Effects of IV Pentobarbital With and Without Fentanyl on End-Tidal Carbon Dioxide Levels During Deep Sedation of Pediatric Patients Undergoing MRI

Anesthesia Management for Pediatrics with Congenital Heart Diseases Who Undergo Cardiac Catheterization in China

Objectives

The goal of this study was to summarize anesthesia management for pediatrics with congenital heart diseases who undergo cardiac catheterization procedure in China.

Methods

The relevant articles were identified through computerized searches in the CNKI, Wanfang, VIP, and PubMed databases through May 2020, using different combinations of keywords: “congenital heart diseases,” “pediatric,” “children,” “anesthesia,” “cardiac catheterization,” “interventional therapy,” “interventional treatment,” “interventional examination,” and “computed tomography.”

Results

The database searches identified 48 potentially qualified articles, of which 25 (9,738 patients in total) were determined to be eligible and included. The authors collect data from the article information. Anesthesia methods included endotracheal intubation or laryngeal mask ventilation general anesthesia, monitored anesthesia care, and combined with sacral canal block. Anesthesia-related complications occurred in 7.41% of the patients and included dysphoria, respiratory depression, nausea, vomiting, cough, increased respiratory secretion, and airway obstruction. The incidence of procedure-related complications was 12.14%, of which the most common were arrhythmia and hypotension.

Conclusions

For pediatric patients with congenital heart diseases who undergo cardiac catheterization procedures in China, arrhythmia and hypotension are the most common procedure-related complications. Monitored anesthesia care is the commonly used anesthesia methods, and dysphoria, cough, nausea, vomiting, and respiratory depression are frequent complications associated with anesthesia.

A single psychotomimetic dose of ketamine decreases thalamocortical spindles and delta oscillations in the sedated rat

BACKGROUND

In patients with psychotic disorders, sleep spindles are reduced, supporting the hypothesis that the thalamus and glutamate receptors play a crucial etio-pathophysiological role, whose underlying mechanisms remain unknown. We hypothesized that a reduced function of NMDA receptors is involved in the spindle deficit observed in schizophrenia.

METHODS

An electrophysiological multisite cell-to-network exploration was used to investigate, in pentobarbital-sedated rats, the effects of a single psychotomimetic dose of the NMDA glutamate receptor antagonist ketamine in the sensorimotor and associative/cognitive thalamocortical (TC) systems.

RESULTS

Under the control condition, spontaneously-occurring spindles (intra-frequency: 10-16 waves/s) and delta-frequency (1-4 Hz) oscillations were recorded in the frontoparietal cortical EEG, in thalamic extracellular recordings, in dual juxtacellularly recorded GABAergic thalamic reticular nucleus (TRN) and glutamatergic TC neurons, and in intracellularly recorded TC neurons. The TRN cells rhythmically exhibited robust high-frequency bursts of action potentials (7 to 15 APs at 200-700 Hz). A single administration of low-dose ketamine fleetingly reduced TC spindles and delta oscillations, amplified ongoing gamma-(30-80 Hz) and higher-frequency oscillations, and switched the firing pattern of both TC and TRN neurons from a burst mode to a single AP mode. Furthermore, ketamine strengthened the gamma-frequency band TRN-TC connectivity. The antipsychotic clozapine consistently prevented the ketamine effects on spindles, delta- and gamma-/higher-frequency TC oscillations.

CONCLUSION

The present findings support the hypothesis that NMDA receptor hypofunction is involved in the reduction in sleep spindles and delta oscillations. The ketamine-induced swift conversion of ongoing TC-TRN activities may have involved at least both the ascending reticular activating system and the corticothalamic pathway.

The Use of Intranasal Dexmedetomidine and Midazolam for Sedated Magnetic Resonance Imaging in Children: A Report From the Pediatric Sedation Research Consortium

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.

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures

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.

The N-Methyl d-Aspartate Glutamate Receptor Antagonist Ketamine Disrupts the Functional State of the Corticothalamic Pathway

The non-competitive N-methyl d-aspartate glutamate receptor (NMDAR) antagonist ketamine elicits a brain state resembling high-risk states for developing psychosis and early stages of schizophrenia characterized by sensory and cognitive deficits and aberrant ongoing gamma (30-80 Hz) oscillations in cortical and subcortical structures, including the thalamus. The underlying mechanisms are unknown. The goal of the present study was to determine whether a ketamine-induced psychotic-relevant state disturbs the functional state of the corticothalamic (CT) pathway. Multisite field recordings were performed in the somatosensory CT system of the sedated rat. Baseline activity was challenged by activation of vibrissa-related prethalamic inputs. The sensory-evoked thalamic response was characterized by a short-latency (∼4 ms) prethalamic-mediated negative sharp potential and a longer latency (∼10 ms) CT-mediated negative potential. Following a single subcutaneous injection of ketamine (2.5 mg/kg), spontaneously occurring and sensory-evoked thalamic gamma oscillations increased and decreased in power, respectively. The power of the sensory-related gamma oscillations was positively correlated with both the amplitude and the area under the curve of the corresponding CT potential but not with the prethalamic potential. The present results show that the layer VI CT pathway significantly contributes in thalamic gamma oscillations, and they support the hypothesis that reduced NMDAR activation disturbs the functional state of CT and corticocortical networks.

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016

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.

Practice advisory on anesthetic care for magnetic resonance imaging: an updated report by the american society of anesthesiologists task force on anesthetic care for magnetic resonance imaging

The American Society of Anesthesiologists Committee on Standards and Practice Parameters and the Task Force on Anesthetic Care for Magnetic Resonance Imaging presents an updated report of the Practice Advisory on Anesthetic Care for Magnetic Resonance Imaging.

Supplemental Digital Content is available in the text.

Significant hypercapnia either in CO(2)-insufflated or air-insufflated colonoscopy under deep sedation

BACKGROUND

previous reports showed that CO(2)-insufflated colonoscopy is safe and less discomfortable. However, hypercapnia remains a vital concernment if deep sedation is necessary for difficult colonoscopy with prolonged CO(2) insufflation. This observational study is to measure bodily CO(2) subjected to colonoscopy facilitated by CO(2)- and air- or air-insufflation in conscious-sedation, deep-sedation and awake patients.

OBJECTIVE

to investigate if CO(2)-insufflated colonoscopy could increase the risk of hypercapnia in awake, conscious-sedation and deep-sedation patients.

METHODS

104 patients in our health center undergoing sequential esophagogastroscopy and colonoscopy screening were included. At patients' request, incremental intravenous sedatives were given in order that the air-insufflated esophagogastroscopy could be carried out without the molestation of gag and cough reflexes. The sedation levels were re-evaluated before proceeding colonoscopy and the patients were divided into conscious-sedation (respond purposefully to verbal commands) and deep-sedation groups and randomly allocated for air or CO(2) insufflation. Transcutaneous capnography (TcCO(2)) was recorded every minute throughout the colonoscopy procedure.

RESULTS

the baseline TcCO(2) in the air- (50.9 ± 5.7 mmHg) and CO(2)-insufflated (53.1 ± 6.5 mmHg) groups under deep sedation was significantly higher than the groups under conscious-sedation and the awake groups (p < 0.01). In both air- and CO(2)-insufflation groups there were also a statistically significant (p < 0.01) correlation in TcCO(2) between the start, the peak and the end of colonoscopy. TcCO(2) did not significantly change throughout the colonoscopy in awake and conscious-sedation groups, either with air or CO(2) insufflation. With deep sedation, TcCO(2) significantly increased and peaked around the time when the scope touching the cecum, and then returned to original state with suction and withdrawl of the colonoscope without significant interaction of CO(2) insufflation and deep sedation.

CONCLUSION

the TcCO(2) during colonoscopy was correlated to the data before inserting colonoscope but significantly different within awake, conscious-sedation and deep-sedation groups. TcCO(2) did not change significantly either with CO(2) insufflation or air insufflations in awake and conscious-sedation groups. However, in deep-sedation groups with significantly higher baseline TcCO(2), further increase of TcCO(2) were significant without interaction with CO(2) insufflation. We concluded that when patients need deep sedation for colonoscopic procedures facilitated by gas insufflation, hypercapnia is still considerably present, not only with CO(2) insufflation but also with air insufflation colonoscopy.

Continuous end-tidal carbon dioxide monitoring in pediatric intensive care units

PURPOSE

End-tidal carbon dioxide (ETCO(2)) monitoring has a variety of clinical applications in critically ill pediatric patients. This study was designed to explore the current availability and utilization patterns for continuous ETCO(2) monitoring in pediatric intensive care units.

METHODS

A Web-based survey was distributed to directors of all accredited pediatric critical care fellowship programs in the United States.

RESULTS

Sixty-six percent of directors completed this survey. One hundred percent of directors had access to ETCO(2) monitoring for intubated patients and 57% for nonintubated patients. Eighty-three percent of respondents used ETCO(2) monitoring "always" or "often" for endotracheal tube confirmation. Fifty percent of respondents used ETCO(2) monitoring "always" or "often" for cardiopulmonary resuscitation, 38% for moderate sedation, and 5% for acid-base disturbances. All respondents who used ETCO(2) monitoring felt that it was easy to use. The most common reason for not using ETCO(2) monitoring was lack of availability (75%).

CONCLUSIONS

End-tidal carbon dioxide monitoring is widely available and used for intubated patients. However, it could be applied more frequently in other clinical situations in pediatric intensive care units.

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.

Pediatric procedural sedation and analgesia

Children often present with painful conditions that require painful interventions. Procedural sedation and analgesia refers to the pharmacologic technique of managing a child's pain and anxiety. Procedural sedation is a safe, effective, and humane way to facilitate appropriate medical care. It is important to distinguish the goals for the procedural sedation, pain relief or anxiolysis or both. Different medications and combinations of medications can be used to achieve the desired effect. It is also important to keep in mind the possible adverse reactions and side effects associated with each medication when choosing the sedation cocktail.

Prevention of Emergence Agitation After Sevoflurane Anesthesia for Pediatric Cerebral Magnetic Resonance Imaging by Small Doses of Ketamine or Nalbuphine Administered Just Before Discontinuing Anesthesia

Magnetic resonance imaging (MRI) requires long-lasting immobilization that frequently can only be provided by general anesthesia in pediatric patients. Sevoflurane provides adequate anesthesia but many patients experience emergence agitation. Small doses of ketamine and nalbuphine provide moderate sedation but their benefits have subsided at the time of emergence. We hypothesized that delaying their administration until the end of the procedure would prevent emergence agitation without prolonging patient wake-up and discharge times from the postanesthesia care unit. We performed a double-blind study involving 90 patients (aged 6 mo to 8 yr) randomly allocated to 1 of 3 groups receiving either saline (S-group), ketamine (0.25 mg/kg) (K-group), or nalbuphine (0.1 mg/kg) (N-group) at the end of an MRI procedure under sevoflurane anesthesia. We evaluated emergence conditions, sedation/agitation status and completion of discharge criteria at 30 min. The three groups were comparable in age, sex ratio, physical status, and associated medical disorders. Emergence conditions did not differ significantly. There were significantly more agitated children, at all times, in the S-group and more obtunded patients at early times (5 and 10 min) in both K- and N-groups. All patients met discharge criteria at 30 min but significantly more children were awake and quiet in the K-group and still more in the N-group. In conclusion, small doses of ketamine or nalbuphine administered at the end of an MRI procedure under sevoflurane anesthesia reduce emergence agitation without delaying discharge. Nalbuphine provided better results than ketamine.

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.

Capnometry in the spontaneously breathing patient

PURPOSE OF REVIEW

Capnography has been used in the operating room by anesthesiologists for over a decade. Along with pulse oximetry, it has reduced anesthesia-related morbidity and mortality. Traditionally, capnography has been used to confirm the placement of the endotracheal tube. This review looks into the literature for an update on the use of capnography in the spontaneously breathing patient.

RECENT FINDINGS

Several studies support the additional safety afforded by the use of capnography in patients undergoing sedation for procedures in various situations outside the operating room. Capnography has been used as an aid in the diagnosis of pulmonary embolism and sleep-related disorders, as a continuous monitor of metabolic status of pediatric patients with diabetic ketoacidosis and, along with pulse oximetry, in lung-function laboratories to estimate blood gases.

SUMMARY

Capnography has become a mandatory or recommended monitoring tool in the practice of anesthesiology. It is making inroads into other medical specialties as a monitoring and diagnostic tool. The use of this technology by non-anesthesiologists will continue to increase. In the opinion of the authors capnography should be used in all cases requiring sedation either in or out of the operating room.