Yeungnam Univ J Med.  2020 Jul;37(3):159-168. 10.12701/yujm.2020.00171.

Drug selection for sedation and general anesthesia in children undergoing ambulatory magnetic resonance imaging

• Jung SM

• KMID: 2506514
• DOI: http://doi.org/10.12701/yujm.2020.00171

Abstract

The demand for drug-induced sedation for magnetic resonance imaging (MRI) scans have substantially increased in response to increases in MRI utilization and growing interest in anxiety in children. Understanding the pharmacologic options for deep sedation and general anesthesia in an MRI environment is essential to achieve immobility for the successful completion of the procedure and ensure rapid and safe discharge of children undergoing ambulatory MRI. For painless diagnostic MRI, a single sedative/anesthetic agent without analgesia is safer than a combination of multiple sedatives. The traditional drugs, such as chloral hydrate, pentobarbital, midazolam, and ketamine, are still used due to the ease of administration despite low sedation success rate, prolonged recovery, and significant adverse events. Currently, dexmedetomidine, with respiratory drive preservation, and propofol, with high effectiveness and rapid recovery, are preferred for children undergoing ambulatory MRI. General anesthesia using propofol or sevoflurane can also provide predictable rapid time to readiness and scan times in infant or children with comorbidities. The selection of appropriate drugs as well as sufficient monitoring equipment are vital for effective and safe sedation and anesthesia for ambulatory pediatric MRI.

Keyword

Ambulatory; Anesthesia; Deep sedation; Magnetic resonance imaging; Pediatrics

Reference

References

1. Uffman JC, Tumin D, Raman V, Thung A, Adler B, Tobias JD. MRI utilization and the associated use of sedation and anesthesia in a pediatric ACO. J Am Coll Radiol. 2017; 14:924–30.

2. Wachtel RE, Dexter F, Dow AJ. Growth rates in pediatric diagnostic imaging and sedation. Anesth Analg. 2009; 108:1616–21.

3. Dial S, Silver P, Bock K, Sagy M. Pediatric sedation for procedures titrated to a desired degree of immobility results in unpredictable depth of sedation. Pediatr Emerg Care. 2001; 17:414–20.

4. Kaila R, Chen X, Kannikeswaran N. Postdischarge adverse events related to sedation for diagnostic imaging in children. Pediatr Emerg Care. 2012; 28:796–801.

5. Committee on Quality Management and Departmental Administration. Continuum of depth of sedation: definition of general anesthesia and levels of sedation/analgesia [Internet]. Schaumburg, IL: American Society of Anesthesiologists;2019. [cited 2020 Mar 20]. https://www.asahq.org/standards-and-guidelines/continuum-of-depth-of-sedation-definition-of-general-anesthesia-and-levels-of-sedationanalgesia.

6. Cote CJ, Wilson S; American Academy of Pediatrics; American Academy of Pediatric Dentistry. Guidelines for monitoring and management of pediatric patients before, during, and after sedation for diagnostic and therapeutic procedures. Pediatrics. 2019; 143:e20191000.

7. Nedoma J, Fajkus M, Martinek R, Nazeran H. Vital sign monitoring and cardiac triggering at 1.5 tesla: a practical solution by an MR-ballistocardiography fiber-optic sensor. Sensors (Basel). 2019; 19:470.

8. Kamat PP, McCracken CE, Gillespie SE, Fortenberry JD, Stockwell JA, Cravero JP, et al. Pediatric critical care physician-administered procedural sedation using propofol: a report from the Pediatric Sedation Research Consortium Database. Pediatr Crit Care Med. 2015; 16:11–20.

9. Sanborn PA, Michna E, Zurakowski D, Burrows PE, Fontaine PJ, Connor L, et al. Adverse cardiovascular and respiratory events during sedation of pediatric patients for imaging examinations. Radiology. 2005; 237:288–94.

10. Mayers DJ, Hindmarsh KW, Sankaran K, Gorecki DK, Kasian GF. Chloral hydrate disposition following single-dose administration to critically ill neonates and children. Dev Pharmacol Ther. 1991; 16:71–7.

11. Litman RS, Soin K, Salam A. Chloral hydrate sedation in term and preterm infants: an analysis of efficacy and complications. Anesth Analg. 2010; 110:739–46.

12. Ratnapalan S. Chloral hydrate sedation in children. Clin Pediatr (Phila). 2014; 53:933–6.

13. National Institute for Health and Care Excellence (NICE). Sedation in under 19s: using sedation for diagnostic and therapeutic procedures (Clinical guideline CG112) [Internet]. London (UK): NICE;2010. [cited 2020 Mar 20]. https://www.nice.org.uk/guidance/cg112.

14. Low E, O'Driscoll M, MacEneaney P, O'Mahony O. Sedation with oral chloral hydrate in children undergoing MRI scanning. Ir Med J. 2008; 101:80–2.

15. Lee YJ, Kim DK, Kwak YH, Kim HB, Park JH, Jung JH. Analysis of the appropriate age and weight for pediatric patient sedation for magnetic resonance imaging. Am J Emerg Med. 2012; 30:1189–95.

16. Malviya S, Voepel-Lewis T, Tait AR, Reynolds PI, Gujar SK, Gebarski SS, et al. Pentobarbital vs chloral hydrate for sedation of children undergoing MRI: efficacy and recovery characteristics. Paediatr Anaesth. 2004; 14:589–95.

17. Dalal PG, Murray D, Cox T, McAllister J, Snider R. Sedation and anesthesia protocols used for magnetic resonance imaging studies in infants: provider and pharmacologic considerations. Anesth Analg. 2006; 103:863–8.

18. Cortellazzi P, Lamperti M, Minati L, Falcone C, Pantaleoni C, Caldiroli D. Sedation of neurologically impaired children undergoing MRI: a sequential approach. Paediatr Anaesth. 2007; 17:630–6.

19. Delgado J, Toro R, Rascovsky S, Arango A, Angel GJ, Calvo V, et al. Chloral hydrate in pediatric magnetic resonance imaging: evaluation of a 10-year sedation experience administered by radiologists. Pediatr Radiol. 2015; 45:108–14.

20. Greenberg SB, Faerber EN, Aspinall CL, Adams RC. High-dose chloral hydrate sedation for children undergoing MR imaging: safety and efficacy in relation to age. AJR Am J Roentgenol. 1993; 161:639–41.

21. Finnemore A, Toulmin H, Merchant N, Arichi T, Tusor N, Cox D, et al. Chloral hydrate sedation for magnetic resonance imaging in newborn infants. Paediatr Anaesth. 2014; 24:190–5.

22. Mace SE, Brown LA, Francis L, Godwin SA, Hahn SA, Howard PK, et al. Clinical policy: critical issues in the sedation of pediatric patients in the emergency department. Ann Emerg Med. 2008; 51:378–99.

23. Lipshitz M, Marino BL, Sanders ST. Chloral hydrate side effects in young children: causes and management. Heart Lung. 1993; 22:408–14.

24. Schulte-Uentrop L, Goepfert MS. Anaesthesia or sedation for MRI in children. Curr Opin Anaesthesiol. 2010; 23:513–7.

25. Ehrnebo M. Pharmacokinetics and distribution properties of pentobarbital in humans following oral and intravenous administration. J Pharm Sci. 1974; 63:1114–8.

26. Mason KP, Zurakowski D, Connor L, Karian VE, Fontaine PJ, Sanborn PA, et al. Infant sedation for MR imaging and CT: oral versus intravenous pentobarbital. Radiology. 2004; 233:723–8.

27. Mallory MD, Baxter AL, Kost SI; Pediatric Sedation Research Consortium. Propofol vs pentobarbital for sedation of children undergoing magnetic resonance imaging: results from the Pediatric Sedation Research Consortium. Paediatr Anaesth. 2009; 19:601–11.

28. Greenberg SB, Adams RC, Aspinall CL. Initial experience with intravenous pentobarbital sedation for children undergoing MRI at a tertiary care pediatric hospital: the learning curve. Pediatr Radiol. 2000; 30:689–91.

29. Mason KP, Sanborn P, Zurakowski D, Karian VE, Connor L, Fontaine PJ, et al. Superiority of pentobarbital versus chloral hydrate for sedation in infants during imaging. Radiology. 2004; 230:537–42.

30. Schlatter J, Kabiche S, Sellier N, Fontan JE. Oral pentobarbital suspension for children sedation during MR imaging. Ann Pharm Fr. 2018; 76:286–90.

31. Rooks VJ, Chung T, Connor L, Zurakowski D, Hoffer FA, Mason KP, et al. Comparison of oral pentobarbital sodium (nembutal) and oral chloral hydrate for sedation of infants during radiologic imaging: preliminary results. AJR Am J Roentgenol. 2003; 180:1125–8.

32. Ross AK, Hazlett HC, Garrett NT, Wilkerson C, Piven J. Moderate sedation for MRI in young children with autism. Pediatr Radiol. 2005; 35:867–71.

33. Kannikeswaran N, Chen X, Sethuraman U. Utility of endtidal carbon dioxide monitoring in detection of hypoxia during sedation for brain magnetic resonance imaging in children with developmental disabilities. Paediatr Anaesth. 2011; 21:1241–6.

34. Boriosi JP, Eickhoff JC, Hollman GA. Safety and efficacy of buccal dexmedetomidine for MRI sedation in school-aged children. Hosp Pediatr. 2019; 9:348–54.

35. Sulton C, Kamat P, Mallory M, Reynolds J. 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; 36:138–42.

36. Ibrahim M. A prospective, randomized, double blinded comparison of intranasal dexmedetomodine vs intranasal ketamine in combination with intravenous midazolam for procedural sedation in school aged children undergoing MRI. Anesth Essays Res. 2014; 8:179–86.

37. Pershad J, Wan J, Anghelescu DL. Comparison of propofol with pentobarbital/midazolam/fentanyl sedation for magnetic resonance imaging of the brain in children. Pediatrics. 2007; 120:e629–36.

38. D'Agostino J, Terndrup TE. Chloral hydrate versus midazolam for sedation of children for neuroimaging: a randomized clinical trial. Pediatr Emerg Care. 2000; 16:1–4.

39. Rupprecht T, Kuth R, Bowing B, Gerling S, Wagner M, Rascher W. Sedation and monitoring of paediatric patients undergoing open low-field MRI. Acta Paediatr. 2000; 89:1077–81.

40. Mazurek MS. Sedation and analgesia for procedures outside the operating room. Semin Pediatr Surg. 2004; 13:166–73.

41. Shannon M, Albers G, Burkhart K, Liebelt E, Kelley M, McCubbin MM, et al. Safety and efficacy of flumazenil in the reversal of benzodiazepine-induced conscious sedation. The Flumazenil Pediatric Study Group. J Pediatr. 1997; 131:582–6.

42. White PF, Way WL, Trevor AJ. Ketamine: its pharmacology and therapeutic uses. Anesthesiology. 1982; 56:119–36.

43. Kim JG, Lee HB, Jeon SB. Combination of dexmedetomidine and ketamine for magnetic resonance imaging sedation. Front Neurol. 2019; 10:416.

44. Tomatir E, Atalay H, Gurses E, Erbay H, Bozkurt P. Effects of low dose ketamine before induction on propofol anesthesia for pediatric magnetic resonance imaging. Paediatr Anaesth. 2004; 14:845–50.

45. Scheer I, Weiss M, Kellenberger C, O'Gorman Tuura R, Klaghofer R, Scheer I, et al. Sedation for magnetic resonance imaging using propofol with or without ketamine at induction in pediatrics: a prospective randomized double-blinded study. Paediatr Anaesth. 2018; 28:264–74.

46. Mahmoud M, Mason KP. Dexmedetomidine: review, update, and future considerations of paediatric perioperative and periprocedural applications and limitations. Br J Anaesth. 2015; 115:171–82.

47. Mahmoud M, Gunter J, Donnelly LF, Wang Y, Nick TG, Sadhasivam S. A comparison of dexmedetomidine with propofol for magnetic resonance imaging sleep studies in children. Anesth Analg. 2009; 109:745–53.

48. Sriganesh K, Saini J, Theerth K, Venkataramaiah S. Airway dimensions in children with neurological disabilities during dexmedetomidine and propofol sedation for magnetic resonance imaging study. Turk J Anaesthesiol Reanim. 2018; 46:214–21.

49. Bloor BC, Ward DS, Belleville JP, Maze M. Effects of intravenous dexmedetomidine in humans. II. Hemodynamic changes. Anesthesiology. 1992; 77:1134–42.

50. Philipp M, Brede M, Hein L. Physiological significance of alpha(2)-adrenergic receptor subtype diversity: one receptor is not enough. Am J Physiol Regul Integr Comp Physiol. 2002; 283:R287–95.

51. Mason KP, Turner DP, Houle TT, Fontaine PJ, Lerman J. Hemodynamic response to fluid management in children undergoing dexmedetomidine sedation for MRI. AJR Am J Roentgenol. 2014; 202:W574–9.

52. Mason KP, Zgleszewski S, Forman RE, Stark C, DiNardo JA. An exaggerated hypertensive response to glycopyrrolate therapy for bradycardia associated with high-dose dexmedetomidine. Anesth Analg. 2009; 108:906–8.

53. Mason KP, Zurakowski D, Zgleszewski SE, Robson CD, Carrier M, Hickey PR, et al. High dose dexmedetomidine as the sole sedative for pediatric MRI. Paediatr Anaesth. 2008; 18:403–11.

54. Ebert TJ, Hall JE, Barney JA, Uhrich TD, Colinco MD. The effects of increasing plasma concentrations of dexmedetomidine in humans. Anesthesiology. 2000; 93:382–94.

55. Boriosi JP, Eickhoff JC, Hollman GA. Safety and efficacy of buccal dexmedetomidine for MRI sedation in school-aged children. Hosp Pediatr. 2019; 9:348–54.

56. Tug A, Hanci A, Turk HS, Aybey F, Isil CT, Sayin P, et al. Comparison of two different intranasal doses of dexmedetomidine in children for magnetic resonance imaging sedation. Paediatr Drugs. 2015; 17:479–85.

57. Teshome G, Belani K, Braun JL, Constantine DR, Gattu RK, Lichenstein R. Comparison of dexmedetomidine with pentobarbital for pediatric MRI sedation. Hosp Pediatr. 2014; 4:360–5.

58. Belleville JP, Ward DS, Bloor BC, Maze M. Effects of intravenous dexmedetomidine in humans. I. Sedation, ventilation, and metabolic rate. Anesthesiology. 1992; 77:1125–33.

59. Konig MW, Mahmoud MA, Fujiwara H, Hemasilpin N, Lee KH, Rose DF. Influence of anesthetic management on quality of magnetoencephalography scan data in pediatric patients: a case series. Paediatr Anaesth. 2009; 19:507–12.

60. Roback MG, Carlson DW, Babl FE, Kennedy RM. Update on pharmacological management of procedural sedation for children. Curr Opin Anaesthesio. 2016; 29(Suppl 1):S21–35.

61. Machata AM, Willschke H, Kabon B, Kettner SC, Marhofer P. Propofol-based sedation regimen for infants and children undergoing ambulatory magnetic resonance imaging. Br J Anaesth. 2008; 101:239–43.

62. Gutmann A, Pessenbacher K, Gschanes A, Eggenreich U, Wargenau M, Toller W. Propofol anesthesia in spontaneously breathing children undergoing magnetic resonance imaging: comparison of two propofol emulsions. Paediatr Anaesth. 2006; 16:266–74.

63. Cho JE, Kim WO, Chang DJ, Choi EM, Oh SY, Kil HK. Titrated propofol induction vs. continuous infusion in children undergoing magnetic resonance imaging. Acta Anaesthesiol Scand. 2010; 54:453–7.

64. Hassan NE, Betz BW, Cole MR, Wincek J, Reischman D, Sanfilippo DJ, et al. Randomized controlled trial for intermittent versus continuous propofol sedation for pediatric brain and spine magnetic resonance imaging studies. Pediatr Crit Care Med. 2011; 12:e262–5.

65. Abdallah C, Hannallah R, Patel K. MR-compatible pumps versus manual titration of propofol for pediatric sedation. J Med Eng Technol. 2010; 34:443–7.

66. Zhou Q, Shen L, Zhang X, Li J, Tang Y. Dexmedetomidine versus propofol on the sedation of pediatric patients during magnetic resonance imaging (MRI) scanning: a meta-analysis of current studies. Oncotarget. 2017; 8:102468–73.

67. Ahmed SS, Unland TL, Slaven JE, Nitu ME. Dexmedetomidine versus propofol: is one better than the other for MRI sedation in children? J Pediatr Intensive Care. 2017; 6:117–22.

68. Fang H, Yang L, Wang X, Zhu H. Clinical efficacy of dexmedetomidine versus propofol in children undergoing magnetic resonance imaging: a meta-analysis. Int J Clin Exp Med. 2015; 8:11881–9.

69. Wu J, Mahmoud M, Schmitt M, Hossain M, Kurth D. Comparison of propofol and dexmedetomedine techniques in children undergoing magnetic resonance imaging. Paediatr Anaesth. 2014; 24:813–8.

70. Bryan YF, Hoke LK, Taghon TA, Nick TG, Wang Y, Kennedy SM, et al. A randomized trial comparing sevoflurane and propofol in children undergoing MRI scans. Paediatr Anaesth. 2009; 19:672–81.

71. Mallory MD, Baxter AL, Yanosky DJ, Cravero JP; Pediatric Sedation Research Consortium. Emergency physician-administered propofol sedation: a report on 25,433 sedations from the pediatric sedation research consortium. Ann Emerg Med. 2011; 57:462–8.

72. Cravero JP, Beach ML, Blike GT, Gallagher SM, Hertzog JH; Pediatric Sedation Research Consortium. The incidence and nature of adverse events during pediatric sedation/anesthesia with propofol for procedures outside the operating room: a report from the Pediatric Sedation Research Consortium. Anesth Analg. 2009; 108:795–804.

73. Srinivasan M, Turmelle M, Depalma LM, Mao J, Carlson DW. Procedural sedation for diagnostic imaging in children by pediatric hospitalists using propofol: analysis of the nature, frequency, and predictors of adverse events and interventions. J Pediatr. 2012; 160:801–6.

74. Picard P, Tramer MR. Prevention of pain on injection with propofol: a equantitative systematic review. Anesth Analg. 2000; 90:963–9.

75. Murphy A, Campbell DE, Baines D, Mehr S. Allergic reactions to propofol in egg-allergic children. Anesth Analg. 2011; 113:140–4.

76. Kol IO, Egilmez H, Kaygusuz K, Gursoy S, Mimaroglu C. Open-label, prospective, randomized comparison of propofol and sevoflurane for laryngeal mask anesthesia for magnetic resonance imaging in pediatric patients. Clin Ther. 2008; 30:175–81.

77. Tsui BC, Wagner A, Usher AG, Cave DA, Tang C. Combined propofol and remifentanil intravenous anesthesia for pediatric patients undergoing magnetic resonance imaging. Paediatr Anaesth. 2005; 15:397–401.

78. Lutterbey G, Wattjes MP, Doerr D, Fischer NJ, Gieseke J Jr, Schild HH. Atelectasis in children undergoing either propofol infusion or positive pressure ventilation anesthesia for magnetic resonance imaging. Paediatr Anaesth. 2007; 17:121–5.

79. Sury MR, Harker H, Thomas ML. Sevoflurane sedation in infants undergoing MRI: a preliminary report. Paediatr Anaesth. 2005; 15:16–22.

80. De Sanctis Briggs V. Magnetic resonance imaging under sedation in newborns and infants: a study of 640 cases using sevoflurane. Paediatr Anaesth. 2005; 15:9–15.

81. Lei H, Chao L, Miao T, Shen Ling L, Yan Ying P, Xiao Han P, et al. Serious airway-related adverse events with sevoflurane anesthesia via facemask for magnetic resonance imaging in 7129 pediatric patients: a retrospective study. Paediatr Anaesth. 2019; 29:635–9.

82. Blitman NM, Lee HK, Jain VR, Vicencio AG, Girshin M, Haramati LB. Pulmonary atelectasis in children anesthetized for cardiothoracic MR: evaluation of risk factors. J Comput Assist Tomogr. 2007; 31:789–94.

83. Mongodi S, Ottonello G, Viggiano R, Borrelli P, Orcesi S, Pichiecchio A, et al. Ten-year experience with standardized non-operating room anesthesia with Sevoflurane for MRI in children affected by neuropsychiatric disorders. BMC Anesthesiol. 2019; 19:235.

84. Schultheis LW, Mathis LL, Roca RA, Simone AF, Hertz SH, Rappaport BA. Pediatric drug development in anesthesiology: an FDA perspective. Anesth Analg. 2006; 103:49–51.

85. Gore R, Chugh PK, Tripathi CD, Lhamo Y, Gautam S. Pediatric off-label and unlicensed drug use and its implications. Curr Clin Pharmacol. 2017; 12:18–25.