indicators 

An annual audit of patients requiring sedation will be carried out for 

complications e.g. failed procedure, adverse reaction, to ascertain that 

procedures were carried out as per the guidelines. 

Appropriate prescription of medication depending on the procedure that the 

child is admitted for, in line with East Cheshire NHS Trust Medicines 

Management Policy and Record Keeping policy. 

The child’s records hold completed documents of appendix1, 2, 3 and 5. 

9 




Appendix 1 

SEDATION CHECKLIST PRIOR TO TRANSFER TO DEPARTMENT 

To be completed by named nurse 

1. Correct identification band: yes / no 

2. Allergies yes / no 

3. Sedation assessment form completed: yes / no 

4. Cannula in situ: yes / no 

5. Consent form signed: yes / no 

6. Notes / x-rays / scans yes / no 

7. Prescription chart complete with sedation and antidote: yes / no 

8. Glasses / nail varnish / jewellery removed: yes / no 

9. Loose teeth / caps / brace yes / no 

10. Fasted from: 

Date:_________ 

Time:_________ 

11. Any variance from above, please record below 

Transfer nurse to complete checklist. Print name 

Signed: 

10 




Appendix 2 

PAEDIATRIC SEDATION ASSESSMENT TOOL 

Part 1 to be completed by medical staff before prescribing sedation 

ADDRESS 

DATE: 

NAME: 

D.O.B: 

WEIGHT: 

PROCEDURE: 

Part 1 

Do any of the following relative or absolute contra-indications to sedation apply to the patient? 

(see appendix 4) 

Raised intracranial pressure yes / no 

Altered conscious level yes / no 

Compromised airway yes / no 

Upper / lower respiratory tract infection yes / no 

Respiratory failure yes / no 

History of apnoea yes / no 

Uncontrolled epilepsy yes / no 

Gastro-oesophageal reflux yes / no 

Significant renal, hepatic or cardiac dysfunction yes / no 

11 




If any of the above exists, check with consultant or middle grade that sedation is 

appropriate. 

Checked 

Yes / No 

Are you satisfied that the parent /Guardian understands the nature of the procedure, and that 

there is a failure rate with sedation? 

Yes / No 

Name: ………………………………………………….. Signed: …………………………………….. 

PAEDIATRIC SEDATION AUDIT TOOL 

Appendix 3 

To be completed by the child’s named nurse following the procedure: 

Was the sedation procedure carried out successfully? YES NO 

If no, please complete sections below: 

Reason sedation procedure unsuccessful: (tick below as appropriate) 

Patient agitated 

Adverse effect 

Parents withdrew consent 

Other (provide details): ……………………………………….……………………………… 

…………………………………………………………………………………………………… 

…………………………………………………………………………………………………… 

Problems with equipment YES NO 

(if yes, tick below as appropriate) 

Suitability of probe 

Accuracy of probe readings 

O 2 sats monitor 

12 




Other (provide details): ………………………………………………………………………. 

…………………………………………………………………………………………………… 

…………………………………………………………………………………………………… 

Documentation completed prior to transfer 

YES 

NO 

Sedation checklist completed by named nurse 

Assessment tool completed by medical staff 

Discharge letter completed: 

Appendix 4 

General comments regarding the sedation of children 

 

Sedation and anaesthesia are a spectrum. 

If you give enough ‘sedation’ to a patient it can induce anaesthesia, i.e. loss of 

consciousness, loss of protective airway reflexes and the inability to feel 

pain. Giving drugs such as Midazolam and morphine IV, and in conjunction with 

one and other, carries a significant risk of respiratory depression. The drugs must 

not be given too rapidly. If the procedure for which sedation is indicated is likely to 

be painful, then titrate analgesia first then deliver the sedative. 

The fine distinction lies in the ability of the patient to maintain vital functions without 

assistance, and their response to being roused, i.e.: 

 

 

 

protection of airway, swallowing, cough reflex 

respiration 

cardiovascular stability 

Loss of any of the above reflexes is routine in anaesthetic environments but should 

not occur when providing sedation. 

VITAL FUNCTION SEDATION ANAESTHESIA 

Response to verbal Present 

Absent 

stimulus 

Respiration Rate and depth may be Rate and depth markedly 

slightly reduced 

reduced or absent 

Swallowing reflex Present Absent (usually) 

Gag reflex Present Absent 

13 




Cough reflex Laryngeal spasm unlikely, 

but possible with sufficient 

provocation 

Cardiovascular stability Mild hypotension may 

occur 

May be present at lighter 

levels but unlikely. 

Laryngeal spasm may 

occur 

Severe hypotension may 

occur 

(Adapted from: North Staffordshire Hospitals Trust, Guidelines for sedation of children.) 

14 




15 




Appendix 6 

PATIENTS AT RISK FROM THE EFFECTS OF SEDATION 

 

 

Some children are more vulnerable to the effects of sedation 

Broad summary – those with problems of respiration or upper airway problems 

Upper Airway Obstruction 

 

 

 

 

 

Croup 

Foreign body 

Congenital stridor? 

cause Pierre-Robin / 

Cleft palate 

Baby with very blocked 

nose 

Pre-existing 

neuromuscular 

problems 

Respiration 

 

Loss of reflexes 

Effects of sedation: 

Central drive (or 

children at risk if CO 2 

) 

Swallowing difficulties. 

Known bulbar problems, 

especially if combined 

with gastric reflux. 

Gastro-oesophageal reflux 

Those at risk: 

HEAD INJURIES 

ICP – space occupying 

lesions. Already receiving 

opiates 

Congenital hypoventilation 

syndrome 

 

Muscle power (or 

respiratory efficiency) 

 

 

 

Myopathies 

Post ICU – generalised 

weakness. 

All small babies 

(especially premature 

babies) 

Lung performance Chest infection. Large 

effusions 

Severe 

Bronchpulmonary 

dysplasia. Any child 

requiring oxygen 

Cardiovascular Hypotension Haemorrhage 

Sepsis 

Cardiomyopathy/ 

16 




cardiac injury 

Appendix 7 

Children's Ward 

Macclesfield District General Hospital 

East Cheshire NHS Trust 

Victoria Road 

Macclesfield 

Cheshire 

SK10 3BL 

Dear Parent 

Your child attended the Children’s Unit as a day case patient 

on ___________________ for ____________________________________ 

s/he was sedated with _______________________________ at __________am/pm. 

You may find that your child is a little unsteady when you get home, but this 

should gradually improve. Allow your child to sleep if they wish and to eat and 

drink as normal. 

If you have any worries or concerns, please contact the Children’s Ward on 

telephone number 01625 661080 of 661084 and ask to speak to the nurse in 

charge who will be pleased to help and advise you. 

Kind regards, 

17 




PART B 

Sedation in Children and Young 

People in A&E (Reference Guide) 

If intending to use Ketamine then use the separate Ketamine 

guidance. 

What is this guide for? 

This guide is to help staff in the emergency department perform safe sedation of 

children and young people for short procedures. 

It can be used to achieve minimal, moderate, conscious and deep sedation (defined 

by the ASA) for procedures that the child would not normally be able to tolerate. 

Examples of what the guide could be used for are: 

Painless imaging (do not routinely use ketamine or opioids). 

 

Painful procedures e.g. orthopaedic manipulation or reduction. 

It is intended for sedative techniques using: 

Nitrous oxide with or without Midazolam. 

Midazolam with or without fentanyl (or other opioid). 

It can also be used for specialist sedation techniques such as propofol +/- 

fentanyl if appropriately trained (propofol must NOT be used without specific 

anaesthetic experience). 

Who should be using this guidance? 

Healthcare professionals delivering sedation should have: 

Knowledge and understanding of and competency in: 

o Sedation drug pharmacology and applied physiology. 

o Assessment of young people. 

o Complications and their immediate management, including paediatric 

life support. 

 

Practical experience of: 

o Effectively delivering the chosen technique and managing 

complications. 

 

Documented up-to-date evidence of competency. 

18 




Does the child need to be fasted? 

Fasting is not needed for minimal sedation, sedation with nitrous oxide, moderate 

sedation during which the child will maintain verbal contact with the healthcare 

professional. Apply the 2-4-6 rule for other elective procedures. Elective situation is 

uncommon in Emergency Dept but may arise if a procedure as being identified on 

one day but deferred to be done the next day. It should be recognised that 

starvation does NOT guarantee lack of vomiting, based on published research. 

For an emergency procedure base the decision to proceed on the urgency of the 

procedure and the target depth of sedation. 

Is sedation suitable for the child or young person? 

 

 

 

Trained healthcare professionals should carry out pre-sedation assessments and documents the 

results in the healthcare record. 

Two trained healthcare professionals should be available during sedation. 

Immediate access to resuscitation and monitoring equipment should be available during sedation. 

Establish suitability for sedation by assessing: 

current medical condition and any surgical problems 

weight 

past medical problems (including any associated with previous sedation or anaesthesia) 

current and previous medication (including allergies) 

physical status (including the airway) 

psychological and development status 

Do any of the following apply? 

There is concern about a potential airway or breathing 

problem. 

The child or young person is ASA grade 3 or greater. 

The patient is a neonate or infant. 

Yes 

Seek specialist advice 

(before delivering 

sedation). 

No 

Choose the most suitable sedation technique based on all the follow factors: 

what the procedure involves 

target level of sedation 

contraindications 

side effects 

patient (or parent or carer) preference 

staff training 

Offer the child or young person and their parents or carers verbal and written information on all of the following: 

proposed sedation technique 

Alternatives to sedation. This should also detail that GA may be an alternative, and may depending on age, 

be referred to Manchester Children’s Hospital for that to happen due to age restriction on GA in children in 

DGH. 

associated risks and benefits 

Obtain and document informed consent 

19 




If you are unclear about any of the above terms please consult the full NICE 

guidance. 

Check list for sedation of a child or young person 

Name: 

DOB: 

Hospital Number: 

Indication for sedation: 

Intended procedure: 

Intended level of sedation: 

Intended method of sedation: 

Time last ate and what: 

Age: 

Weight: 

Preoperative assessment: 

Past medical problems Yes □ No □ 

Past anaesthetic problems Yes □ No □ 

Current medication Yes □ No □ 

Allergies 

Airway concerns Yes □ No □ 

SpO 2 , RR, HR and pain score recorded Yes □ No □ 

Written consent obtained Yes □ No □ 

Written information given Yes □ No □ 

Equipment: 

Supplementary oxygen Yes □ No □ 

X-ray trolley Yes □ No □ 

Trolley capable of head down tilt Yes □ No □ 

Resuscitation equipment available Yes □ No □ 

Monitoring 

B: Respiration Yes □ No □ 

B: Oxygen saturation Yes □ No □ 

B: End tidal CO 2 * Yes □ No □ 

C: Heart rate Yes □ No □ 

C: BP (every 5 mins)* Yes □ No □ 

C: Three-lead ECG* Yes □ No □ 

D: Pain Yes □ No □ 

D: Depth of sedation A V P U 

(circle appropriate) 

20 




*Only needed for deep sedation. 

Drugs: 

Drug: Dose: Time: 

Drug: Dose: Time: 

Nitrous oxide Yes □ No □ 

Antagonists available Yes □ No □ 

Level of sedation: 

Responds to verbal stimulus Yes □ No □ 

Responds to painful stimulus Yes □ No □ 

Airway patent Yes □ No □ 

Post-sedation: 

Airway patent Yes □ No □ 

Protecting airway Yes □ No □ 

Haemodynamically stable Yes □ No □ 

Easily roused Yes □ No □ 

Morbidity /Complications recorded Yes □ No □ 

Discharge criteria: 

Vital signs have returned to normal levels Yes □ No □ 

Patient is awake Yes □ No □ 

No further risk of reduced level of consciousness Yes □ No □ 

Vomiting Yes □ No □ 

References: 

NICE Clinical Guideline 112: Sedation in Children and Young People published in 

December 2010. 

Appendix (added Aug 2011) 

21 




Ketamine Guidance 

The guidance on ketamine below will replicate much of what is written above, but 

this appendix is used by ED staff as quick reference guide, without need to work 

through the rest of the document 

Ketamine pack containing 

 

 

 

 

 

Guidelines for use of ketamine 

What to use it for 

Contraindications 

Side effects 

General Preparation 

Equipment needed 

Sedation Procedure 

Recovery 

Check list form-ketamine sedation 

Ketamine information sheet for parents 

Ketamine dosage table 

Atropine dosage table 

Ketamine check list 

Check list form 

Ketamine information sheet for parents 

From file “guidance for ketamine in Macc ED 2011” on electronic folder ED teaching 

on main AE nurse login 

What to use it for 

Any child who requires a painful procedure not exceeding 20minute duration 

performed in the A&E department but would not be able to tolerate (combative 

children) the procedure without sedation. 

This may include 

1. Lacerations 

2. Finger tip injuries 

3. Removal of Foreign Bodies 

4. Reduction of dislocations 

5. occasionally burns dressing changes 

Initially the procedure must be undertaken by a consultant or middle grade A&E 

doctor (specifically trained in ketamine sedation) with a qualified A&E nurse. 

22 




Contraindications for use of ketamine 

Common contra-indications 

0. Inadequate nursing staff to provide 1:1 cares till sedation worn off 

1. Current respiratory tract infection 

2. significant head injury or altered loss of consciousness 

3. Aged less than 1 year old 

Uncommon contra-indications 

1. Co-existing injury for which GA is necessary 

2. Severe cognitive or motor delay. 

3. Hypertension, congenital heart disease, severe behavioural problems, previous 

psychosis, or porphyria. 

4. Uncontrolled epilepsy 

5. Intracranial hypertension with CSF obstruction 

6. hyperthyroidism, or thyroxine medication 

7. Glaucoma or penetrating ocular injury 

8. Prior adverse reaction to ketamine. 

Caution 

Recent food intake is not a contraindication to procedural sedation (Annals Emer 

Med 1998, 31,663-677) and no specific time period of starvation guarantees an 

empty stomach, or avoidance of vomiting. 

As children get older (age> 8yo) they, and adults, are more likely to have 

emergence delirium-therefore consider alternative sedation 

Side effects 

1. Ketamine can very rarely cause laryngospasm, resulting in noisy 

breathing. This is usually dealt with by using a simple airway opening-head 

tilt/chin lift/jaw thrust- manoeuvres with oxygen. 

2. Vomiting 10% 

3. Transient red rash in 10% 

4. Lacrimation and salivation 10% 

5. Rarely, vivid dreams in children. 

6. Brief tonic clonic movements. These are not epileptic seizures 

7. Emergence delirium with hallucinations may occur but is usually mild and 

does not require specific treatment-it settles within 1 hr and in children is not 

helped by Midazolam. 

General Preparation 

1. The parent must be given the advice sheet on ketamine. 

2. Informed consent MUST be obtained, and a consent form signed. 

3. The child must be accurately weighed and the weight documented. 

4. If a delay of over 45 minutes is likely e.g. the child is not fasted for 1hr, then 

apply topical local anaesthetic cream to the thigh in readiness for the I.M. 

ketamine injection. 

23 




5. Ensure that the paediatric resuscitation equipment is available in the 

resuscitation room or major trauma room and that the suction, pulse oximeter 

and oxygen is available and working. 

6. Note time the child last ate drank. For an emergency procedure in a child who 

has not fasted, base the decision to proceed with sedation on the urgency of the 

procedure. If the department is very busy it may be appropriate to defer the 

sedation till following morning in which case apply 2-4-6 fasting rule: 2hr for clear 

fluids-4hr for breast milk-6hr for solids. Please BE AWARE this does NOT 

guarantee and empty stomach so still check suction and head down tilt on 

trolley. 

Equipment Needed 

Ketamine and atropine dosage chart 

Atropine 

500mcg/ml or 600mcg/ml 

Ketamine vial 

1ml syringe without attached needle 

2 orange needles 

A vomit bowl 

Appropriate equipment for the procedure 

Sedation Procedure 

1. The appropriate volume of 2.5mg/kg ketamine and 10mcg /kg atropine 

should be drawn up together into one syringe 1or 2 ml 

2. The injection is given in the outer aspect of the middle thigh (at the site of the 

EMLA if used).Injection MUST be IM not subcut.-consider blue needle 

3. The time of injection should be noted, and after 5 minutes the child’s state of 

awareness should be assessed. The ideal state is one where by the painful 

area can be handled without the child becoming distressed. If the desired 

degree of sedation is not achieved with the first injection then a second dose 

of Ketamine (1.5 mg/kg) may be given. 

4. Local anaesthetic should be injected into any wound requiring suturing. 

During the procedure the nurse may have to gently hold the child’s head or limbs, 

as the child may move their head or her arms in a random fashion. 

Recovery. 

At the end of the procedure the child should be placed on his or her side with 

a vomit bowl available on the trolley. During this period the child may appear 

confused, say inappropriate words, sing or cry as he or she wakes up. After 

about 30 minutes the child can be transferred to an alternative area. 

The child will be allowed home once they fully recognise their parent(s) and ideally 

can walk unaided. (At home the child should not walk independently for the first 2 

hours after discharge). This will normally take 60 to 90 minutes. During this period, 

the parents should be advised to keep the child as still as possible, as rapid 

movements may precipitate an episode of vomiting. 

Only clear fluids should be allowed during this time, because vomiting can occur 

during this period. 

24 




References: 

College of Emergency medicine: Ketamine Sedation of Children in EDs Sept 2009, 

NICE Clinical Guideline 112. Sedation in Children and young People. 

Check list form- Ketamine sedation 

Procedure 

Age 

Weight 

__________________________ 

______yrs 

______kg 

CALCULATED DOSES OF 

Any contra-indications to ketamine? 

• Parents read the information sheet? 

• consent form signed 

yes no 

yes no 

yes no 

• child’s weight documented in the A&E card 

yes no 

• Ametop applied to thigh if there is a delay of over 30 minutes 

yes no 

• A least 3 staff required: Dr to manage the airway after sedation, clinician to perform the 

procedure, experienced nurse to support the patient, document physiological observations 

support the family and the staff 

• Child transferred to critical care room or Resus. 

yes no 

• suction and oxygen to hand and working 

yes no 

• pulse oximetry used 

• NICE guidance recommends capnography 

yes no 

yes /no 

• 3 lead ECG and Blood pressure monitoring 

yes no 

Suture set plus local anaesthetic / dressing pack as appropriate yes no 

• 

• Atropine 0.6mg vials, 1ml syringe without attached needle plus orange needles. 

• Ketamine 50mg/ml vial- drug dosages calculated 

• Second dose ketamine if necessary 

• adverse reactions recorded in the A&E card yes no 

• doctor code on Extramed CRIS-sedation (within treatment column), over and above suture or f.b 

removal as applicable 

• follow up arranged 

25 




• Ensure parents are given a vomit bowl in the cubicle and when discharged 

Ketamine Information Sheet for parents 

If you are reading this it means your child probably has a cut that needs stitches and that your child 

would be distressed /combative with just a needle of local anaesthetic 

The purpose of this information sheet is to help reduce some of the stress you will be having 

from bringing your child into hospital. 

Ketamine is 

is a reliable drug for making children sleepy 

which, after an injection in the leg, usually works by 5 minutes, 

It lasts for about 15 minutes and then your child will gradually wake up over an hour 

Ketamine is not 

A general anaesthetic, in the dose we use here 

Are there any side effects? 

As the drug takes effect your child will get wobbly eye movements, and may make small jerky 

movements of the legs or arms 

As the drug wears off, some children, particularly if they are over 8 years old, may hallucinate 

and swear-this is called emergence delirium and is usually mild (in 20%) 

As the drug wears off they are very wobbly –as if drunk-and unsafe on their feet for 

approximately an hour or so. 

Some children get a rash 

Some children vomit. This happens usually in A&E after they have woken up fully. Occasionally 

they may continue to vomit for up to 24 hours, but this does not require admission or treatment. 

What alternative exist? 

Depending on the problem and child’s age e.g. wound or foreign body, the only alternative may be 

transfer to Manchester children hospital, hospital admission, and general anaesthetic to achieve 

the same end point. 

While risks of General anaesthesia in current practice are very low, the risks exceed sedation. 

Vomiting can exit after both approaches: GA or sedation. Emergency delirium while uncommon and 

self limiting does not occur after GA. 

Different drugs for sedation may be considered again depending on weight of child and the Dr may 

go into detail, if you wish, about the relative / benefit risks of the other drugs sometimes used for 

sedation. 

When can they go home? 

When they are talking normally 

Ideally but not necessarily when they can walk normally. For some children it may take 2 hours 

for them to return to normal ability to walk and in this time they should be closely supervised by 

parent to prevent further fall and potential injury 

Anything to watch out for at home? 

Supervise all playing, bathing in next 8 hours after getting home. 

Do not let your child swim or use play equipment that may cause an accident for next 

24hours 

Do not let them have a meal for at least 2 hours, but small amounts clear liquid or jelly should 

be tried first. 



Paediatric A&E Sedation Guidelines written by Dr M Nichol August 2011 

26

Some children do not sleep properly the first night at home 

Some children may behave differently for a day or two! 

Rarely some children vomit within first 24 hours at home 

If you are worried 

Phone 01625-661451 and ask for the Emergency department nurse 

Ketamine dosage schedule for paediatric procedural 

sedation 

! Pitfalls! 

Check the concentration of ketamine on the bottle as drug errors relate to not 

checking the volume is appropriate for the two different concentrations of ketamine 

bottle. 

(It is not always possible to have only one concentration available) 

Occasionally it may be necessary to provide a top up dose of 1.5mg/kg after the 

initial 2.5mg/kg.im ketamine is usually most pragmatic, some staff may feel IV 

access and IV 1mg/kg as pragmatic alternative. 

Child’s weight 

kg 

Dose at 

2.5mg/kg 

Volume if using bottle 

concentration of 

50mg/ml 

100mg/ml 

10 kg 25 0.5 ml 0.25 ml 

12 kg 30 0.6 0.3 ml 

14 kg 35 0.7 0.35 ml 

16 kg 40 0.8 0.4 ml 

18 kg 45 0.9 0.45 ml 

20 kg 50 1 0.5 ml 

22 kg 55 1.1 0.55 ml 

24 kg 60 1.2 0.6 ml 

26 kg 65 1.3 0.65 ml 

28 kg 70 1.4 0.7 ml 

KETAMINE initial dose 2.5 mg/kg 

Dose of ketamine required = child’s weight (kg) X 2.5 = 

______mg 

Volume of 50mg/ml ketamine = mg of ketamine/50= ______mls 

27 




ATROPINE DOSAGE CHART (10mcg/kg) 

This chart is calculated for atropine vials concentration 600 micrograms per millilitre when used in 

conjunction with ketamine for paediatric sedation 

CHILD’S WEIGHT 

Kg 

DOSE OF 

ATROPINE 

mcg 

VOLUME OF 

ATROPINE 

@600mcg/ml 

ml 

10 100 0.16 

11 110 0.18 

12 120 0.20 

13 130 0.21 

14 140 0.23 

15 150 0.25 

16 160 0.26 

17 170 0.28 

18 180 0.30 

19 190 0.31 

20 200 0.33 

21 210 0.35 

22 220 0.36 

23 230 0.38 

24 240 0.40 

25 250 0.41 

26 260 0.43 

27 270 0.45 

28 280 0.46 

29 290 0.48 

30 300 0.50 

ATROPINE 

10 microgram/kg 

Dose of atropine required = child’s weight (kg) X 10 =______micrograms 

28 




Volume of 600 mcg/ml atropine = mcg of atropine/600 = 

Patient sticky label 

______mls 

Date: --------------------------------------- 

Procedure required laceration repair / foreign body removal / 

other … 

Doctor sedating ------------------ 

Doctor doing procedure ----------------- 

Nurse assistant ------------------- 

Location of ketamine sedation------------------- 

Time (s) 

Ketamine 

given 

Other 

drug 

given 

Knife to 

skin/start 

time 

O2 l/min 

SpO2 

RRate 

PR 

ECG 

rhythm 

Bp 

systolic 

diastolic 

Conscious 

level 

AVPU 

Morbidity: rash, vomit, hypoxia, aspiration 

29 




REFERENCES 

Bhatt-Mehta, V. & Rosen, D.A. (1998) 

Sedation in children; current concepts. Pharmacotherapy. 18(4); 790-807 

 

Chapman, S. & Nakielny, R. (2004). A guide to Radiological procedures - 4 tth 

edition. Elsevier ltd: London. 

Henderson, J.M., Brodsky, D.A., Fisher, DM et al (1988) 

Pre-induction of anaesthesia, in paediatric patients with nasally administered 

sufentanil. Anaesthesiology. 68: 671-675 

Lloyd, C.J., Already, T. & Lowry, J.C. (2000) 

Intranasal midazolam as an alternative to general anaesthesia in the 

management of children with oral and maxillofacial trauma. British Journal of 

oral maxillofacial surgery. 38; 593-95 

Royal College of Paediatrics and Child Health (2009) 

Medicines for Children ISBN: 190095468 0 

Ruddle, T. (2003) 

Sedation: an overview. Paediatric Nursing. Vol.15 (1) p38-41 

American Society of Health System Pharmacists, Inc. Copyright (2003) 

Drug Information: Midazolam hydrochloride. p2370-2378 

Secobarbital sodium. P2352-2353 

Royal College of Surgeons of England ( 2003) 

Commission on the provision of surgical services: Report of the working party on 

Guidelines for Sedation by Non-anaesthetists (June 2003) 

Nicol M.F. (1999) 

Sedation for non-anaesthetists: Are we complying with the National Guidelines - A 

risk management audit. J Accid Emerg Med vol 16 p120-122 1999 

Randall C. (2001) 

Paediatric midazolam: suspected ADR's reported to CSM. (Personal 

communication with Dr M. F. Nicol) 

www.healthcare.micromedex.com 

Chloral hydrate: Overview 

30 




Appendix 1 

SEDATION CHECKLIST PRIOR TO TRANSFER TO DEPARTMENT 

To be completed by named nurse 

1. Correct identification band: yes / no 

2. Allergies yes / no 

3. Sedation assessment form completed: yes / no 

4. Cannula in situ: yes / no 

5. Consent form signed: yes / no 

6. Notes / x-rays / scans yes / no 

7. Prescription chart complete with sedation and antidote: yes / no 

8. Glasses / nail varnish / jewellery removed: yes / no 

9. Loose teeth / caps / brace yes / no 

10. Fasted from: 

Date:_________ 

Time:_________ 

11. Any variance from above, please record below 

Transfer nurse to complete checklist. Print name 

Signed: 

31 




Equality Analysis (Impact assessment) 

What is being assessed? Name of the policy, procedure, proposal, strategy or 

service: 

Amalgamated Paediatric Sedation Guidelines 

Details of person responsible for completing the assessment: 

Name: J Shippey 

Job title: Paediatric Practice Development Nurse 

Team: Paediatrics 

State main purpose or aim of the policy, procedure, proposal, strategy or service: 

(usually the first paragraph of what you are writing. Also include details of legislation, 

guidance, regulations etc which have shaped or informed the document) 

The purpose of the paediatric sedation guideline is to support nurses and medical staff in ensuring 

the safety of children requiring sedation. Procedures for which children require sedation are 

included, with preference of medication to be prescribed. In the event of an adverse reaction, or a 

dosage error, instructions are provided to manage the situation. 

2. CONSIDERATION OF DATA AND RESEARCH 

To carry out the equality analysis you will need to consider information about the people 

who use the service and the staff that provide it. 

2.1 Give details of RELEVANT information available that gives you an understanding 

of who will be affected by this document 

All paediatric patients having sedation 

2.2 Evidence of complaints on grounds of discrimination: (Are there any complaints 

either from patients or staff (grievance) relating to the policy, procedure, proposal, 

strategy or service or its effects on different groups?) 

none 

2.3 Does the information gathered from 2.1 – 2.3 indicate any negative impact as a 

result of this document? 

no 

3. ASSESSMENT OF IMPACT 

Now that you have looked at the purpose, etc. of the policy, procedure, proposal, 

strategy or service (part 1) and looked at the data and research you have (part 2), this 

section asks you to assess the impact of the policy, procedure, proposal, strategy or 

service on each of the strands listed below. 

32 




RACE: 

From the evidence available does the policy, procedure, proposal, strategy or service affect, or have 

the potential to affect, racial groups differently? Yes No 

Explain your response: Where there is a patient and parents whose first language is not English, staff 

should follow the trust interpretation and translation policy – eg in obtaining consent, ensuring parents 

understand written information leaflets, ensuring correct checks made immediately prior to sedation and 

accurate patient history. 

GENDER (INCLUDING TRANSGENDER): 


the potential to affect, different gender groups differently? Yes No x 

Explain your response: No differential impact identified as both genders would be treated the same. 


DISABILITY 

the potential to affect, disabled people differently? Yes No 

Explain your response: If the patient or carers are deaf, then a British sign language interpreter may be 

needed (in the future staff will have access to signtranslate – an online translation tool used with a 

webcam). If the patient or carer is blind, then information can be recorded in audio format. If the patient 

or parent has learning disabilities, staff should ensure information is understood and appropriate methods 

of communication are used. There is a picture communications book in the Communication Box on the 

ward/dept and staff should be aware of how to access the health facilitator for children with learning 

disabilities from Cheshire & Wirral Partnership Trust. Staff should ensure they have accessed trust 

learning disability awareness training. 

Guidance on helping/approaching patients with disabilities can be found in the trust’s ‘Welcoming people 

with disabilities’ booklet (also in the communications box. 

AGE: 

From the evidence available does the policy, procedure, proposal, strategy or service, affect, or have 

the potential to affect, age groups differently? Yes No 

Explain your response: The policy is specifically targeted at children and young people and their 

parents. 

LESBIAN, GAY, BISEXUAL: 


the potential to affect, lesbian, gay or bisexual groups differently? Yes No x 

Explain your response: Care and treatment would be the same regardless of sexual orientation. Same 

sex couple would be involved in their child’s care in the same way as heterosexual couples. All staff have 

equality and human rights training in statutory/mandatory training. 

RELIGION/BELIEF: 


the potential to affect, religious belief groups differently? Yes No 

Explain your response: There may be drugs used which contain porcine products. If staff do not know 

whether a drug contains such products and it is a Muslim patient, they should check with pharmacy at the 

time. 

CARERS: 


the potential to affect, carers differently? Yes No 

Explain your response: See details in above sections. 

OTHER: EG Pregnant women, people in civil partnerships, human rights issues. 


the potential to affect any other groups differently? Yes No x 

Explain your response: No other issues identified. 

33 




4. Safeguarding Assessment - CHILDREN 

a. Is there a direct or indirect impact upon children? Yes x No 

b. If yes please describe the nature and level of the impact (consideration to be given to all 

children; children in a specific group or area, or individual children. As well as consideration of 

impact now or in the future; competing / conflicting impact between different groups of children 

and young people: 

Policy only relates to Children so will directly impact children who are having sedation. Any information 

given to children/young people should be age appropriate. There is a picture communications book in the 

ward communications box. 

c. If no please describe why there is considered to be no impact / significant impact on children 

5. Relevant consultation 

Having identified key groups, how have you consulted with them to find out their views and 

made sure that the policy, procedure, proposal, strategy or service will affect them in the 

way that you intend? Have you spoken to staff groups, charities, national organisations etc? 

All relevant staff groups have had the opportunity to read and comment on this policy. Policy has been 

amended to reflect their opinions. 

6. APPROVAL – At this point, you should forward the template to: 

The Trust’s Equality and Diversity Lead lynbailey@nhs.net 

The Named Nurse for Safeguarding Children melaniebarker@nhs.net 

Equality and Diversity response: Approved 

Safeguarding Children response: Approved 

7. Any actions identified: Have you identified any work which you will need to do in the 

future to ensure that the document has no adverse impact? 

Action Lead Date to be Achieved 

1. Ensure all staff have been on learning 

disability awareness training 

2. Ensure all staff aware of communications 

box and contents 

3. Ensure age appropriate information 

available 

8. Review Date: 

Date completed: 

This is 

covered by 

Paediatrics 

The 

Essentials 

which all 

staff 

attend 

annually 

JS and 

Ann 

Costello 

(HPS) 

All staff attend anually 

August 2012 

The Trust’s Equality and Diversity Lead: 

The Named Nurse for Safeguarding Children:… Melanie Barker 

34

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