Episode 34: The Pediatric sedation podcast with dr. dana libov and dr. anand swaminathan

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 (e.g., set up your lac tray with your back to the patient). If the child is aware or anxious about seeing the needle, maintain that approach during the procedure and pair with distraction techniques (e.g., allowing the child to watch a phone or tablet). Building their trust will allow for cooperation! 

• Use comfort holds

• Intranasal medications:

  • Technique: Aim up and toward the ipsilateral ear—absorption occurs via the turbinates.

  • Avoid sniffing: This drives medication posteriorly, decreasing absorption as the medicine. Too often in practice, the nurses encourage the patient to sniff but the medicine then becomes intraoral instead of intranasal. 

  • Push quickly: Rapid administration allows atomization (as opposed to a slow dribble which just waterboards the patient).

  • Dosing:

  • IN Midazolam (Versed): 0.5 mg/kg (max 10 mg)

  • IN Fentanyl: 2 mcg/kg (max 100 mcg)

• Ensure nursing uses the correct concentration. Versed, in particular, comes in multiple concentrations.

• Oral anxiolysis:

  • Oral midazolam is often a great option since it avoids the discomfort/burning of intranasal administration and doesn’t need to be timed as precisely with procedures. The dosing can surprise clinicians (max 20 mg), but appropriate dosing is key for effectiveness. Children metabolize medications quickly and are less often affected by polypharmacy, so underdosing is a common pitfall.

• Combine sedation with analgesia:

  • Even during procedural sedation, use local anesthetic or analgesic adjuncts to minimize total sedative requirements (e.g., apply LET for laceration repairs or perform a hematoma block for forearm reductions).