Stanford PICU Sedation Protocol v2.0- Continuous Sedation (see below for intermittent)

Intermittent Sedation Protocol v1.0

FLACC and SBSS Scoring

Sedation Meds and Mechanisms (Courtesy of Richard Pierce, MD)

General Approach

Opioid Rotation (Continuous Sedation with Dose Decrement) (From CHOP Sedation Guidelines)

PCA Dosing and Respiratory Effects, Courtesy of Richard Pierce, MD


General Considerations:

1)       What is the overall goal? (i.e. pain control?, amnesia to procedure?, etc.)

2)       What is the medical condition of the patient? (i.e. co-morbidities?)

3)       How quickly do you want the desired effect? [most relevant when considering intubation]

4)       What is the duration of the desired effect?

5)       What are the potential side effects, and are they unacceptable in that particular setting?

6)       How is the medication metabolized/cleared, and is this important?

7)       Is the route of delivery important?

8)       Are there cost considerations?


Sedation and NMB, courtesy of Kato Han, MD

Neuromuscular Blockers:



Neuromuscular Blockers not on Formulary:





Analgesics (cont.):










1) 9 month old infant with jaundice and liver failure requiring percutaneous liver biopsy.

2) Same patient 2 hours later, tachycardic, appearing pale and mottled.

3) Same patient 24 hours later, on HFOV for ARDS, requiring epinephrine infusion, no urine for past 8 hours.

4) 10 year old s/p MVA, initially following commands but now becoming unresponsive after arrival into the trauma room.

5) 6 year old initially admitted for septic shock/ARDS/MODS, continuing to require moderate amounts of support and increasing sedative doses for “agitation”; seems somewhat “wild” at times.

Sedation Chart, Sedation Chart 2




1) Curley MA, Wypij D, Watson RS, Grant MJ, Asaro LA, Cheifetz IM, Dodson BL,Franck LS, Gedeit RG, Angus DC, Matthay MA; RESTORE Study Investigators and the

Pediatric Acute Lung Injury and Sepsis Investigators Network. Protocolized sedation vs usual care in pediatric patients mechanically ventilated for acute

respiratory failure: a randomized clinical trial. JAMA. 2015 Jan 27;313(4):379-89. doi: 10.1001/jama.2014.18399. PubMed PMID: 25602358.

2) Franck LS, Harris SK, Soetenga DJ, Amling JK, Curley MA. The Withdrawal Assessment Tool-1 (WAT-1): an assessment instrument for monitoring opioid andbenzodiazepine withdrawal symptoms in pediatric patients. Pediatr Crit Care Med. 2008 Nov;9(6):573-80.

3) Adult CPG for Pain, Sedation, Delirium, Mobility, CCM 2018