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Artunduaga M, Liu CA, Morin CE, Serai SD, Udayasankar U, Greer MLC, Gee MS. Safety challenges related to the use of sedation and general anesthesia in pediatric patients undergoing magnetic resonance imaging examinations. Pediatr Radiol 2021; 51:724-735. [PMID: 33860861 PMCID: PMC8049862 DOI: 10.1007/s00247-021-05044-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 01/17/2021] [Accepted: 03/01/2021] [Indexed: 12/17/2022]
Abstract
The use of sedation and general anesthesia has facilitated the significant growth of MRI use among children over the last years. While sedation and general anesthesia are considered to be relatively safe, their use poses potential risks in the short term and in the long term. This manuscript reviews the reasons why MRI examinations require sedation and general anesthesia more commonly in the pediatric population, summarizes the safety profile of sedation and general anesthesia, and discusses an amalgam of strategies that can be implemented and can ultimately lead to the optimization of sedation and general anesthesia care within pediatric radiology departments.
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Affiliation(s)
- Maddy Artunduaga
- Pediatric Radiology Division, Department of Radiology, University of Texas Southwestern Medical Center, Children's Health Medical Center,, 5323 Harry Hines Blvd., CMC F1.02, Dallas, TX, 75390, USA.
- Children's Health Medical Center, Dallas, TX, USA.
| | - C Amber Liu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Cara E Morin
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Suraj D Serai
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Unni Udayasankar
- Department of Medical Imaging, The University of Arizona Health Sciences, Tucson, AZ, USA
| | - Mary-Louise C Greer
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada
- Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - Michael S Gee
- Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
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Mason KP, Kelhoffer ER, Prescilla R, Mehta M, Root JC, Young VJ, Robinson F, Veselis RA. Feasibility of measuring memory response to increasing dexmedetomidine sedation in children. Br J Anaesth 2018; 118:254-263. [PMID: 28100530 DOI: 10.1093/bja/aew421] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The memory effect of dexmedetomidine has not been prospectively evaluated in children. We evaluated the feasibility of measuring memory and sedation responses in children during dexmedetomidine sedation for non-painful radiological imaging studies. Secondarily, we quantified changes in memory in relation to the onset of sedation. METHODS A 10 min bolus of dexmedetomidine (2 mcg kg-1) was given to children as they named simple line drawings every five s. The absence of sedation was identified as any verbal response, regardless of correctness. After recovery, recognition memory was tested with correct Yes/No recognitions (50% novel pictures) and was matched to sedation responses during the bolus period (subsequent memory paradigm). RESULTS Of 64 accruals, 30 children (mean [SD]6.1 (1.2) yr, eight male) received dexmedetomidine and completed all study tasks. Individual responses were able to be modelled successfully in the 30 children completing all the study tasks, demonstrating feasibility of this approach. Children had 50% probability of verbal response at five min 40 s after infusion start, whereas 50% probability of subsequent recognition memory occurred sooner at four min five s. CONCLUSIONS Quantifying memory and sedation effects during dexmedetomidine infusion in verbal children was possible and demonstrated that memory function was present until shortly before verbal unresponsiveness occurred. This is the first study to investigate the effect of dexmedetomidine on memory in children. CLINICAL TRIAL REGISTRATION NCT 02354378.
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Affiliation(s)
- K P Mason
- Department of Anesthesia, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - E R Kelhoffer
- Department of Anesthesiology and Critical Care, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.,Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - R Prescilla
- Department of Anaesthesiology, Perioperative and Pain Medicine, Harvard Medical School, MA, USA
| | - M Mehta
- Department of Anesthesiology and Critical Care, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.,Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - J C Root
- Department of Anesthesiology and Critical Care, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.,Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA.,Department of Psychology in Anesthesiology, Neurocognitve Research Lab, Memorial Sloan-Kettering Cancer Center, New York, NY,USA
| | - V J Young
- Department of Anesthesia, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | | | - R A Veselis
- Department of Anesthesiology and Critical Care, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.,Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
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Comparison between chloral hydrate and propofol-ketamine as sedation regimens for pediatric auditory brainstem response testing. Braz J Otorhinolaryngol 2017; 85:32-36. [PMID: 29137881 PMCID: PMC9442876 DOI: 10.1016/j.bjorl.2017.10.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 10/03/2017] [Indexed: 11/29/2022] Open
Abstract
Introduction The use of diagnostic auditory brainstem response testing under sedation is currently the “gold standard” in infants and young children who are not developmentally capable of completing the test. Objective The aim of the study is to compare a propofol-ketamine regimen to an oral chloral hydrate regimen for sedating children undergoing auditory brainstem response testing. Methods Patients between 4 months and 6 years who required sedation for auditory brainstem response testing were included in this retrospective study. Drugs doses, adverse effects, sedation times, and the effectiveness of the sedative regimens were reviewed. Results 73 patients underwent oral chloral hydrate sedation, while 117 received propofol-ketamine sedation. 12% of the patients in the chloral hydrate group failed to achieve desired sedation level. The average procedure, recovery and total nursing times were significantly lower in the propofol-ketamine group. Propofol-ketamine group experienced higher incidence of transient hypoxemia. Conclusion Both sedation regimens can be successfully used for sedating children undergoing auditory brainstem response testing. While deep sedation using propofol-ketamine regimen offers more efficiency than moderate sedation using chloral hydrate, it does carry a higher incidence of transient hypoxemia, which warrants the use of a highly skilled team trained in pediatric cardio-respiratory monitoring and airway management.
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Rogerson CM, Abulebda K, Hobson MJ. Association of BMI With Propofol Dosing and Adverse Events in Children With Cancer Undergoing Procedural Sedation. Hosp Pediatr 2017; 7:542-546. [PMID: 28798230 DOI: 10.1542/hpeds.2016-0191] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Obesity increases the risk of complications during pediatric procedural sedation. The risk of being underweight has not been evaluated in this arena. We therefore investigated the association of BMI with sedation dosing and adverse events in children across a range of BMIs. METHODS A total of 1976 patients ages 2 to 21 years old with oncologic diagnoses underwent lumbar punctures and/or bone marrow aspirations. All children received a standard adjunctive dose of ketamine before sedation with propofol. Weight categories were stratified by BMI percentile: underweight <5%, normal weight 5% to 85%, overweight >85%, and obese >95%. Dosing and adverse events (hypoxia, apnea, bradycardia, or hypotension) were reviewed. RESULTS There were no differences in propofol dosing for procedural sedation between patients who were normal weight and underweight. However, children who were overweight and those who were obese used less propofol compared with children who were normal weight (P < .01). Children who were underweight had a higher proportion of adverse events overall relative to those children of normal weight (P < .001). In contrast, there was not an increase in adverse events for patients who were overweight and obese. CONCLUSIONS Children who are overweight and children with obesity who require deep sedation can undergo successful sedation with lower propofol dosing relative to children of a normal weight. This dosing strategy may help to mitigate the risks associated with sedating patients who are obese. Notably, children who were underweight had an increased rate of complications despite receiving an equal amount of sedation compared with patients who were normal weight. This should alert the clinicians to the risks associated with sedating children who are underweight.
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Affiliation(s)
- Colin M Rogerson
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana; and
| | - Kamal Abulebda
- Division of Pediatric Critical Care Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana
| | - Michael J Hobson
- Division of Pediatric Critical Care Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana
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Pediatric Procedural Sedation Using the Combination of Ketamine and Propofol Outside of the Emergency Department: A Report From the Pediatric Sedation Research Consortium. Pediatr Crit Care Med 2017. [PMID: 28650904 PMCID: PMC6287759 DOI: 10.1097/pcc.0000000000001246] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Outcomes associated with a sedative regimen comprised ketamine + propofol for pediatric procedural sedation outside of both the pediatric emergency department and operating room are underreported. We used the Pediatric Sedation Research Consortium database to describe a multicenter experience with ketamine + propofol by pediatric sedation providers. DESIGN Prospective observational study of children receiving IV ketamine + propofol for procedural sedation outside of the operating room and emergency department using data abstracted from the Pediatric Sedation Research Consortium during 2007-2015. SETTING Procedural sedation services from academic, community, free-standing children's hospitals, and pediatric wards within general hospitals. PATIENTS Children from birth to less than or equal to 21 years old. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 7,313 pediatric procedural sedations were performed using IV ketamine + propofol as the primary sedative regimen. Median age was 84 months (range, < 1 mo to ≤ 21 yr; interquartile range, 36-144); 80.6% were American Society of Anesthesiologists-Physical Status less than III. The majority of sedation was performed in dedicated sedation or radiology units (76.1%). Procedures were successfully completed in 99.8% of patients. Anticholinergics (glycopyrrolate and atropine) or benzodiazepines (midazolam and lorazepam) were used in 14.2% and 41.3%, respectively. The overall adverse event and serious adverse event rates were 9.79% (95% CI, 9.12-10.49%) and 3.47% (95% CI, 3.07-3.92%), respectively. No deaths occurred. Risk factors associated with an increase in odds of adverse event included ASA status greater than or equal to III, dental suite, cardiac catheterization laboratory or radiology/sedation suite location, a primary diagnosis of having a gastrointestinal illness, and the coadministration of an anticholinergic. CONCLUSIONS Using Pediatric Sedation Research Consortium data, we describe the diverse use of IV ketamine + propofol for procedural sedation in the largest reported cohort of children to date. Data from this study may be used to design sufficiently powered prospective randomized, double-blind studies comparing outcomes of sedation between commonly administered sedative and analgesic medication regimens.
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Experience with the use of propofol for radiologic imaging in infants younger than 6 months of age. Pediatr Radiol 2017; 47:974-983. [PMID: 28488002 DOI: 10.1007/s00247-017-3844-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 02/24/2017] [Accepted: 03/21/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND There is an increased risk associated with procedural sedation of infants younger than 6 months of age. The use of propofol for radiologic imaging of this age group is not well studied. OBJECTIVE We hypothesize that adverse events are higher in the infant population receiving propofol for radiologic imaging. MATERIALS AND METHODS A retrospective chart review was undertaken of 304 infants younger than 6 months old who received propofol for procedural sedation from October 2012 to February 2015. Patient demographics, propofol dosing, sedation-related adverse events and interventions were collected. Serious adverse events were defined as laryngospasm, aspiration, the need for admission, cardiac arrest or death. RESULTS Procedural sedation for radiologic imaging was successful in 301/304 (99%) of infants using propofol. Of these 304 patients, 130 (42.8%) patients were female, and 240 of the 304 (79%) were between 3 and 6 months of age. The majority of patients (172/304 [56.6%]) were American Society of Anesthesiologists-Physical Status Class II. There were 57 sedation-related, minor adverse events in 39 out of 304 (12.8%) patients. Thirteen of the 304 (4.3%) patients had 14 serious adverse events, with airway obstruction the most common. Eighty interventions were required in 56/304 (18.4%) patients. The most common interventions were continuous positive airway pressure (CPAP) in 25/304 patients (8.2%) and jaw thrust in 15/304 (4.9%). The median induction propofol dose was 4.7 mg/kg. A need for an increase in the propofol infusion rate during the procedure was noted in 162/304 (53.3%) infants. No significant predictors of sedation-related adverse events were detected. CONCLUSION Propofol can be used for radiologic imaging of infants younger than 6 months of age with a high success rate. Practitioners should be mindful of significantly higher dosing requirements and a higher incidence of airway events, which can be easily identified and managed by a team of experienced sedation providers.
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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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Veselis R, Kelhoffer E, Mehta M, Root JC, Robinson F, Mason KP. Propofol sedation in children: sleep trumps amnesia. Sleep Med 2016; 27-28:115-120. [PMID: 27938911 DOI: 10.1016/j.sleep.2016.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 08/31/2016] [Accepted: 10/04/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Detailed assessments of the effects of propofol on memory in children are lacking. We assessed the feasibility of measuring memory during propofol infusion, as commonly performed in sedation for MRI scanning. In addition, we determined the onset of memory loss in relation to the onset of sedation measured by verbal responsiveness. MATERIALS AND METHODS Children scheduled for sedation for MRI received a 10-min infusion of propofol (3 mg/kg) as they viewed and named 100 simple line drawings, one shown every five seconds, until they were no longer responsive (encoding). A control group receiving no sedation for MRI underwent similar tasks. Sedation was measured as any verbal response, regardless of correctness. After recovery from sedation, recognition memory was tested, with correct yes/no recognitions matched to sedation responses during encoding (subsequent memory paradigm). RESULTS Of the 48 children who received propofol, 30 could complete all study tasks (6.2 ± 1.6 years, 16 males). Individual responses could be modeled in all 30 children. On average, there was a 50% probability of no verbal response 3.1 min after the start of infusion, with 50% memory loss at 2.7 min. Children receiving propofol recognized 65 ± 16% of the pictures seen, whereas the control group recognized 93 ± 5%. CONCLUSION Measurement of memory and sedation is possible in verbal children receiving propofol by infusion in a clinical setting. Despite propofol being an amnestic agent, there was little or no amnestic effect of propofol while the child was verbally responsive. It is important for sedation providers to realize that propofol sedation does not always produce amnesia while the child is responsive. CLINICALTRIALS. GOV NUMBER NCT02278003.
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Affiliation(s)
- Robert Veselis
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, United States; Department of Anesthesiology, Weill Cornell Medical College, New York, NY, United States
| | - Eric Kelhoffer
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, United States; Department of Anesthesiology, Weill Cornell Medical College, New York, NY, United States
| | - Meghana Mehta
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, United States
| | - James C Root
- Neurocognitive Research Lab, Memorial Sloan-Kettering Cancer Center, New York, NY, United States; Department of Psychology in Anesthesiology, Weill Cornell Medical College, New York, NY, United States
| | | | - Keira P Mason
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Boston Children's Hospital, Boston, MA, United States.
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The safety of propofol sedation for elective nonintubated esophagogastroduodenoscopy in pediatric patients. Pediatr Crit Care Med 2014; 15:e261-9. [PMID: 24849145 DOI: 10.1097/pcc.0000000000000147] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES To evaluate the safety of deep sedation provided by pediatric intensivists for elective nonintubated esophagogastroduodenoscopy. DESIGN Retrospective observational study. SETTING The sedation program at the Helen DeVos Children's Hospital. PATIENTS A 4-year retrospective analysis was done on all outpatient elective pediatric esophagogastroduodenoscopy procedures performed in an intensivist run sedation program. Safety was examined by reviewing the occurrence of minor and major adverse effects during esophagogastroduodenoscopy sedation. Interventions were studied and reported. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS During the study period, 12,447 sedations were performed by the pediatric sedation program for various procedures. Two thousand one hundred forty-seven patients received 2,325 sedations (18.6%) for esophagogastroduodenoscopies performed for various indications. During the same time period, 53 (one for every 40 esophagogastroduodenoscopy sedations) were screened, found unsuitable for nonintubated sedation, and referred for general anesthesia. There were 2,254 sedations with propofol, 65 methohexital, five ketamine, and one fentanyl/midazolam sedation. Propofol sedation proved safe with a 2.1% prevalence of minor adverse events and no major events. Methohexital, on the other hand, had higher rate (p < 0.001) of minor events and one patient developed an anaphylactic reaction to its use. Regression analysis showed that other sedative agents were 8.6 times more likely to be associated with complications than propofol (odds ratio, 8.6; 95% CI, 4.1-18.2; p < 0.001). CONCLUSIONS This study demonstrates that deep sedation for elective esophagogastroduodenoscopies can be provided safely in the appropriately screened patient by nonanesthesiologist physicians in a sedation program. These data suggest that propofol is a safe and effective agent for esophagogastroduodenoscopy sedation.
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