Pediatric ICU Sedation Data Form
Pediatric ICU Sedation Data Form – Please complete all fields relevant to this sedation record.
Date and time of sedation event
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Patient age group
*
Please Select
Neonate (0-28 days)
Infant (1-12 months)
Toddler (1-3 years)
Preschool (3-5 years)
School Age (6-12 years)
Adolescent (13-18 years)
Reason for sedation
*
Please Select
Procedural
Ventilation
Agitation
Other
Sedative administered
*
Please Select
Midazolam
Dexmedetomidine
Propofol
Ketamine
Fentanyl
Other
Dosage (mg or mcg/kg)
*
Route of administration
*
Please Select
Intravenous
Oral
Intramuscular
Other
Observed response to sedation
*
Adequate sedation
Undersedation
Oversedation
Adverse events observed
None
Hypotension
Bradycardia
Respiratory depression
Other
Sedation assessment score or comments
Name and role of person completing this form
*
Submit Record
Should be Empty: