Pediatric Procedural Sedation — Med-Peds Resources

Pre-sedation assessment, fasting, monitoring, rescue readiness, recovery, and discharge checks for children sedated outside the operating room.

Scope

This is a bedside safety checklist for infants and children receiving sedation for diagnostic or therapeutic procedures outside the operating room. Use the local sedation policy, scope of practice, and rescue pathway. The AAP/AAPD guideline requires a systematic safety approach and the ability to rescue a child from one level deeper than the intended sedation level (AAP/AAPD 2019).

Before sedation

Confirm medical or dental supervision, trained staff, age- and size-appropriate airway equipment, suction, oxygen, monitors, rescue drugs, and reversal agents before giving a sedative (AAP/AAPD 2019).
Assess age, weight, birth history, allergies, medications, airway anatomy, tonsillar hypertrophy, snoring or obstructive sleep apnea, pregnancy possibility, prior sedation complications, and ASA status (AAP/AAPD 2019).
Document the focused airway examination and the plan for airway obstruction, aspiration, and rescue, including IV access appropriate to the planned depth (AAP/AAPD 2019).

Elective fasting

The AAP/AAPD guideline adopts the following minimum intervals for elective sedation. The amount and type of intake still matter, and local policy may be more restrictive.

Ingested material	Minimum interval	Source
Clear liquids	2 hours	AAP/AAPD 2019
Human milk	4 hours	AAP/AAPD 2019
Infant formula	6 hours	AAP/AAPD 2019
Nonhuman milk	6 hours	AAP/AAPD 2019
Light meal	6 hours	AAP/AAPD 2019

For an urgent procedure, there is no single universal fasting rule. Balance the aspiration risk, procedure urgency, and the depth of sedation, and use the lightest effective sedation with nonpharmacologic or local/regional alternatives where feasible (AAP/AAPD 2019).

During sedation

Moderate sedation

Continuously monitor oxygen saturation and heart rate (AAP/AAPD 2019).
Monitor ventilation with capnography when the child can communicate; it is strongly preferred. When the child cannot communicate, ventilation monitoring by capnography or an amplified pretracheal or precordial stethoscope is required (AAP/AAPD 2019).
Record heart rate, respiratory rate, blood pressure, oxygen saturation, and expired carbon dioxide at least every 10 minutes (AAP/AAPD 2019).

Deep sedation

Have at least two people trained in patient rescue with current PALS or APLS skills; one must be a dedicated observer who is not performing the procedure (AAP/AAPD 2019).
Make an ECG monitor and pediatric defibrillator readily available, and place IV access at the start or have skilled pediatric vascular access immediately available (AAP/AAPD 2019).
Continuously observe the child and record heart rate, respiratory rate, blood pressure, oxygen saturation, and expired carbon dioxide at least every 5 minutes (AAP/AAPD 2019).
Use capnography for almost all deeply sedated children unless a documented circumstance makes it infeasible (AAP/AAPD 2019).

Recovery and discharge

Recover the child in a dedicated, equipped area with suction, oxygen, positive pressure ventilation, rescue drugs, and age- and size-appropriate equipment (AAP/AAPD 2019).
If the child is not fully alert, continuously monitor oxygen saturation and heart rate until discharge criteria are met (AAP/AAPD 2019).
Before discharge, confirm stable airway and cardiorespiratory status, easy arousal, intact protective reflexes, age-appropriate ability to talk and sit, and adequate hydration (AAP/AAPD 2019).
Observe longer after reversal agents because re-sedation can occur after the antagonist wears off (AAP/AAPD 2019).

Red flags for escalation

Stop or reduce sedation and escalate for loss of airway patency, inadequate respiratory gas exchange, unexpected depth of sedation, cardiovascular instability, or failure to return to the presedation level of consciousness. These are rescue triggers under the guideline’s safety framework (AAP/AAPD 2019).