Appropriate sedation management of the pediatric population prior to magnetic resonance imaging (MRI) and computerized tomography (CT) has received considerable attention in the last 10 years. Both of these diagnostic procedures require strict immobility and sedation for a successful outcome.
A recent study set up and evaluated an organized pediatric sedation program to determine its effect on the success rates and duration times of head MRIs. The 15-month period (January 1992 through March 1993) of the study was compared to a 1-year period prior to the start of the program. Since only a small number of children had been scanned in the high-powered MRI scanner prior to the program, only low-field scanner (0.38 Telsa) procedures were included in the study. The program was conducted by a second-year pediatric resident, a pediatric critical care attending physician, and two registered nurses, each with more than 2 years' experience in a pediatric intensive care unit and certification in pediatric basic and advanced life support. Radiology and anesthesiology staff were not directly involved with the actual sedation process but did take part in the policy and procedure chart. Success of failure of the MRI procedure along with the times of arrival and departure were recorded in logbooks. The charts and logbooks for the two time periods were compared. Both groups in each time period were similar in sex and age. In the year prior to the organized sedation program, head MRIs of 33 (14.0%) of 222 children were not completed because of inadequate sedation. In the 15-month span of the program, only 4 (1.9%) of the 215 children scheduled for head MRIs were unable to complete the exam because of sedation-related problems. Total arrival-to-departure times for scans with contrast in the first time period averaged 71.8 +/- 3.0 minutes (n=79). In the organized program, these times averaged 58.7 +/- 1.4 minutes (n=134). In scans without contrast, the first group averaged 58.5 +/- 1.9 minutes (n=107) as compared to the sedation program group's 46.7 +/- 1.2 minutes (n=71). Departure times for 3 children in the first group and 6 patients in the second group were not documented; thus, they were not included in the results.
In the first time period, chloral hydrate (maximum dose 2 g) was the most common sedative, followed by pentobarbital and intramuscular (IM) Demerol, Phenergan, and Thorazine. Of the 33 failures in this group, 20 received chloral hydrate (doses 25-100 mg/kg); 11 of these patients received only an initial dose. Failures associated with pentobarbital (2-5 mg/kg) totaled 9 (7 intravenous (IV), 2 IM); 6 of the 9 received a single dose. During the course of the organized study program, IV pentobarbital was the primary sedative administered. Thirty-three (28.7%) received a second dose (2 mg/kg) because of inadequate sedation; 13 (11.3%) of these patients also received one dose of midazolam (0.05 mg/kg). The second and third most frequent sedatives given were chloral hydrate (maximum 2.5 g) and enteral midazolam respectively with chloral hydrate (20 mg/kg) given as a supplement for inadequate sedation. Failure associated with chloral hydrate totaled two; pentobarbital and midazolam totaled one each. In the Pediatric Sedations Program, pentobarbital was the most frequent initial sedative used prior to head MRIs with a success rate of 99%. Of these, 25% of the patients received supplemental doses. Prior to the program only 13.1% of the patients initially received pentobarbital and frequently were not supplemented.
A comparison of complications during each time period was not done because of poor documentation of complications during the first time period. No major complications occurred during the Pediatric Sedation Program; however, 3 of the 4 failures were associated with transient oxygen desaturation; however, there was a prompt response to suctioning, repositioning, and oxygen administrations. Oxygen desaturation in 2 children was associated with coughing which was quickly abated with repositioning and oxygen administration.
Safe and effective sedation can be achieved through continuous monitoring by a nurse- physician sedation team. With their expert knowledge regarding individual sedatives, the induction time and duration of action, side effects, failure rates, and scan time can be reduced. Vigilant monitoring will reduce the number of incomplete studies which result in the child receiving additional sedatives or readmission for a second sedation or general anesthesia. Such monitoring is imperative when quick scan results are crucial in making management decisions.
Delays or incomplete studies can cause delays in scheduling and lack of cost effective use of personnel and MRIs. The success rate and faster scan times for head MRIs are beneficial to both child and family by decreasing the number of second sedations and readmissions required to complete a study. An organized pediatric sedation program can also lead to a decrease in revenue loss and allows more effective use of hospital resources.
Hollman, GA, Elderbrook MK, and VanDenLangenberg B: Results of a pediatric sedation program on head MRI scan success rates and procedure duration times, Clinical Pediatrics: 300- 305, 1995.
See Chapters 21 and 27 in Essentials of Pediatric Nursing, 5th edition.
See Chapter 27 and 37 in Nursing Care of Infants and Children, ed. 6.
March 15, 2002
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