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To compare the Bispectral Index with clinical sedation assessment using the Ramsay score in normal sedated and paralyzed critically ill children.Prospective observational study.Multidisciplinary 18-bed pediatric intensive care unit at a university-affiliated children’s hospital.A total of 48 pediatric intensive care unit patients requiring mechanical ventilation and sedation. Of these, 24 patients were not paralyzed.Twenty-four pediatric intensive care unit children with normal mentation who were sedated and being ventilated in the intensive care unit were included in the study. The Ramsay score as assessed by the nurses was compared with the blinded Bispectral Index score. The regression coefficient between the Bispectral Index score and Ramsay score was 0.77 (p < 0.0001). The second group of patients included normal children similar to the previous group but paralyzed. The Ramsay score, as expected, was a poor tool for sedation assessment in a paralyzed patient. The nurse assessment only detected 8% of those patients at risk for awareness and recall (Bispectral Index score, ≥80). Nurse assessment for oversedation (Bispectral Index score, <40) was better with a sensitivity of 89.7% but a poor specificity of 38.6%.The Bispectral Index correlates well with the Ramsay score in the normal sedated child. The Ramsay score and bedside nurse assessment are inadequate for monitoring the depth of sedation in paralyzed children. The Bispectral Index is a useful adjunct in assessing sedation in a paralyzed patient.