IV Nembutal: safe sedation for children undergoing CT

Assessment of the practice of pediatrics procedural sedation and analgesia for magnetic resonance imaging and computed tomography scan at a teaching hospital, Ethiopia, 2020: A clinical audit

BACKGROUND

The main goals of paediatric sedation/general anesthesia vary according to the specific imaging procedure, but generally includes anxiety relief, pain control and control of excessive movement. The quality of magnetic resonance imaging (MRI) and computed tomography (CT) depends largely on immobility of the patient during the procedure, which is often difficult to achieve without sedation in children. Sedation is the depression of the central nervous system and reflexes by the administration of drugs. Brain imaging is routinely used to identify stroke, hemorrhage, and structural abnormalities. All patients undergoing procedural sedation and those receiving general anesthesia should be evaluated equally.

AIM

The study aimed to perform a clinical audit of sedation and analgesia practices for magnetic resonance imaging and computed tomography compared against the guidelines/standards to determine if practice meets the standards and identify areas of non-compliance at a teaching Referral Hospital in Ethiopia.

METHODS

This clinical audit was conducted from January 1 to May 30/2020 for 5 months at a teaching Referral Hospital in Ethiopia. All children below the age of 6 years underwent MRI and CT imaging procedures under sedation during a study period were included. Data were collected through direct observation using checklists of standards by a trained data collector. Descriptive statistics were presented with tables, graphs of sums and percentages of items using SPSS version 20.

RESULTS

A total of 40 children underwent MRI and CT imaging were observed at the Hospital imaging sites. Among the 20 standards, 6 of them had 100% compliance rate, 3 of the standards had 0% complaince rate and 11 of the standards had the compliance rate of between 0 and 100%.

CONCLUSIONS AND RECOMMENDATIONS

In general, even though the practice guidelines of procedural sedation for MRI and CT recommend to practice procedures based on the standards, this study showed there were a number of standards that had <100% compliance rate. Therefore, it is recommended that staff should adopt standards or locally prepared protocols for their day-to-day practice.

Options and Considerations for Procedural Sedation in Pediatric Imaging

As pediatric imaging capabilities have increased in scope, so have the complexities of providing procedural sedation in this environment. While efforts by many organizations have dramatically increased the safety of pediatric procedural sedation in general, radiology sedation creates several special challenges for the sedation provider. These challenges require implementation of additional safeguards to promote safety during sedation while maintaining effective and efficient care. Multiple agent options are available, and decisions regarding which agent(s) to use should be determined by both patient needs (i.e., developmental capacities, underlying health status, and previous experiences) and procedural needs (i.e., duration, need for immobility, and invasiveness). Increasingly, combinations of agents to either achieve the conditions required or mitigate/counterbalance adverse effects of single agents are being utilized with success. To continue to provide effective imaging sedation, it is incumbent on sedation providers to maintain familiarity with continuing evolutions within radiology environments, as well as comfort and competence with multiple sedation agents/regimens. This review discusses the challenges associated with radiology sedation and outlines various available agent options and combinations, with the intent of facilitating appropriate matching of agent(s) with patient and procedural needs.

Complications of three deep sedation methods for magnetic resonance imaging

Background:

Propofol and pentobarbital are commonly used to sedate children undergoing magnetic resonance imaging (MRI).

Aim/Objective:

To compare the safety of three types of sedation: intravenous propofol (PROP), mixed pentobarbital/propofol (PENT), and mixed pentobarbital group requiring supplemental sedation (PENT SUPP) regimens in pediatric patients following deep sedation (DS) for noncardiac MRI.

Materials and Methods:

We conducted a case-control study matching 619 cases with complications with 619 controls using data from our institution's sedation database for children deeply sedated for noncardiac MRI. Cases were defined as patients with any complication and we characterized complications from cases, and used a conditional logistic regression model to assess the association between three DS methods and occurrence of complications after adjusting for confounding variables.

Results:

We found that complications occurred in association with 794 (10.1%) of the 7,839 DSs performed for MRI between 1998 and 2008. Of the 794 cases, 619 cases met inclusion criteria for the study. Among the 619 cases that met inclusion criteria, 24 (0.3% of 7,839 DSs total) were associated with major complications. Type of sedation was significantly associated with the occurrence of complications, and the PENT group was associated with decreased odds of complications when compared to the PROP regimen (OR 0.68; 95% CI 0.46, 0.98; P=0.040) and compared to the PENT SUPP group (OR 0.60; 95% CI 0.31, 0.89; P<0.0001).

Conclusions:

DS with a pentobarbital technique was associated with decreased odds for complications when compared to a propofol-based technique or a pentobarbital technique requiring supplemental sedation.

Sedation and anesthesia for CT: emerging issues for providing high-quality care

During the past decades, the use of CT to diagnose conditions and monitor treatment in the pediatric setting has increased. Infants and children often require procedural sedation to maintain a motionless state to ensure high-quality imaging. Various medication regimens have been recommended to achieve satisfactory sedation for this painless procedure. While the incidence of adverse events remains low, procedural sedation carries the risk of serious morbidity and mortality. The use of evidence-based, structured approaches to procedural sedation should be used to reduce variation in clinical practice and improve outcomes.

Population pharmacokinetics of pentobarbital in neonates, infants, and children after open heart surgery

OBJECTIVES

To determine the pharmacokinetics of pentobarbital in neonates, infants, and young children with congenital heart disease after open-heart surgery.

STUDY DESIGN

Thirty-five subjects (3.0 days-4.4 years) after open-heart surgery who received pentobarbital as standard of care were enrolled. Serial pharmacokinetic blood samples were obtained. A population-based, nonlinear mixed-effects modeling approach was used to characterize pentobarbital pharmacokinetics.

RESULTS

A two-compartment model with weight as a co-variate allometrically expressed on clearance (CL), inter-compartmental clearance, central (V1) and peripheral volume of distributions, bypass grafting time as a co-variate on CL and V1, and age and ventricular physiology as co-variates on CL best described the pharmacokinetics. A typical infant (two-ventricle physiology, 6.9 kg, 5.2 months, and bypass grafting time of 60 minutes) had a CL of 0.12 L/hr/kg, V1 of 0.45 L/kg, and peripheral volume of distributions of 0.98 L/kg. The bypass grafting effect was poorly estimated. For subjects <12 months age, an age effect on CL remained after accounting for weight and was precisely estimated.

CONCLUSIONS

Pentobarbital pharmacokinetics is influenced by age and weight. Subjects with single-ventricle physiology demonstrated a 15% decrease in clearance when compared with subjects with two-ventricle physiology.

Sedation trends in the 21st century: the transition to dexmedetomidine for radiological imaging studies

Sedation for radiological imaging studies encompasses the majority of all sedation-related procedures outside of the intensive care unit. This review will follow the evolution of pediatric sedation for radiological imaging studies in North America as well as the transition of sedation services from the oversight of radiologists to those of other providers. The evolving options for sedation agents will be reviewed, with attention given to examining the advantages, limitations, and risks of replacing the standard sedatives with dexmedetomidine.

Midazolam as a sole sedative for computed tomography imaging in pediatric patients

OBJECTIVE

To evaluate the efficacy and adverse effects of i.v. midazolam as a sole agent for sedation in children for computed tomography (CT) imaging.

MATERIALS AND METHODS

Prospective clinical trial in which 516 children under ASA classification II-IV (273 boys and 243 girls) in the age group of 6 months to 6 years for elective CT scan were enrolled over a 17-month period. Patients were administered i.v. midazolam 0.2 mg x kg(-1) and further boluses of 0.1 mg x kg(-1) (total 0.5 mg x kg(-1)) if required. Measurements included induction time, efficacy, side effects, complications, and degree of sedation. Sedation was graded on the basis of Ramsay sedation score (RSS) as over sedated (RSS 5-6), adequately sedated (AS, RSS 3-4), under sedated (RSS 1-2), or failed if the procedure could not be completed or another agent had to be administered.

RESULTS

Of the 516 procedures, 483 brains, 16 chests, and 17 abdomens were scanned with a mean duration of 4.75 +/- 1.75 min with a mean dose of 0.212 mg x kg(-1) of i.v. midazolam. Four hundred and sixty-five (90.12%) patients were AS in 5.9 +/- 0.7 min while 40 (7.75%) patients required additional boluses. Of these 40 patients, 24 (4.65%) required a single bolus, 12 (2.32%) required two boluses, whereas the remaining four (0.78%) required three boluses. In 11 (2.13%; P < 0.0001) patients, the scan could not be completed satisfactorily. Side effects were seen in 46 (9.11%) patients in the form of desaturation, hiccups (seven patients, 1.38%), and agitation (four patients, 0.79%). Desaturation (SpO2 90-95%) was seen in 35 (6.93%) patients, which was corrected by topical application of oxygen. None of the patients exhibited any complications such as pulmonary aspiration or need to maintain airway. The patients were kept under observation for 1 h after the procedure.

CONCLUSION

The level of sedation achieved in children with midazolam 0.2 mg x kg(-1) is adequate for imaging with minimal side effects, no airway complications, and fast recovery. It can be recommended as the sole agent for sedation in pediatric patients for CT imaging.

Dexmedetomidine for procedural sedation in children with autism and other behavior disorders

Dexmedetomidine has been increasingly in use for pediatric noninvasive procedural sedation. This retrospective study examined experience in children with autism and other neurobehavioral disorders, populations often difficult to sedate. Records of children with autism or neurobehavioral disorders sedated with dexmedetomidine at Chris Evert Children's Hospital and Kosair Children's Hospital were reviewed. Demographic and sedation-related data were collected, including sedative doses, time to sedation, efficacy, and complications. Comparisons of sedative doses, efficacy between autism and neurobehavioral patients, and analysis of age-related factors were performed. In all, 315 patients were sedated, most commonly for magnetic resonance imaging. Mean induction and total dexmedetomidine doses were 1.4 +/- 0.6 and 2.6 +/- 1.6 microg/kg, respectively, with no differences between autism and neurobehavior patients. Most patients (90%) patients received concomitant midazolam. There was an age-related decrease in dexmedetomidine dose, independent of midazolam use. Seven patients required intervention for hypotension, bradycardia, or both, and only one adverse respiratory event (obstruction requiring nasopharyngeal airway placement) occurred. There were two episodes of overt recovery-related agitation. All but four procedures were successfully completed (4/315, or 98.7%). Dexmedetomidine with or without midazolam was an effective sedative in this population. The regimen appeared to be well tolerated with few adverse events, including recovery-related agitation, and appears to be an attractive option for this population.

Propofol vs pentobarbital for sedation of children undergoing magnetic resonance imaging: results from the Pediatric Sedation Research Consortium

BACKGROUND

Pentobarbital and propofol are commonly used to sedate children undergoing magnetic resonance imaging (MRI). The Pediatric Sedation Research Consortium (PSRC) was created in 2003 to improve pediatric sedation process and outcomes.

OBJECTIVE

To use PSRC records to compare the effectiveness, efficiency and adverse events of propofol vs pentobarbital for sedation of children undergoing MRI.

METHODS

Pediatric Sedation Research Consortium records of children aged 6 months to 6 years who were primarily sedated with either i.v. pentobarbital or propofol were included. Participating PSRC investigators obtained institutional review board approval before data collection.

RESULTS

Of 11 846 sedations for MRI, 7079 met inclusion criteria (propofol: n = 5072; pentobarbital: n = 2007). Demographic details were similar between the two groups. Ideal sedation was produced in 96.45% of the pentobarbital group and in 96.8% of the propofol group (P = 0.478), but pentobarbital was more likely to result in poor sedation cancelling the procedure (OR 5.88; CI 2.24, 15.40). Propofol resulted in physiologic changes more frequently than did pentobarbital (OR 5.69; CI 1.35, 23.97). Pentobarbital was associated with prolonged recovery (OR 16.82; CI 4.98, 56.8), unplanned admission (OR 5.60; CI 1.02, 30.82), vomiting (OR 36.76; CI 4.84, 279.2) and allergic complication (OR 9.15; CI 1.02, 82.34). The incidence of airway complications was not significantly different between the two. The median recovery time for patients receiving propofol was 30 min, whereas for pentobarbital it was 75 min (P < 0.001).

CONCLUSION

Among institutions contributing data to the PSRC, it is found that propofol provides more efficient and effective sedation than pentobarbital for children undergoing MRI. Although apnea occurred with a greater frequency in patients who received propofol, the rate of apnea and airway complications for propofol was not statistically different from that seen in patients who received pentobarbital.

Sedation with propofol for flexible bronchoscopy in children

BACKGROUND

The purpose of this study was to report our experience with intravenous propofol (IVP) sedation for flexible bronchoscopy (FB) in children.

METHODS

The following data were collected: demographics, pre- and post-procedure diagnoses, induction time (IT), sedation time (ST), procedure time (PT), time to discharge from the hospital (TTD), induction dose (ID) of IVP, total dose (TD) of IVP, and complications. HR, RR, systolic BP (SBP), diastolic BP (DBP), and SpO(2) were recorded every 5 min.

RESULTS

One hundred three (66 males, 37 females) consecutive patients (age: 4.7 +/- 4.3 years) and (weight: 21.2 +/- 16 kg) were enrolled over a 3-year-period. Airway Abnormalities were diagnosed in 93 (90%) patients leading to a change in therapy in 68 (66%) patients. In 20 (19.4%) patients abnormalities unrelated to the primary indication for FB were found. IT was 4.64 +/- 2 min, PT was 6.2 +/- 3.1 min, ST was 27 +/- 14 min, and TTD was 80 +/- 44 min.The ID and TD for IVP were 2.8 +/- 0.1 mg/kg, and 3.1 +/- 0.1 mg/kg respectively. Patients 4-7 years of age required higher induction doses (IDs) of propofol (3.5 +/- 1 mg/kg) compared to infants (2.8 +/- 0.9 mg/kg), 1-3 years of age (2.7 +/- 0.78 mg/kg) and 8-17 years of age (2.4 +/- 0.7 mg/kg) (P < 0.001). There was a correlation between the TD of IVP and TTD from the hospital (r = 0.5, P < 0.01). The drop in SBP (104 +/- 15 vs. 92 +/- 13 mm Hg, P < 0.05) and DBP (57 +/- 13 vs. 46 +/- 9 mm Hg, P < 0.05) during IVP were statistically significant compared to baseline, however none of the patients met the criteria for hypotension. Two patients developed short (<20 sec) respiratory pauses without hypoxia. No patient required fluid resuscitation or endotracheal intubation.

CONCLUSIONS

FB may be performed successfully in children using IVP and is associated with insignificant cardio-respiratory complications.

Comparison of propofol with pentobarbital/midazolam/fentanyl sedation for magnetic resonance imaging of the brain in children

OBJECTIVE

Propofol and pentobarbital, alone or combined with other agents, are frequently used to induce deep sedation in children for MRI. However, we are unaware of a previous comparison of these 2 agents as part of a randomized, controlled trial. We compared the recovery time of children after deep sedation with single-agent propofol with a pentobarbital-based regimen for MRI and considered additional variables of safety and efficacy.

METHODS

This prospective, randomized trial at a tertiary children's hospital enrolled 60 patients 1 to 17 years old who required intravenous sedation for elective cranial MRI. Patients were assigned randomly to receive a loading dose of propofol followed by continuous intravenous infusion of propofol or to receive sequential doses of midazolam, pentobarbital, and fentanyl until a modified Ramsay score of >4 was attained. A nurse who was blind to group assignment assessed discharge readiness (Aldrete score > 8) and administered a follow-up questionnaire. We compared recovery time, time to induction of sedation, total sedation time, quality of imaging, number of repeat-image sequences, adverse events, caregiver satisfaction, and time to return to presedation functional status.

RESULTS

The groups were similar in age, gender, race, American Society of Anesthesiology physical status class, and frequency of cognitive impairment. No sedation failure or significant adverse events were observed. Propofol offered significantly shorter sedation induction time, recovery time, total sedation time, and time to return to baseline functional status. Caregiver satisfaction scores were also significantly higher in the patients in the propofol group.

CONCLUSIONS

Propofol permits faster onset and recovery than, and comparable efficacy to, a pentobarbital/midazolam/fentanyl regimen for sedation of children for MRI.

Sédation au pentobarbital par voie rectale pour enregistrement des PEA chez l'enfant

OBJECTIVES

The aim of our study was to determine if rectal sedation with pentobarbital sodium provides safe and effective sedation for children undergoing auditory brainstem response (ABR) testing.

MATERIAL AND METHODS

A prospective study was conducted in the ENT pediatric department of Robert Debre's hospital (APHP, Paris). 68 children under 8 years of age were given rectal pentobarbital for ABR testing at a dosage of about 5 mg/kg.

RESULTS

61 children of 68 (89.7%) were adequately sedated with rectal pentobarbital. The mean elapsed time from drug administration to full sedation was 36,1 minutes. No adverse event was reported in 84.1% of children.

CONCLUSION

Pentobarbital provides safe and effective sedation. Rectal administration is easy, painless and with brief duration of action. It's a good alternative to general anesthesia for young children undergoing ABR testing.

Procedural sedation in the pediatric patient

The demand for safe and effective procedural sedation for children is rapidly increasing because of the increased awareness about procedure-related anxiety even in young infants and children. The development of short-acting sedatives, improved monitoring, and new regulatory requirements have led to the evolution of new paradigms of safe, effective, and resource-efficient systems for providing procedural sedation outside the operating rooms by anesthesiologists and nonanesthesiologists.

Moderate sedation for MRI in young children with autism

Autism is a pervasive neurodevelopmental disorder. Because of the deficits associated with the condition, sedation of children with autism has been considered more challenging than sedation of other children.

OBJECTIVE

To test this hypothesis, we compared children with autism against clinical controls to determine differences in requirements for moderate sedation for MRI.

MATERIALS AND METHODS

Children ages 18-36 months with autism (group 1, n = 41) and children with no autistic behavior (group 2, n = 42) were sedated with a combination of pentobarbital and fentanyl per sedation service protocol. The sedation nurse was consistent for all patients, and all were sedated to achieve a Modified Ramsay Score of 4. Demographics and doses of sedatives were recorded and compared.

RESULTS

There were no sedation failures in either group. Children in group 1 (autism) were significantly older than group 2 (32.02+/-3.6 months vs 28.16+/-6.7 months) and weighed significantly more (14.87+/-2.1 kg vs 13.42+/-2.2 kg). When compared on a per-kilogram basis, however, group 1 had a significantly lower fentanyl requirement than group 2 (1.25+/-0.55 mcg/kg vs 1.57+/-0.81 mcg/kg), but no significant difference was found in pentobarbital dosing between groups 1 and 2, respectively (4.92+/-0.92 mg/kg vs 5.21+/-1.6 mg/kg).

CONCLUSION

Autistic children in this age range are not more difficult to sedate and do not require higher doses of sedative agents for noninvasive imaging studies.

The management of infants and children for painless imaging

The ability of a child to remain sufficiently immobile for painless imaging depends upon their behaviour and the imaging itself. Anaesthesia allows imaging to be optimised but it is expensive, scarce and inappropriate for many situations. Fortunately, sedation and behavioural techniques are sufficiently successful for the majority of scanning, and success rates are high provided that suitable children are selected. Sedation, however, administered by non-anaesthetists, may have catastrophic complications such as airway obstruction. Current UK recommendations demand that any sedation technique has a 'wide margin of safety', but in addition to this, safety is dependent on trained, skillful and experienced staff. Magnetic resonance imaging frightens many children and special planning is necessary for sedation and anaesthesia. When planning an imaging service for children, all the management techniques should be considered in order to achieve maximum efficiency, quality and safety.

The pharmacology of sedation

There is no single "miracle drug" for sedation. However, the range of available agents is broad and provides many safe and effective sedation options for medical procedures and studies. Providers of pediatric sedation should be thoroughly familiar with these agents.

Prospective evaluation of dexmedetomidine for noninvasive procedural sedation in children

OBJECTIVE

Children often require sedation for lengthy noninvasive procedures. Conventional agents such as chloral hydrate, benzodiazepines, or barbiturates have been associated with sedation failure, respiratory depression, and paradoxic agitation. Dexmedetomidine is a newer alpha(2)-adrenergic receptor agonist with sedative properties and minimal respiratory depression. We hypothesized that it would be an effective agent for these procedures.

DESIGN

Prospective case series.

SETTING

Tertiary care children's hospital.

PATIENTS

Children undergoing noninvasive procedures.

INTERVENTIONS

Children were sedated with dexmedetomidine given as a bolus of 0.5-1.0 microg/kg over 5-10 mins followed by an infusion of 0.5-1.0 microg/kg/hr. Vital signs, sedative effectiveness, recovery patterns, and complications were prospectively recorded.

MEASUREMENTS AND MAIN RESULTS

Forty-eight patients, aged 6.9 +/- 3.7 yrs, were sedated. Fifteen received dexmedetomidine after failing sedation with chloral hydrate and/or midazolam. Sedation was induced with 0.92 +/- 0.36 microg/kg over 10.3 +/- 4.7 mins and maintained with an infusion of 0.69 +/- 0.32 microg/kg/hr. All procedures were completed. Heart rate, blood pressure, and respiratory rate decreased (p < .0001) but remained within normal limits for age. End-tidal CO(2) exceeded 50 mm Hg in seven of 404 measurements (1.7%). Mean recovery time was 84 +/- 42 mins and was significantly longer in the rescue (117 +/- 41 mins) vs. primary (69 +/- 34 mins) group (p < .0001). No patient developed agitation during recovery.

CONCLUSIONS

Dexmedetomidine provided effective sedation in children undergoing noninvasive procedures and represents an alternative sedative choice for this population.

Oral and intravenous caffeine for treatment of children with post-sedation paradoxical hyperactivity

BACKGROUND

Paradoxical hyperactivity (PH) is a known complication of sedation in children, especially with barbiturates such as pentobarbital. The accompanying inconsolable irritability and agitation, similar to behaviors reported in children with attention deficit hyperactivity disorder (ADHD), is uncomfortable for the child and anxiety-provoking for parents and health-care workers. Our objective was to describe our experience with oral (PO) and intravenous (IV) caffeine as a treatment for sedation-induced PH.

MATERIALS AND METHODS

From January 2000 to April 2003, 19,894 children were sedated in our institution for radiology procedures. Of these, 360 children were diagnosed with PH. A total of 229 children exhibiting symptoms of PH after sedative administration were treated with PO caffeine ( n=88; 43 boys, 45 girls; mean age 4.5 years, mean weight 18.7 kg) or IV caffeine ( n=131; 73 boys, 58 girls; mean age 4.8 years, mean weight 20.1 kg) or both ( n=10; 8 boys, 2 girls; mean age 5.0 years, mean weight 19.9 kg). A positive effect was defined as a decrease in agitation, crying, or hyperactivity within 40 min of caffeine administration. A control group ( n=45) was obtained from those 141 children who experienced post-sedation PH but were not treated with caffeine, and matched for age and sex with samples of children treated with IV caffeine ( n=45) and PO caffeine ( n=45).

RESULTS

Children treated intravenously received the equivalent of 20 mg/kg caffeine citrate (to a maximum of 200 mg). Of those treated with IV caffeine, 82/131 (63%) showed a positive effect, and returned to baseline behavioral status after an average of 33 min (SD=23 min). The untreated control group required a significantly longer time to recover ( P<0.01) than those treated with IV caffeine. Children treated orally received approximately 1.0-2.5 mg/kg caffeine in Mountain Dew (Pepsi-Cola Company), and 36/88 (41%) showed a positive effect and returned to baseline behavioral status after an average of 42 min (SD=27 min). Of the 10 children treated with both PO and IV caffeine, 6 showed a positive effect. There was no significant difference in recovery time between the untreated control group and either the matched orally treated group or the group treated with both IV and PO caffeine. No complications occurred after caffeine administration.

CONCLUSION

IV caffeine appears to be an effective treatment for PH in children with sedation-induced PH. Further controlled prospective study is needed to determine the optimum dose and route of administration and to compare efficacy with other potential drug classes.

Infant sedation for MR imaging and CT: oral versus intravenous pentobarbital

PURPOSE

To compare the effectiveness and safety of oral (PO) versus intravenous (IV) pentobarbital sedation for magnetic resonance (MR) imaging and computed tomography (CT) in infants younger than 12 months.

MATERIALS AND METHODS

The institutional review board approved the review of medical records and determined informed consent to be unnecessary. All parents gave informed consent for patient sedation. Prior to MR imaging or CT, infants younger than 12 months were sedated with PO pentobarbital (4-8 mg per kilogram body weight) or IV pentobarbital (2-6 mg/kg), depending on the presence of an IV catheter or need for IV contrast medium. A computer database used to record sedation data was reviewed for data from January 1997 to September 2003. PO and IV sedation groups were compared for mean age, weight, dose, time to sedation, time to discharge, and duration of sedation with a two-sample Student t test. Multivariate analysis of covariance was used to determine whether differences in sedation time, time to discharge, and duration of sedation between groups were independent of age, weight, sex, American Society of Anesthesiologists physical status classification, dose, and type of procedure. Sedation effectiveness (outcome) was determined as the percentage of sedation failures in each group. Safety was determined separately for other adverse events as a total and for respiratory adverse events.

RESULTS

A total of 2164 infants received 2419 (1264 PO, 1155 IV) doses of pentobarbital for sedation. Weight and sex were comparable between groups. Time to sedation was significantly longer with PO than with IV pentobarbital (18 minutes +/- 11 vs 7 minutes +/- 7; P < .01), but time to discharge was similar, at approximately 108 minutes +/- 35. Total adverse events rate during sedation was not significantly different (0.8% [PO] vs 1.3% [IV]), but incidence of abnormal oxygen saturation (5% decrease from baseline, >1 minute duration) differed significantly (0.2% [PO] vs 0.9% [IV]; P = .02). Sedation effectiveness was comparable (failure rate, 0.5% [PO] vs 0.3% [IV]; P = .76).

CONCLUSION

PO pentobarbital has comparable effectiveness and a lower rate of respiratory complications compared with IV pentobarbital in infants younger than 12 months; its use should be considered, regardless of presence of an IV catheter.

Etomidate versus pentobarbital for sedation of children for head and neck CT imaging

OBJECTIVES

We compare etomidate to pentobarbital for sedation of children for head and neck computed tomography imaging.

METHODS

We performed a prospective, randomized, double-blinded trial of patients aged 6 months to 6 years enrolled from the emergency department or radiology department at a large urban children's hospital. The primary outcome measure was sedation success rate.

RESULTS

A total of 61 patients were enrolled in the study (27 etomidate group, 34 pentobarbital group) at 2 different dosing regimens for etomidate. The final analysis group included 17 etomidate patients and 33 pentobarbital patients. The success rate for the etomidate group was 57% at total doses of up to 0.3 mg/kg (n = 7) and 76% at total doses of up to 0.4 mg/kg (n = 17), in contrast to a success rate of 97% for pentobarbital at a total dose of up to 5 mg/kg (n = 33). The success rate for pentobarbital was significantly greater than the final etomidate group (P = 0.04; difference in proportions 20.5%, 95% CI 1.9% to 44.4%). Patients receiving etomidate had significantly shorter induction times (P = 0.02; difference of means 2.1 minutes, 95% CI 0.35 to 3.86), sedation times (P < 0.001; difference of means 31.3 minutes, 95% CI 24.0 to 38.5), and total examination times (P < 0.001; difference of means 53.1 minutes, 95% CI 40.8 to 65.3). Significantly more parents in the etomidate group perceived their child to be back to baseline by discharge from the hospital (P < 0.001; difference of proportions 60.7, 95% CI 29.1 to 92.4) and expressed fewer concerns about their child's behavior after discharge (P = 0.024; difference of proportions 28.6, 95% CI 6.5 to 50.7).

CONCLUSIONS

At the dosing used in this study, pentobarbital is superior to etomidate when comparing success rates for sedation. However, among the successful sedations, the duration of sedation was shorter in the etomidate group than in the pentobarbital group. Pentobarbital is associated with more frequent side effects and parental concerns compared to etomidate.

Pentobarbital vs chloral hydrate for sedation of children undergoing MRI: efficacy and recovery characteristics

BACKGROUND

Chloral hydrate (CH) sedation for magnetic resonance imaging (MRI) is associated with significant failure rates, adverse events and delayed recovery. Pentobarbital (PB), reportedly produces successful sedation in 98% of children undergoing diagnostic imaging. This study compared the efficacy, adverse events and recovery characteristics of CH vs PB in children undergoing MRI.

METHODS

With Institutional Review Board approval and written consent, children were randomly assigned to receive intravenous (i.v.) PB (maximum 5 mg x kg(-1) in incremental doses) or oral CH (75 mg x kg(-1)) prior to MRI. Sedation was augmented with 0.05 mg x kg(-1) doses of i.v. midazolam (maximum 0.1 mg x kg(-1)) as necessary. Adverse effects, including hypoxaemia, failed sedation, paradoxical reactions and behavioural changes, the return of baseline activity, and parental satisfaction were documented. The quality of MRI scans was evaluated by a radiologist blinded to the sedation technique.

RESULTS

PB facilitated an earlier onset of sedation (P = 0.001), higher sedation scores (P = 0.01), and less need for supplemental midazolam compared with CH. Severe hypoxaemia occurred in two children (6%) in the PB group. Fourteen per cent of the PB group experienced a paradoxical reaction, 9% sedation failure and 11% major motion artefact, compared with 0% (P = 0.05), 3 and 2% (P = NS), respectively, in the CH group. CH and PB were both associated with a high incidence of motor imbalance, and agitation. However, children who received PB had a slower return to baseline activity (P = 0.04).

CONCLUSIONS

Although PB facilitated a quicker sedation onset and reduced the requirement for supplemental sedation, it produced a higher incidence of paradoxical reaction and prolonged recovery with a similar failure rate compared with CH.

Deep sedation with propofol for children undergoing ambulatory magnetic resonance imaging of the brain: experience from a pediatric intensive care unit

OBJECTIVES

Use of intravenous propofol sedation to facilitate completion of magnetic resonance imaging of the brain in children.

DESIGN

Retrospective, cross-sectional.

SETTING

A university-affiliated pediatric intensive care unit.

PATIENTS

A total of 115 children who received intravenous propofol to complete magnetic resonance imaging of the brain January 1 through December 31, 2001.

INTERVENTIONS

Intravenous propofol infusion.

MEASUREMENTS AND MAIN RESULTS

The mean age was 4.2 +/- 3.1 yrs, and there were 63 boys and 52 girls. Sixty-nine percent of patients belonged to ASA physical status class I, and 31% belonged to ASA class II. All studies were completed with satisfactory image quality. The total dose of propofol used to complete a magnetic resonance image of the brain was 4.3 +/- 1.7 mg/kg body weight. The mean duration of sedation induction was 4.5 +/- 3.5 mins. The mean time to recovery (from the end of the procedure) was 20 +/- 15 mins. The duration of the procedure averaged 39 +/- 20 mins, and the time to discharge from the hospital was 50 +/- 21 mins from the end of the procedure. No episodes of hypoxia, apnea, or a need for artificial airway were noted. Systolic blood pressure decreased 10% +/- 13%, but none of the patients met the criteria for hypotension. A telephone call the next day to the family did not reveal any delayed complications.

CONCLUSIONS

Propofol can safely facilitate ambulatory magnetic resonance imaging of the brain in children, and it is associated with brief induction, recovery, and discharge times from the hospital. A drop in blood pressure, although mild and transient, does occur. Therefore, appropriate monitoring and preparedness for cardiorespiratory support are essential.

Comparison of oral pentobarbital sodium (nembutal) and oral chloral hydrate for sedation of infants during radiologic imaging: preliminary results

OBJECTIVE

The purpose of this study was to compare the safety and efficacy of oral cherry-flavored pentobarbital sodium (Nembutal) and oral chloral hydrate to sedate infants undergoing radiologic imaging.

SUBJECTS AND METHODS

We prospectively recorded data for all infants sedated with oral cherry-flavored pentobarbital sodium and oral chloral hydrate for imaging examinations between January 1997 and August 1999. The parameters recorded were each patient's age, weight, and American Society of Anesthesiologists classification; the time required to sedate; the total length of sedation time; the time required to discharge from the recovery room; and adverse events. The two-sample Student's t test and Fisher's exact test were used for statistical analysis.

RESULTS

Oral pentobarbital sodium was administered to 317 infants. These infants had a mean age +/- SD of 6.9 +/- 3.1 months and a mean weight of 7.8 +/- 4.8 kg; they received a median dose of 4 mg/kg of body weight. Oral chloral hydrate was administered to 358 infants. These infants had a mean age of 5.9 +/- 3.3 months and a mean weight of 7.3 +/- 4.9 kg; they received a median dose of 50 mg/kg of body weight. The mean time required to sedate was 19 +/- 14 min for infants receiving oral pentobarbital sodium and 16 +/- 11 min for infants receiving oral chloral hydrate (p = 0.02); the mean time required to discharge was 100 +/- 35 min for infants in the oral pentobarbital sodium group and 103 +/- 36 min for infants in the oral chloral hydrate group (p = 0.31); the mean length of sedation was 81 +/- 34 min for the oral pentobarbital sodium group and 86 +/- 36 min for the oral chloral hydrate group (p = 0.07); and median American Society of Anesthesiologists classification for both groups was P1. Oral pentobarbital sodium was inadequate for sedation in one patient (0.3%) and chloral hydrate was inadequate for sedation in another (0.3%) (p = 1.00). Adverse events were recorded for five patients (1.6%) in the oral pentobarbital sodium group and for six patients (1.7%) in the chloral hydrate group (p = 0.99).

CONCLUSION

Oral pentobarbital sodium is as safe and efficacious as oral chloral hydrate for sedating infants.

Adverse effects of sedatives in children

The application of sedation/analgesia in paediatric patients is rapidly expanding as less invasive, non-operative techniques of diagnosis and treatment are applied to the paediatric population. Medical providers who are asked to provide sedation may include radiologists, paediatricians, nurses and emergency physicians, as well as anaesthesiologists and intensive care physicians. At the same time, the range of drugs used in these settings has expanded considerably. As there is no single drug fulfilling the criteria for the ideal sedative (rapid-onset, rapid recovery, no adverse effects, immobility appropriate to procedure being performed), multiple drugs may be used in combination. It is imperative that practitioners using drugs for sedation/analgesia in children be aware of the adverse effect profile(s) of these drugs, both individually and in combination. The purpose of this review is to describe the adverse effects of sedative and reversal agents currently used in paediatric sedation/analgesia.

Magnetic resonance imaging of soft-tissue tumors in children

Magnetic resonance imaging (MRI) has become an important diagnostic tool in the detection and characterization and local anatomic staging of soft-tissue tumors in children. This article outlines some of the procedural issues unique to the pediatric population.

Oropharyngeal airway diameter during sedation in children with and without developmental delay

STUDY OBJECTIVE

To determine whether children with developmental delay would have closer apposition of upper airway tissues during sedation, perhaps because of poor coordination of upper airway musculature.

DESIGN

Case-control and retrospective chart review.

SETTING

Tertiary-care pediatric teaching hospital.

PATIENTS

40 children 3 to 6 years of age, with and without a diagnosis of developmental delay.

MEASUREMENTS

Subjects received only pentobarbital sedation by a protocol. Magnetic resonance imaging (MRI) scans of the head were reviewed, and transverse airway diameters at the soft palate and tongue were determined from midline sagittal images.

MAIN RESULTS

Age, weight, sedative dose, MRI window level, and window width were not different between patients with and without developmental delay. We found the airway diameter at the level of the soft palate was decreased 40% in children with developmental delay compared with those children without delay, 3 mm (1.4, 5.5 interquartile range) versus 5 mm (3, 8); p = 0.035, power 76%.

CONCLUSIONS

The anteroposterior oropharyngeal airway diameter was smaller in children with developmental delay than in those without developmental delay, in static MRI images. It is possible that children with developmental delay are at higher risk for airway obstruction during sedation.

Sedatives used in pediatric imaging: comparison of IV pentobarbital with IV pentobarbital with midazolam added

OBJECTIVE

This study was designed to evaluate safety, efficacy, and success of adding IV midazolam to an established IV pentobarbital protocol for pediatric sedation for radiologic imaging. Outcomes included sedation and discharge times as well as adverse events

SUBJECTS AND METHODS

This prospective study compared two different sedation protocols developed by the radiology sedation committee and approved by the hospital sedation committee at our institution. Patients in the pentobarbital group received IV pentobarbital alone, and patients in the pentobarbital--midazolam group received a combination of IV pentobarbital and midazolam. A total of 1070 infants and children were enrolled, and sedation data were entered into a computer database and reviewed at bimonthly radiology sedation committee meetings for safety, efficacy, efficiency, failed sedations, and adverse outcomes.

RESULTS

Mean age distribution, sex, American Society of Anesthesiologists physical status classification, fasting status, weight, and types of examinations were similarly distributed between the two study groups. Analysis of variance indicated longer times were required to sedate and to discharge patients who had received pentobarbital--midazolam (p < 0.001 for both times), even after adjusting for differences in the patients' ages and weights. The pentobarbital--midazolam group required more time to be successfully sedated and more time to discharge from the recovery room. The rates of adverse events and failed sedations were similar for both groups.

CONCLUSION

Midazolam does not have a beneficial effect on pentobarbital sedation and has no effect on the rate of adverse events. The prolonged time needed both to sedate and to discharge (timed from the initial dose of sedation) pediatric patients who have received midazolam should discourage physicians from combining it with pentobarbital for pediatric sedation.

Sedation/Analgesia for diagnostic and therapeutic procedures in children

Sedation/analgesia for diagnostic and therapeutic procedures in children has been associated with life-threatening adverse events. Reports of adverse events and recognition of wide variability in sedation practices has led to the development of guidelines and standards of care to ensure the safety of sedated children. The safety of sedated children can be enhanced by detailed presedation evaluation, careful patient selection, and the use of drugs with a wide margin of safety that are carefully titrated to desired depth of sedation by trained personnel. Once sedative drugs are administered, stringent monitoring, including continuous pulse oximetry and frequent assessment of vital signs and sedation depth, will permit early recognition of untoward drug effects and permit early intervention. Children with underlying medical conditions, such as airway abnormalities, may not be suitable subjects for sedation and may require consideration for general anesthesia to aid their procedure. Although significant strides have been made in recognition of the risks of sedation and in development of guidelinesfor safe sedation practices, further work must focus on development of newer sedation regimens with shorter-acting drugs and wider margins of safety.

Comparison of intravenous midazolam with pentobarbital for sedation for head computed tomography imaging

OBJECTIVE

To compare the efficacy of intravenous (IV) midazolam with that of IV pentobarbital when used for sedation for head computed tomography (CT) imaging in emergency department (ED) pediatric patients.

METHODS

Prospective, randomized clinical trial in an urban children's hospital. During a two-and-a-half-year period, 55 patients were enrolled: 34 males and 21 females. Measurements included induction time, recovery time, efficacy, side effects, complications, and failure with each drug. Success of sedation was graded as good (GS), adequate (AS), poor (PS), or unsuccessful (US).

RESULTS

Sedation for CT was used for patients with the following problems: head trauma (21/55), central nervous system pathology (17/55), ventriculoperitoneal shunt evaluation (6/55), periorbital cellulitis (6/55), and retropharyngeal abscess (5/55). Twenty-nine (53%) patients received pentobarbital (mean +/- SD dose 3.75 +/- 1. 10 mg/kg) and 26 (47%) patients received midazolam (mean +/- SD dose 0.2 +/- 0.03 mg/kg). In the pentobarbital group, 28 (97%) patients were scanned and successfully sedated. Pentobarbital's mean induction time was 6 minutes and duration of sedation averaged 86 minutes. In the midazolam group, only five (19%) patients were successfully scanned with midazolam alone. Of the 21 (81%) patients given midazolam who were unsuccessfully sedated, 12 (61%) were subsequently sedated with the addition of pentobarbital for completion of CT imaging. Mild oxygen desaturation, O(2) sat >90% yet <94%, was seen in only four patients. All four patients responded to blow-by oxygen and required no other intervention.

CONCLUSION

Intravenous pentobarbital is more effective than IV midazolam for sedation of children requiring CT imaging.

Paediatric sedation for CT scanning: the safety and efficacy of quinalbarbitone in a district general hospital setting

The aim of this study was to review retrospectively the safety and efficacy of a paediatric sedation protocol in a district general hospital radiology department. 256 children attended for CT scanning over a 40-month period. 40 children required sedation and were given quinalbarbitone. 34 (85%) of this group were adequately sedated. Of the children who received quinalbarbitone, 35 were under 5 years of age. 32 of this group (91.4%) were adequately sedated. Failures in children under 5 years were all caused by problems with administration whilst failures in the older children were due to paradoxical excitement. No problems with respiratory depression were encountered. Sedation can be safely performed in a district general hospital radiology department if a structured protocol is adhered to. Quinalbarbitone is a safe, effective oral agent in children under the age of 5 years.

Adverse events and risk factors associated with the sedation of children by nonanesthesiologists

After implementation of hospital-wide monitoring standards, a quality assurance (QA) tool was prospectively completed for 1140 children (aged 2.96 +/- 3.7 yr) sedated for procedures by nonanesthesiologists. The tool captured data regarding demographics, medications used, adequacy of sedation, monitoring, adverse events, and requirement for escalated care. The medical records of children who experienced adverse events were reviewed. Most (99%) children were monitored with pulse oximetry. Chloral hydrate was the most frequently used sedative (74.9% of cases). Of the children, 239 (20.1%) experienced adverse events related to sedation, including inadequate sedation in 150 (13.2%) and decrease in oxygen saturation in 63 (5.5%). Five of these children experienced airway obstruction and two became apneic. No adverse event resulted in long-term sequelae. Of the 854 children who received chloral hydrate, 46 (5.4%) experienced decreased oxygen saturation (> or = 90% of baseline). Children experienced desaturation after the use of chloral hydrate had received the recommended doses of chloral hydrate (38-83 mg/kg). ASA physical status III or IV and age < 1 yr were predictors of increased risk of sedation-related adverse events. These data underscore the importance of appropriate monitoring that includes pulse oximetry to permit early detection of adverse events.

IMPLICATIONS

This quality assurance study highlights the risks associated with the sedation of children and emphasizes the importance of appropriate monitoring by trained personnel. Children with underlying medical conditions and those who are very young are at increased risk of adverse events, which indicates that a greater degree of vigilance may be required in these patients.

Comparative review of the adverse effects of sedatives used in children undergoing outpatient procedures

Children often fear medical procedures and interventions. Sedative agents enhance the care of these children who undergo outpatient procedures by decreasing anxiety, increasing cooperativity, and providing amnesia. Although higher dosages and intravenous administration of sedatives often produce improved sedation, adverse effects and complications are more frequent. The goals of therapeutic efficacy and safety must be balanced in all patients. The presence or anticipation of anxiety and pain helps in deciding whether to use a sedative alone, or a regimen also providing analgesia. The patient's clinical cardiorespiratory or neurological status, other relative contraindications, the duration of the intended procedure, and the presence or absence of an intravenous line will help in choosing specific drugs. Drug complications are a common cause of adverse events in patients. The combination of a sedative and analgesic, especially a benzodiazepine and an opioid given intravenously, is associated with a higher risk of serious complications. The practitioner responsible for the administration of a sedative to a child must be competent in its use and have the ability to detect and manage complications. Patients who are deeply sedated should be continuously monitored and observed by an individual dedicated to this task. Vital signs and oxygen saturation should be documented at frequent intervals and the patient should be appropriately monitored until discharge criteria have been met. The risk of serious complications with these agents may be reduced with vigorous monitoring and a judicious choice of dosage.

Deep sedation with propofol in preschool children undergoing radiation therapy

Immobilization of children undergoing radiation therapy always requires anaesthesia. Deep sedation with continuous infusion of propofol and spontaneous breathing, (we call it ¿sedative anaesthesia'), may be an alternative to general anaesthesia with intubation and controlled ventilation. This clinical report deals with 155 anaesthetics performed in 11 consecutive paediatric oncology patients, mean age 30 months (range 19-42), who required radiation therapy for from seven to 33 consecutive days. Mean duration of anaesthesia was 18 ( +/- 11) mins. For induction, a loading dose of 3.6 (SD +/- 0.59) mg.kg-1 propofol was administered immediately followed by a continuous infusion of 7.4 ( +/- 2.2) mg.kg-1.h-1 for maintenance of anaesthesia. There were no complications of clinical importance involving respiration, circulation or neurology, except for one short episode of transient desaturation, which was managed by suctioning and changing head position. Children opened their eyes spontaneously four ( +/- 3.7) min after discontinuing the propofol infusion and could be discharged about 30 mins later. Tachyphylaxis or unpleasant side effects during and after anesthesia have not been observed. Sedative anaesthesia with propofol seems to be an excellent method to immobilize paediatric patients during radiotherapeutic procedures.

Results of a pediatric sedation program on head MRI scan success rates and procedure duration times

The purpose of this study was to determine if a pediatric sedation program improved head magnetic resonance imaging (MRI) scan success rates and procedure duration times compared with the year preceding the program. Sedation was successful in 189 (85.1%) of 222 children before the program compared with 211 (98.1%) of 215 children during the program (P < 0.001). Mean procedure duration times for head MRI scans with and without contrast were shorter in the program compared with before the program (58.7 +/- 1.4 min versus 71.8 +/- 3.0 min, P < 0.001, and 46.7 +/- 1.2 min versus 58.5 +/- 1.9 minutes, P < 0.001, respectively). No major complications occurred during the 15-month period in the sedation program. We conclude that sedation for pediatric MRI, managed by an organized pediatric sedation program, is highly successful, efficient, and safe.

Sedative-analgesic agent administration in children: analysis of use and complications in the emergency department

The frequency of, indications for, and complications from non-acetaminophen sedative-analgesic agents (SAAs) administered to children less than 16 years of age in the emergency department (ED) were determined by a retrospective review. All 21,353 charts from a single university hospital ED over a 16-month period were included. Few children (N = 759; 3.5%) received SAAs. Of 919 total doses, 13% of children received a second and 4.5% received a third SAA. The group was 59% male. Most children were < or = 10 years of age. Sixty-two percent of SAAs were either sedatives or opioids. Sedatives given included chloral hydrate, diazepam, lorazepam, midazolam, and phenobarbital. Opioids given included morphine, codeine, and meperidine. Indications for SAAs included painful procedures, analgesia, radiographic imaging, and seizure activity. Complications (N = 51; 6.7%) included inadequate sedation, vomiting, and respiratory depression or oxygen desaturation. Respiratory depression or oxygen desaturation occurred only after intravenous administration of SAAs for seizures. In children, non-acetaminophen SAAs are used most commonly in younger patients requiring sedation for painful procedures or for radiologic imaging. Respiratory depression was observed only after intravenous administration of anticonvulsants.

Sedation, anesthesia, and physiologic monitoring during MR imaging: evaluation of procedures and equipment

The authors developed safe standard sedation and general anesthesia procedures for adults and children, including adequate physiologic monitoring, during magnetic resonance (MR) imaging. Six-year results are reported from one institution; 75% of the 600 patients per year who require sedation or anesthesia are children who require sedation only. Testing was done to determine MR compatibility of various types of equipment essential for monitoring and supporting sedated or anesthetized patients in 1.0- and 1.5-T MR imagers. Use of sedation procedures that include oral chloral hydrate after sleep deprivation resulted in a failure rate of 3.8% in sedating outpatient children. Every physiologic parameter that can be monitored under normal circumstances in the critical care unit or operating room can be monitored during MR imaging. Our experience indicates that with careful consideration of the unique MR environment and with rigorous testing of monitoring equipment, MR imaging can be performed safely in sedated or anesthetized patients.

Pediatric sedation: short-term effects

A prospective investigation on the short-term effects of various sedation regimens on 549 nonhospitalized magnetic resonance (MR) patients was performed. The drugs evaluated were chloral hydrate, pentobarbital, midazolam, and diazepam (fentanyl was used for enhancement after any of these drugs). The overall safety and efficacy were quite good with all the regimens. Overall, 84% of children slept less than 8 h after the examination, 90% were drowsy and/or unsteady for less than 8 h after they awoke, and 97% resumed their usual activities by 24 h. Significant hyperactivity was seen only with pentobarbital and occurred in 8.4% of children over 8 years of age. The multiple-dose regimen of pentobarbital and fentanyl had a significant short-term effect on the children less than 8 years of age, with 35% sleeping longer than 8 h after the MR. Ten children who had needed the multiple-dose pentobarbital regimen or who had failed prior pentobarbital sedation presented for repeat sedation. Midazolam was effective in 9 of these 10 children.