The Pediatric Sedation Podcast
This Only in Staten episode features Dr. Dana Libov, who is dual-boarded in EM and PEM and works at Cohen Children's and North Shore, in conversation with Dr. Anand Swaminathan about pediatric procedural sedation and anxiolysis.
Learning points
Keep sharps out of view
For any procedure involving sharps, keep them out of the child's line of sight as long as possible. For example, set up the laceration tray with your back to the patient.
If the child is aware of or anxious about the needle, keep it hidden throughout the procedure and pair this with distraction (for example, letting the child watch a phone or tablet). Building trust earns cooperation.
Use comfort holds
Positioning the child in a caregiver's arms (a comfort hold) can reduce distress and the need for restraint.
Intranasal medications
Technique: aim up and toward the ipsilateral ear. Absorption occurs across the turbinates.
Avoid sniffing. Sniffing drives medication posteriorly, so it is swallowed and absorbed less well. Nurses often encourage the patient to sniff, but the medication then ends up oral rather than intranasal.
Push quickly. Rapid administration atomizes the drug; a slow dribble just runs down the back of the throat.
Dosing:
IN midazolam: 0.5 mg/kg (max 10 mg)
IN fentanyl: 2 mcg/kg (max 100 mcg)
Confirm the concentration with nursing. Midazolam in particular comes in several concentrations.
Oral anxiolysis
Oral midazolam is often a great option. It avoids the burning of intranasal administration and does not need to be timed as precisely with the procedure.
The dose (max 20 mg) can surprise clinicians, but adequate dosing is key to effectiveness. Children metabolize drugs quickly and are less often affected by polypharmacy, so underdosing is a common pitfall.
Combine sedation with analgesia
Even during procedural sedation, use local anesthetics or analgesic adjuncts to minimize total sedative requirements. For example, apply LET for laceration repairs, or perform a hematoma block for forearm fracture reductions.
Clinical pearls
Hide the needle, distract the child, and keep a caregiver close.
Intranasal: aim toward the ear, push fast, no sniffing.
Pain control and anxiolysis are separate goals. Treat both.
