Drug regimens using methoxyflurane, nitrous oxide, midazolam or an opioid for conscious sedation in children

If conscious sedation is appropriate for a child, the following drug regimens may be used; see Principles of conscious sedation for a discussion of whether these regimens should be used alone or in combination. Additive drug effects are likely when the regimens are combined and reduced doses may be required.

Inhaled analgesics (ie methoxyflurane or nitrous oxide) must only be used for conscious sedation by suitably trained and credentialed practitioners. In children aged 2 to 4 years, use:

nitrous oxide 50 to 75% with oxygen via a nonpatient-triggered system using continuous flow, inhaled to maintain adequate analgesia and sedation for the duration of the painful procedure. Full analgesic effect is expected after 5 to 8 inhalations. procedural sedation and analgesia, conscious sedation (children) nitrous oxide

In children 5 years or older, use:

1 methoxyflurane via a self-administered device, inhaled intermittently to maintain adequate analgesia and sedation for the duration of the painful procedure¹. Full analgesic effect is expected after 5 to 8 inhalations. Do not exceed a dose of 6 mL in 24 hours procedural sedation and analgesia, conscious sedation (children) methoxyflurane

OR

1 nitrous oxide 50% with oxygen 50% via a patient-triggered device, inhaled intermittently to maintain adequate analgesia and sedation for the duration of the painful procedure². Full analgesic effect is expected after 5 to 8 inhalations nitrous oxide

OR

1 nitrous oxide 50 to 75% with oxygen via a nonpatient-triggered system using continuous flow, inhaled to maintain adequate analgesia and sedation for the duration of the painful procedure. Full analgesic effect is expected after 5 to 8 inhalations. nitrous oxide

Opioids must only be used for conscious sedation by suitably trained and credentialed practitioners. If an opioid is indicated for conscious sedation in children 2 years or older, use:

1 fentanyl 50 micrograms/mL solution³ procedural sedation and analgesia, conscious sedation (children) fentanyl

spray 1.5 micrograms/kg up to 100 micrograms intranasally, via atomiser attached to a small syringe. Spray up to 0.3 mL (15 micrograms) into each nostril, alternating between nostrils up to the required dose⁴. After 5 minutes, give a single repeat dose of 0.75 micrograms/kg up to 50 micrograms intranasally, if required. Use lower doses if the child has received opioids in the previous 2 hours or receiving concomitant sedatives (eg midazolam)⁵

OR

1 fentanyl 0.5 micrograms/kg up to 25 micrograms intravenously. After 5 minutes, give a single repeat dose of 0.25 micrograms/kg up to 10 micrograms intravenously, if required. Use lower doses if the child has received opioids in the previous 2 hours or receiving concomitant sedatives (eg midazolam) fentanyl ⁵

OR

1 morphine 50 micrograms/kg up to 2.5 mg intravenously. After 10 minutes, give a single repeat dose of 25 micrograms/kg up to 1 mg intravenously, if required. Use lower doses if the child has received opioids in the previous 2 hours or is receiving concomitant sedatives (eg midazolam)⁵. procedural sedation and analgesia, conscious sedation (children) morphine

Midazolam must only be used for conscious sedation by suitably trained and credentialed practitioners. It may be administered buccally, intranasally or intravenously in children. Buccal or intranasal midazolam may be preferred to intravenous administration because attempts at venous access can cause significant distress and intravenous midazolam is more likely to cause inadvertent deep sedation. Intravenous midazolam should only be used if the situation is urgent and rapid dose titration is required.

Note: Midazolam must only be used for conscious sedation by suitably trained and credentialed medical practitioners.

If buccal or intranasal midazolam is indicated as part of combination therapy for conscious sedation in children 2 years or older, use:

1 midazolam 0.25 to 0.5 mg/kg up to 10 mg buccally, as a single dose, 20 to 30 minutes before the procedure. Use the lower end of the dose range if the child is receiving opioids or other sedatives⁵ ⁶ procedural sedation and analgesia, conscious sedation (children) midazolam

OR

2 midazolam 0.2 to 0.3 mg/kg up to 10 mg intranasally, as a single dose, 10 to 15 minutes before the procedure. Use the lower end of the dose range if the child is receiving opioids or other sedatives⁵ ⁷. midazolam

Midazolam can cause ataxia, so the child should stay in bed or sit on the parent’s lap until its effects have resolved.

¹ Methoxyflurane must always be administered using the device supplied with the vials because they have a fitted charcoal filter, which minimises nonpatient exposure.Return

² The fixed-concentration preparation of nitrous oxide 50% with oxygen 50% is known as Entonox.Return

³ A 300 micrograms/mL solution is available in some hospitals; due to the smaller volume required, dividing the dose between nostrils may not be necessary.Return

⁴ The dose is divided into actuations because volumes over 0.3 mL are unlikely to be absorbed from the nasal mucosa; excess solution runs down the back of the throat limiting the effect due to poor gastrointestinal absorption of the swallowed portion.Return

⁵ For overweight children, use ideal body weight to calculate the dose.Return

⁶ Midazolam has a bitter taste and is more palatable buccally if administered with apple juice.Return

⁷ Midazolam stings when given by the intranasal route—avoid this route for repeated procedures.Return