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Johnson KL, Cochran J, Webb S. Lower-Dose Propofol Use for MRI: A Retrospective Review of a Pediatric Sedation Team's Experience. Pediatr Emerg Care 2021; 37:e700-e706. [PMID: 33181790 DOI: 10.1097/pec.0000000000002289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE The aim of the study was to evaluate, in children undergoing procedural sedation for magnetic resonance imaging (MRI) scans, whether lower doses of propofol than previously published permitted a high rate of successful MRI completion, whether lower dosages result in a more rapid recovery, and whether age or behavioral diagnosis increases propofol requirements. METHODS After institutional review board approval, we retrospectively reviewed the pediatric sedation team's sedation database of children receiving propofol infusion for MRI scans between 2007 and 2016. Data collected included propofol induction dose (in milligrams per kilogram), propofol infusion dose (in micrograms per kilogram per hour), total propofol dose (in milligrams per kilogram and in milligrams per kilogram per hour), and the number of administered ancillary sedative medications. Additional data included the American Society of Anesthesiologist status, sedation duration, recovery duration, and successful completion of MRI. Dosing data were also stratified by age. RESULTS A total of 2354 patients met inclusion criteria. Eight percent of patients received propofol infusion alone, 79% received midazolam before their propofol induction, and 13% received a combination of propofol and other drugs. Mean induction dose was 2.2 + 0.9 mg/kg, mean infusion dose was 93.5 + 29.0 μg/kg per minute, and total mean dose was 9.0 + 3.0 mg/kg per hour. Mean recovery time was 44 minutes, and 99.3% of the scans were completed with good images. We noted an increase requirement in the mean induction dose and total dose in children younger than 1 year. CONCLUSIONS Propofol infusion doses lower than commonly reported permit successful completion of scans and similar recovery times in a single institution. Younger children require more propofol for successful procedural sedation.
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Affiliation(s)
- Kay L Johnson
- From the Division of Pediatrics, Medical University of South Carolina Children's Hospital, Charleston, SC
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The Use of Intranasal Dexmedetomidine and Midazolam for Sedated Magnetic Resonance Imaging in Children: A Report From the Pediatric Sedation Research Consortium. Pediatr Emerg Care 2020; 36:138-142. [PMID: 28609332 DOI: 10.1097/pec.0000000000001199] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The objective of this study was to describe the use of intranasal dexmedetomidine (IN DEX) for sedated magnetic resonance imaging (MRI) examinations in children. The use of IN DEX for MRI in children has not been well described in the literature. MATERIALS AND METHODS The Pediatric Sedation Research Consortium (PSRC) is a collaborative and multidisciplinary group of sedation practitioners dedicated to understanding and improving the process of pediatric sedation. We searched the 2007 version of the PSRC database solely for instances in which IN DEX was used for MRI diagnostic studies. Patients receiving intravenous medications were excluded. Patient demographics, IN DEX dose, adjunct medications and dose, as well as procedure completion, complications, interventions, and monitoring providers were analyzed. RESULTS A total of 224 sedation encounters were included in our primary analysis. There were no major adverse events. Most sedations (88%) required no intervention. Registered nurses were the monitoring provider in over 99% of cases. The median (interquartile range) dose of dexmedetomidine was 3 (2.5-3) mcg/kg. Adjunctive midazolam was used in 219/224 (98%) of the cases. All procedures were completed. CONCLUSIONS This report from the PSRC shows that IN DEX in combination with midazolam is an effective medication regimen for children who require an MRI with sedation.
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Mongodi S, Ottonello G, Viggiano R, Borrelli P, Orcesi S, Pichiecchio A, Balottin U, Mojoli F, Iotti GA. Ten-year experience with standardized non-operating room anesthesia with Sevoflurane for MRI in children affected by neuropsychiatric disorders. BMC Anesthesiol 2019; 19:235. [PMID: 31852450 PMCID: PMC6921558 DOI: 10.1186/s12871-019-0897-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 11/29/2019] [Indexed: 12/20/2022] Open
Abstract
Background Children require anesthesia for MRI to maintain immobility and reduce discomfort; clear indications about the best anesthesiologic management are lacking and each center developed its own protocol. Moreover, children with neuropsychiatric disorders more likely require sedation and are described in literature as more prone to general and respiratory complications. Aim of this study was to analyze the applicability of a sevoflurane-based approach, to describe general and respiratory complications and to identify risk factors in a pediatric neuropsychiatric population. Methods Retrospective cohort study, university Hospital (January 2007–December 2016). All the 1469 anesthesiologic records of children addressed from Neuropsychiatric Unit to undergo MRI under general anesthesia were analyzed; 12 patients equal or older than 18-year-old were excluded. We identified post-hoc nine macro-categories: static encephalopathies, metabolic/evolutive encephalopathies, epileptic encephalopathies, neuromuscular diseases, autistic spectrum disorders, migraine, psychiatric disorders, intellectual disabilities, others. A logistic regression model for events with low frequency (Firth’s penalized likelihood approach) was carried out to identify the mutually adjusted effect among endpoints (complications) and the independent variables chosen on the basis of statistical significance (univariate analysis, p ≤ 0.05) and clinical judgment. Results Of 1457 anesthesiologic records (age 4.0 (IQR 2.0 to 7.0) year-old, males 891 (61.2%), weight 17.0 (IQR 12.0 to 24.9) kg), 18 were cancelled for high anesthesiologic risk, 50 were cooperative, 1389 were anesthetized. A sevoflurane-based anesthesia was feasible in 92.3%; these patients required significantly less mechanical ventilation (8.6 vs. 16.2%; p = 0.012). Complications’ rate was low (6.2%; 3.1% respiratory). The risk for general complications increases with ASA score > 1 (OR 2.22, 95 CI% 1.30 to 3.77, p = 0.003), male sex (OR 1.73, 95% CI 1.07 to 2.81, p = 0.025), multi-drug anesthesia (OR 2.98, 95 CI% 1.26 to 7.06, p = 0.013). For respiratory complications, it increases with ASA score > 1 (OR 2.34, 95 CI% 1.19 to 4.73, p = 0.017), autumn-winter (OR 2.01, 95 CI% 1.06 to 3.78, p = 0.030), neuromuscular disorders (OR 3.18, 95 CI% 1.20 to 8.41, p = 0.020). We had no major complications compromising patients’ outcome or requiring admission to ICU. Conclusions Sevoflurane anesthesia is feasible and safe for children affected by neuropsychiatric disorders undergoing MRI. Specific risk factors for general and respiratory complications should be considered.
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Affiliation(s)
- Silvia Mongodi
- Anesthesia and Intensive Care, Rianimazione 1 Fondazione IRCCS Policlinico S. Matteo, 27100, Pavia, Italy.
| | - Gaia Ottonello
- Anaesthesia and Intensive Care, Merate, DEA ASST Lecco, Lecco, Italy
| | - Raffaelealdo Viggiano
- Department of medical-surgical, diagnostic and paediatric sciences, University of Pavia, Pavia, Italy
| | - Paola Borrelli
- Department of Public Health, Experimental and Forensic Medicine, Unit of Biostatistics and Clinical Epidemiology, University of Pavia, Pavia, Italy
| | - Simona Orcesi
- Child Neurology and Psychiatry Unit, IRCCS Mondino Foundation, Pavia, Italy.,Child Neurology and Psychiatry Unit, Department of Brain and Behavioural Sciences, University of Pavia, Pavia, Italy
| | - Anna Pichiecchio
- Neuroradiology department, IRCCS Mondino Foundation, Pavia, Italy.,Department of Brain and Behavioural Sciences, University of Pavia, Pavia, Italy
| | - Umberto Balottin
- Child Neurology and Psychiatry Unit, IRCCS Mondino Foundation, Pavia, Italy.,Child Neurology and Psychiatry Unit, Department of Brain and Behavioural Sciences, University of Pavia, Pavia, Italy
| | - Francesco Mojoli
- Anesthesia and Intensive Care, Rianimazione 1 Fondazione IRCCS Policlinico S. Matteo, 27100, Pavia, Italy.,Department of medical-surgical, diagnostic and paediatric sciences, University of Pavia, Pavia, Italy
| | - Giorgio Antonio Iotti
- Anesthesia and Intensive Care, Rianimazione 1 Fondazione IRCCS Policlinico S. Matteo, 27100, Pavia, Italy.,Department of medical-surgical, diagnostic and paediatric sciences, University of Pavia, Pavia, Italy
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Coté CJ, Wilson S. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures. Pediatrics 2019; 143:peds.2019-1000. [PMID: 31138666 DOI: 10.1542/peds.2019-1000] [Citation(s) in RCA: 137] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of appropriately trained staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.
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Kim D, Lee EK, Jeong JS, Gil NS, Hahm TS, Shin YH. Incidence and risk factors of unplanned intubation during pediatric sedation for MRI. J Magn Reson Imaging 2019; 49:1053-1061. [PMID: 30350443 DOI: 10.1002/jmri.26314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 08/08/2018] [Accepted: 08/09/2018] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND It is often difficult for the pediatric patient to cooperate or to remain immobile during MR scans. Therefore, sedation is usually needed for children. PURPOSE To evaluate the incidence and contributing factors of unanticipated intubation during sedation for MRI scan in children. STUDY TYPE Retrospective observational study. POPULATION/SUBJECTS In all, 1165 charts were reviewed retrospectively of patients who had been sedated by anesthesiologists at a single institution from May 2015 to June 2016. ASSESSMENT Patient's demographics, the region of the MRI scan, total amount of medication, duration of sedation, and any adverse event during MRI were assessed. The adverse events during sedation including airway obstruction, apnea, desaturation, bradycardia, and hypotension were also assessed. STATISTICAL TESTS Risk factors of unplanned intubation during MRI sedation were identified by univariate and multivariate analysis. Firth's exact logistic regression was used for univariate and multivariate analysis. According to the results from multiple logistic regression, a nomogram was developed to predict the risk. RESULTS A total of 1165 children aged 7 days to 18 years with sedation used during an MRI scan during the study period showed an incidence of unexpected intubation as ~2% (n = 23, 95% confidence interval [CI]; 0.0123, 0.0295). Multivariate logistic regression revealed the following risk factors of unplanned intubation: American Society of Anesthesiologists (ASA) class III patients (odds ratio [OR] 1.212, P < 0.001), premature birth (OR 2.317, P < 0.001), and the presence of gastroesophageal reflux disease (GERD) (OR 1.474, P < 0.001) or congenital heart disease (OR 1.118, P < 0.001). DATA CONCLUSION This study identified risk factors of unplanned intubation as follows: ASA class III patients, premature birth, and the presence of GERD or congenital heart disease. The physician should screen risk factors of unexpected intubation and maintain adequate sedation during MRI scans in pediatric patients. Level of Evidence 3. Technical Efficacy Stage 5. J. Magn. Reson. Imaging 2019;49:1053-1061.
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Affiliation(s)
- Doyeon Kim
- Department of Anesthesiology and Pain medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Eun Kyung Lee
- Department of Anesthesiology and Pain medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ji Seon Jeong
- Department of Anesthesiology and Pain medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Nam-Su Gil
- Department of Anesthesiology and Pain medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Tae Soo Hahm
- Department of Anesthesiology and Pain medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young Hee Shin
- Department of Anesthesiology and Pain medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Sedation and analgesia for procedures in the pediatric emergency room. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2017. [DOI: 10.1016/j.jpedp.2017.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Ramalho CE, Bretas PMC, Schvartsman C, Reis AG. Sedation and analgesia for procedures in the pediatric emergency room. J Pediatr (Rio J) 2017; 93 Suppl 1:2-18. [PMID: 28945987 DOI: 10.1016/j.jped.2017.07.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 05/26/2017] [Accepted: 05/26/2017] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Children and adolescents often require sedation and analgesia in emergency situations. With the emergence of new therapeutic options, the obsolescence of others, and recent discoveries regarding already known drugs, it became necessary to review the literature in this area. DATA SOURCES Non-systematic review in the PubMed database of studies published up to December 2016, including original articles, review articles, systematic reviews, and meta-analyses. References from textbooks, publications from regulatory agencies, and articles cited in reviews and meta-analyses through active search were also included. DATA SYNTHESIS Based on current literature, the concepts of sedation and analgesia, the necessary care with the patient before, during, and after sedoanalgesia, and indications related to the appropriate choice of drugs according to the procedure to be performed and their safety profiles are presented. CONCLUSIONS The use of sedoanalgesia protocols in procedures in the pediatric emergency room should guide the professional in the choice of medication, the appropriate material, and in the evaluation of discharge criteria, thus assuring quality in care.
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Affiliation(s)
- Carlos Eduardo Ramalho
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, São Paulo, SP, Brazil; Universidade de São Paulo (USP), Faculdade de Medicina, Departamento de Pediatria, São Paulo, SP, Brazil
| | - Pedro Messeder Caldeira Bretas
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, São Paulo, SP, Brazil; Universidade de São Paulo (USP), Faculdade de Medicina, Departamento de Pediatria, São Paulo, SP, Brazil
| | - Claudio Schvartsman
- Universidade de São Paulo (USP), Faculdade de Medicina, Departamento de Pediatria, São Paulo, SP, Brazil; Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo, SP, Brazil
| | - Amélia Gorete Reis
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, São Paulo, SP, Brazil; Universidade de São Paulo (USP), Faculdade de Medicina, Departamento de Pediatria, São Paulo, SP, Brazil.
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Jones NE, Kelleman MS, Simon HK, Stockwell JA, McCracken C, Mallory MD, Kamat PP. Evaluation of methohexital as an alternative to propofol in a high volume outpatient pediatric sedation service. Am J Emerg Med 2017; 35:1101-1105. [PMID: 28330689 DOI: 10.1016/j.ajem.2017.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Revised: 03/02/2017] [Accepted: 03/07/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Propofol is a preferred agent for many pediatric sedation providers because of its rapid onset and short duration of action. It allows for quick turn around times and enhanced throughput. Occasionally, intravenous (IV) methohexital (MHX), an ultra-short acting barbiturate is utilized instead of propofol. OBJECTIVE Describe the experience with MHX in a primarily propofol driven outpatient sedation program and to see if it serves as an acceptable alternative when propofol is not the preferred pharmacologic option. METHODS Retrospective chart review from 2012 to 2015 of patients receiving IV MHX as their primary sedation agent. Data collected included demographics, reason for methohexital use, dosing, type of procedure, success rate, adverse events (AE), duration of the procedure, and time to discharge. RESULTS Methohexital was used in 240 patient encounters. Median age was 4years (IQR 2-7), 71.8% were male, and 80.4% were ASA-PS I or II. Indications for MHX use: egg+soy/peanut allergy in 93 (38.8%) and mitochondrial disorder 9 (3.8%). Median induction bolus was 2.1mg/kg (IQR, 1.9-2.8), median maintenance infusion was 4.5mg/kg/h (IQR, 3.0-6.0). Hiccups 15 (6.3%), secretions requiring intervention 14 (5.8%), and cough 12 (5.0%) were the most commonly occurring minor AEs. Airway obstruction was seen in 28 (11.6%). Overall success rate was 94%. Median time to discharge after procedure completion was 40.5min (IQR 28-57). CONCLUSION Methohexital can be used with a high success rate and AEs that are not inconsistent with propofol administration. Methohexital should be considered when propofol is not a preferred option.
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Affiliation(s)
- Nicholas E Jones
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States.
| | - Michael S Kelleman
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States.
| | - Harold K Simon
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States; Children's Healthcare of Atlanta, Atlanta, GA, United States.
| | - Jana A Stockwell
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States; Children's Healthcare of Atlanta, Atlanta, GA, United States.
| | - Courtney McCracken
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States.
| | - Michael D Mallory
- Pediatric Emergency Medicine Associates, Atlanta, GA, United States.
| | - Pradip P Kamat
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States; Children's Healthcare of Atlanta, Atlanta, GA, United States.
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Boriosi JP, Eickhoff JC, Klein KB, Hollman GA. A retrospective comparison of propofol alone to propofol in combination with dexmedetomidine for pediatric 3T MRI sedation. Paediatr Anaesth 2017; 27:52-59. [PMID: 27779360 DOI: 10.1111/pan.13041] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIM Both propofol and dexmedetomidine have been found to be safe and effective sedation for magnetic resonance imaging (MRI). Our program experienced an increase in patients arousing and experiencing an adverse airway event during propofol sedation for MRI in the first months of using a new 3T (Tesla) MRI scanner that was found to have a longer reverberation time compared to the previous 1.5 T MRI. In an effort to decrease patient arousal and adverse airway events during MRI, we administered a dexmedetomidine load prior to our standard propofol protocol. The objective was to compare adverse events and other outcome measures of patients sedated with propofol alone (Pro) and propofol preceded by a dexmedetomidine load (D+P). METHODS We reviewed a sedation database and medical records for all children undergoing 3T MRI studies while sedated with propofol alone or propofol preceded by a dexmedetomidine load in 2014. RESULTS Two hundred and fifty-six sedations were performed for MRI (87 Pro and 169 D+P). The two groups were comparable with regard to age, weight, gender, and American Society of Anesthesiologists status. Subjects in the D+P cohort had significantly fewer adverse events (10/169 patients (5.9%) vs 23/87 patients (26.4%) [OR 0.18, 95% CI: 0.08-0.39, P < 0.001]), particularly upper airway obstruction. Mean discharge time was longer in the D+P cohort compared to the Pro cohort (87.1, SD 26.3 min vs 69.7, SD 23.6; [mean difference 17.7 min, 95% CI: 10.6-24.8, P < 0.001]). CONCLUSIONS The addition of a dexmedetomidine infusion prior to our propofol MRI sedation protocol resulted in fewer sedation-related adverse events, particularly upper airway obstruction. Further studies are needed to evaluate the potential for a reduction on adverse events with this drug combination.
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Affiliation(s)
- Juan P Boriosi
- Department of Pediatrics, University of Wisconsin, Madison, WI, USA
| | - Jens C Eickhoff
- Department of Biostatistics, University of Wisconsin, Madison, WI, USA
| | - Kristi B Klein
- Department of Radiology, University of Wisconsin, Madison, WI, USA
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Coté CJ, Wilson S. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. Pediatrics 2016; 138:peds.2016-1212. [PMID: 27354454 DOI: 10.1542/peds.2016-1212] [Citation(s) in RCA: 145] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.
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11
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Baez JC, Seethamraju RT, Mulkern R, Ciet P, Lee EY. Pediatric Chest MR Imaging: Sedation, Techniques, and Extracardiac Vessels. Magn Reson Imaging Clin N Am 2016; 23:321-35. [PMID: 25952523 DOI: 10.1016/j.mric.2015.01.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Thoracic MR imaging in the pediatric population provides unique challenges requiring tailored protocols and a practical approach to pediatric issues, such as patient motion and sedation. Concern regarding the use of ionizing radiation in the pediatric population has continued to advance the use of MR imaging despite these challenges. This article provides a practical approach to thoracic vascular MR imaging with special attention paid to pediatric-specific issues such as sedation. Thoracic vascular anatomy and pathology are discussed with an emphasis on protocols that can facilitate accurate diagnosis.
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Affiliation(s)
- Juan C Baez
- Mid-Atlantic Permanente Medical Group, 2101 East Jefferson Street, Rockville, MD 20852, USA; Department of Radiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Ravi T Seethamraju
- Magnetic Resonance, Research and Development, Siemens Healthcare, 1620 Tremont St., Boston, MA 02120, USA
| | - Robert Mulkern
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Pierluigi Ciet
- Department of Radiology and Pediatric Pulmonology, Sophia Children's Hospital, Erasmus Medical Center, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands; Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA 02215, USA
| | - Edward Y Lee
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
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Emrath ET, Stockwell JA, McCracken CE, Simon HK, Kamat PP. Provision of deep procedural sedation by a pediatric sedation team at a freestanding imaging center. Pediatr Radiol 2014; 44:1020-5. [PMID: 24859263 DOI: 10.1007/s00247-014-2942-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Revised: 02/01/2014] [Accepted: 02/17/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Freestanding imaging centers are popular options for health care systems to offer services accessible to local communities. The provision of deep sedation at these centers could allow for flexibility in scheduling imaging for pediatric patients. Our Children's Sedation Services group, comprised of pediatric critical care medicine and pediatric emergency medicine physicians, has supplied such a service for 5 years. However, limited description of such off-site services exists. The site has resuscitation equipment and medications, yet limited staffing and no proximity to hospital support. OBJECTIVE To describe the experience of a cohort of pediatric patients undergoing sedation at a freestanding imaging center. MATERIALS AND METHODS A retrospective chart review of all sedations from January 2012 to December 2012. Study variables include general demographics, length of sedation, type of imaging, medications used, completion of imaging, adverse events based on those defined by the Pediatric Sedation Research Consortium database and need for transfer to a hospital for additional care. RESULTS Six hundred fifty-four consecutive sedations were analyzed. Most patients were low acuity American Society of Anesthesiologists physical class ≤ 2 (91.8%). Mean sedation time was 55 min (SD ± 24). The overwhelming majority of patients (95.7%) were sedated for MRI, 3.8% for CT and <1% (three patients) for both modalities. Propofol was used in 98% of cases. Overall, 267 events requiring intervention occurred in 164 patient encounters (25.1%). However, after adjustment for changes from expected physiological response to the sedative, the rate of events was 10.2%. Seventy-five (11.5%) patients had desaturation requiring supplemental oxygen, nasopharyngeal tube or oral airway placement, continuous positive airway pressure or brief bag valve mask ventilation. Eleven (1.7%) had apnea requiring continuous positive airway pressure or bag valve mask ventilation briefly. One patient had bradycardia that resolved with nasopharyngeal tube placement and continuous positive airway pressure. Fifteen (2.3%) patients had hypotension requiring adjustment of the sedation drip but no fluid bolus. Overall, there were six failed sedations (0.9%), defined by the inability to complete the imaging study. There were no serious adverse events. There were no episodes of cardiac arrest or need for intubation. No patient required transfer to a hospital. CONCLUSION Sedation provided at this freestanding imaging center resulted in no serious adverse events and few failed sedations. While this represents a limited cohort with sedations performed by predominately pediatric critical care medicine and pediatric emergency medicine physicians, these findings have implications for the design and potential scope of practice of outpatient pediatric sedation services to support community-based pediatric imaging.
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Affiliation(s)
- Elizabeth T Emrath
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
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Abstract
OBJECTIVES Deep sedation enables effective performance of imaging or procedures in children, but failed sedation still occurs. We desired to determine the factors that were associated with failed sedation in children receiving deep sedation by a dedicated nonanesthesia sedation service and hypothesized that the presence of an upper respiratory infection (URI) and/or other risk factors would increase the probability of failing sedation. METHODS Patient sedation records from January 2007 to December 2011 were reviewed to identify 83 failed sedations. A convenience sample of 523 patients with successful sedation from January 2009 to February 2009 was identified for comparison. RESULTS Seven of the 13 predictors were significantly associated with failed sedation; these are as follows: (1) URI (P = 0.008); (2) congenital heart disease (P = 0.021); (3) obstructive sleep apnea (OSA)/snoring (P < 0.001); (4) the American Society of Anesthesiologists (ASA) class of above II (P < 0.001); (5) obesity (P < 0.001); (6) increased weight (P < 0.001); and (7) older age (P < 0.001). Sex, prematurity, asthma, gastroesophageal reflux, and cerebral palsy/developmental delay were not associated with failure. Pulmonary hypertension was not able to be assessed because only 1 patient with pulmonary hypertension was sedated. A forward stepwise regression identified 5 variables that could be considered useful predictors of failed sedation, which are as follows: (1) URI (odds ratio [OR], 2.73 [range, 1.58-4.73]); (2) OSA/snoring (OR, 2.06 [range, 1.22-3.48]); (3) ASA class III (OR, 2.31 [range, 1.40-3.84]); (4) obesity (OR, 1.95 [range, 1.01-3.75]); and (5) older age (OR, 1.15 [range, 1.08-1.21). CONCLUSIONS Presence of a URI, a history of OSA/snoring, ASA class III, obesity, and older age are associated with increased probability of failed sedation. A prospective, multicenter observational study would allow for the robust modeling of comorbidities to guide pediatric sedation management.
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14
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Owusu-Agyemang P, Grosshans D, Arunkumar R, Rebello E, Popovich S, Zavala A, Williams C, Ruiz J, Hernandez M, Mahajan A, Porche V. Non-invasive anesthesia for children undergoing proton radiation therapy. Radiother Oncol 2014; 111:30-4. [PMID: 24560754 DOI: 10.1016/j.radonc.2014.01.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Revised: 01/21/2014] [Accepted: 01/21/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND Proton therapy is a newer modality of radiotherapy during which anesthesiologists face specific challenges related to the setup and duration of treatment sessions. PURPOSE Describe our anesthesia practice for children treated in a standalone proton therapy center, and report on complications encountered during anesthesia. MATERIALS AND METHODS A retrospective review of anesthetic records for patients ⩽18years of age treated with proton therapy at our institution between January 2006 and April 2013 was performed. RESULTS A total of 9328 anesthetics were administered to 340 children with a median age of 3.6years (range, 0.4-14.2). The median daily anesthesia time was 47min (range, 15-79). The average time between start of anesthesia to the start of radiotherapy was 7.2min (range, 1-83min). All patients received Total Intravenous Anesthesia (TIVA) with spontaneous ventilation, with 96.7% receiving supplemental oxygen by non-invasive methods. None required daily endotracheal intubation. Two episodes of bradycardia, and one episode each of; seizure, laryngospasm and bronchospasm were identified for a cumulative incidence of 0.05%. CONCLUSIONS In this large series of children undergoing proton therapy at a freestanding center, TIVA without daily endotracheal intubation provided a safe, efficient, and less invasive option of anesthetic care.
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Affiliation(s)
- Pascal Owusu-Agyemang
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, United States.
| | - David Grosshans
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, United States
| | - Radha Arunkumar
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, United States
| | - Elizabeth Rebello
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, United States
| | - Shannon Popovich
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, United States
| | - Acsa Zavala
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, United States
| | - Cynthia Williams
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, United States
| | - Javier Ruiz
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, United States
| | - Mike Hernandez
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, United States
| | - Anita Mahajan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, United States
| | - Vivian Porche
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, United States
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15
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Abstract
The volume of pediatric invasive and noninvasive procedures outside the operating room continues to increase. The acuity and complexity of patient clinical condition has resulted in the expansion of the anesthesiologist's role in remote sites. The anesthesia provider must ensure patient safety by assuring appropriate patient preparation, having available required equipment for monitoring and rescue, planning careful sedation/anesthesia management, continuing vigilance and observation into the recovery phase, and requiring strict discharge criteria. A quality improvement program for the department of anesthesiology should review anesthetic and sedation outcomes of patients both inside and outside the operating room.
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Affiliation(s)
- Katrin Campbell
- Division of Sedation, Texas Children's Hospital, Baylor College of Medicine, 6621 Fannin St, Suite A300, Houston, TX 77030, USA
| | - Laura Torres
- Department of Pediatrics, Sedation Oversight Committee, Texas Children's Hospital, Baylor College of Medicine, 6621 Fannin St, Suite A300, Houston, TX 77030, USA
| | - Stephen Stayer
- Pediatric Anesthesiology, Texas Children's Hospital, Baylor College of Medicine, 6621 Fannin St, Suite A300, Houston, TX 77030, USA.
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