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Anaesthesia or sedation for MR
I in childrenLeonie Schulte-Uentrop and Matthias S. GoepfertDepartment of Anaesthesiology, University MedicalCenter Hamburg-Eppendorf, Hamburg, Germany
Correspondence to Leonie Schulte-Uentrop,Department of Anaesthesiology, University MedicalCenter Hamburg-Eppendorf, Martinistrasse 52, 20246Hamburg, GermanyTel: +49 40 15222816109;e-mail: [email protected]
Current Opinion in Anaesthesiology 2010,23:513–517
Purpose of review
The purpose of this review is to focus on recent literature about sedation or anaesthesia
in paediatric MRI. Special features of the MRI working environment, recent studies
about sedation or anaesthesia, and success rates and risk profiles in this setting are
presented. Finally, information for physicians to decide between sedation or
anaesthesia in individual situations is presented.
Recent findings
Owing to advances in MRI and its crucial role in the diagnosis of various diseases, deep
sedation or anaesthesia for MRI in children is requested increasingly. According to
current guidelines maximum patient safety and welfare has to be ensured. Recently
different sedation regimens comparing effectiveness, safety and outcome have been
published. Chloral hydrate, pentobarbital and midazolam are unfavourable for MRI
sedation. Dexmedetomidine appears to be convenient for sedation in patients without
cardiac risk. Propofol can be effectively used for sedation or anaesthesia in the
presence of anaesthesiologists or paediatric intensivists. General anaesthesia should
be preferred in preterm or small children as safety and success are predictable.
Summary
The MRI unit is a work station where all processes have to be well planned and staff
trained to guarantee maximum patient safety, superior quality of imaging and economic
needs. For optimal performance trained, experienced and certified personnel,
appropriate drugs for the individual patient risk profile and sufficient monitoring
equipment are essential.
Keywords
anaesthesia, MRI, paediatric, sedation
Curr Opin Anaesthesiol 23:513–517� 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins0952-7907
Introduction
MRI is a noninvasive, radiation-free diagnostic procedure.
A magnetic field with strength of 1.5–7 T (140 000 times
the Earth’s natural magnetic field) is used to perform MRI
clinically. These magnetic forces orient all protons in the
magnetic field in a longitudinal direction and create a spin.
A high-frequency radio impulse is then applied with the
same frequency as the spin. This triggers the protons to
absorb energy. After stopping the radio frequency, the
protons return to their initial position and emit radio waves
that serve as raw material for the MRI [1�,2].
Depending on the diagnostic needs an MRI scan takes
about 10–30 min, is quite noisy and the patient is moved
into a narrow pipe with limited access. For optimum image
quality enabling precise diagnosis patients have to remain
motionless. Metallic materials have to be removed as they
impair image quality and may induce undesirable side
effects, e.g. warming. The high-frequency radio impulses
can cause damage to or dysfunction of medical devices. For
this reason an anaesthesia workstation in an MRI environ-
ment has to fulfil specific criteria to meet the highly
opyright © Lippincott Williams & Wilkins. Unauth
0952-7907 � 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
specialized respective needs. Nevertheless, it also has to
perform as any other anaesthesia unit with a ventilator,
anaesthetic gas measurement, capnography, pulse oxime-
try, ECG monitor, blood pressure measurement and respir-
atory frequency monitor.
For paediatric anaesthesia, the ventilator in the MRI
setting has to be equipped with compliance compen-
sation, and resuscitation material has to be within reach.
Finally it must be pointed out that an MRI emergency
stop takes some minutes to be effective and is expensive.
The frequency of MRI scans in children has increased in
recent years owing to significant improvements in MRI
opening up new diagnostic perspectives [3]. If young
patients are unable to cooperate or to be at rest, either
sedation or anaesthesia is required. Most children who
need MRI diagnostic procedures have neurological dis-
eases, vascular malformation or oncological tumour
growth. Epilepsy and spastic or mental retardation are
common symptoms in these patients [4,5��]. These facts
must be taken into account when sedation or anaesthesia
for MRI in children is required. In the end, however, the
orized reproduction of this article is prohibited.
DOI:10.1097/ACO.0b013e32833bb524
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514 Anesthesia outside the operating room
main goals to be achieved are maximum patient safety,
successful scanning and paramount image quality.
Sedation for MRIUsually the Observer’s Assessment of Alertness and
Sedation (OAAS) scale or the Ramsey score are used to
describe sedation depth clinically [6]. For children the
American Academy of Pediatrics defined four sedation
steps: anxiolysis, conscious sedation, deep sedation and
anaesthesia [7]. Goals of sedation in the paediatric patient
for diagnostic and therapeutic procedures are defined as:
guard the patient’s safety and welfare; minimize physical
discomfort and pain; control anxiety, minimize psycho-
logical trauma, and maximize the potential for amnesia;
control behaviour and/or movement to allow the safe
completion of the procedure; and return the patient to a
state in which safe discharge from medical supervision, as
determined by recognized criteria, is possible. These goals
can be achieved by selecting the lowest dose of one drug
with the highest therapeutic index for the procedure.
Concerning children and MRI, because of noise and tube
narrowness, deep sedation is the required depth for
examination in most cases. Stopping an MRI scan is
expensive and ineffective, thus the failure rate has to
be minimized.
Prerequisites for sedation are the same as for general
anaesthesia: fasting, intravenous access, vital signs
monitoring, emergency equipment and physicians who
are experienced in using the technical equipment and
trained in paediatric airway management.
In this context it must be pointed out that disabled
children do not need higher doses of sedatives but are
three times more at risk of hypoxia under sedation [5��].
As the view of and access to the patient are limited in the
MRI setting, the physician has to be very experienced in
paediatric medication and airway management in new-
borns and children. If hypoventilation occurs, stopping
the scan, pulling the scan desk outside the tube and
attending to the patient in this special surrounding is time
consuming and needs to be practised. In newborns and
infants immediately after oxygen desaturation occurs
bradycardia starts. This has to be kept in mind when
choosing a suitable procedure and monitoring for our
paediatric patients.
A very safe and simple technique for newborns is the
‘feed and scan’ technique in which children are fed and
one has to wait until the young patient falls asleep.
Remarkable disadvantages of this technique are the
unpredictable ‘induction times’ and the high failure rates
of the scanning procedure. This time-consuming pro-
cedure therefore seems not to be practicable in most
opyright © Lippincott Williams & Wilkins. Unautho
modern medical centres. In 2008 Beauve and colleagues
compared the feed and scan technique with moderate
chloral hydrate sedation in neonates. The MRI failure
rate was similar, but the time until MRI was started was
shorter for chloral hydrate sedation [8]. As still only a few
studies exist on the exact mode of action of different
sedative drugs in paediatric patients and off-label use has
to be performed in many cases the feed and scan tech-
nique has to be considered as a relevant alternative [9].
In another investigation melatonin was used for sleep
induction before MRI. The success of this sleep induc-
tion concept was not convincing. Nevertheless high doses
of this substance combined with sleep withdrawal might
have an effect but needs further proof [10,11].
Who should perform sedation, a physician or a specially
trained nurse? In most countries in Europe and overseas,
anaesthesiologists are responsible or indispensable owing
to regulatory frameworks. In the UK or France, however,
sedation is also provided by trained nurses. This topic has
been discussed controversially [12]. Krauss et al. [13]
described the advantages and disadvantages of the US
model, which has helped to make sedation and analgesia
significantly safer and more professional than procedures
performed 20 years ago in the United States.
The Paediatric Sedation Research Consortium recently
reported on 49 836 sedation or anaesthesia cases involving
propofol over a 3-year period. Two cardiac arrests, four
aspiration events, and no deaths were among this cohort.
One in 65 sedations was associated with stridor or lar-
yngospasm or airway obstruction or expiratory wheezing
or central apnea [14��].
In this context it has to be pointed out that chest excursions
cannot be observed easily and saturation might fall late
after cessation of breathing, particularly if oxygen is insuf-
flated. For this reason end-tidal CO2 monitoring is indis-
pensable in MRI sedation and anaesthesia procedures.
Long-distance ventilator or capnometry tubes are often
used in the MRI setting. Therefore there are significant
drawbacks in using these devices. Another alternative to
measure respiratory excursions is a special respiratory belt
that monitors chest excursions during MRI scanning.
There is a variety of drugs available for sedation. Which
of these substances are favourable for MRI sedation?
When choosing an adequate sedative for MRI in children
the review of Krauss et al. [15] about procedural sedation
and analgesia is helpful.
Chloral hydrateChloral hydrate is a sedative and hypnotic drug with
barbiturate-like features. Onset time if applied orally is
rized reproduction of this article is prohibited.
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Anaesthesia or sedation for MRI in children Schulte-Uentrop and Goepfert 515
15–30 min, and duration is 60–120 min. If given in thera-
peutic doses it has only a slight effect on ventilation and
blood pressure, but its therapeutic index is small. Dosing
is between 25 and 100 mg/kg [15].
A recent review analysed chloral hydrate sedations
in term and preterm infants. The occurrence of post-
procedural oxyhaemoglobin desaturation was directly
correlated with younger chronological age in term infants
and younger postconceptional age in preterm infants
[16��].
Cortellazzi et al. [17] reported on 1104 chloral hydrate
sedations. In 20% MRI scan could not be finished suc-
cessfully, airway obstruction was seen in 2.8%, oxygen
saturation<90% occurred in 0.4%; no assisted ventilation
was necessary [17]. Low et al. [18] examined 36 children
aged<1 year when oral chloral hydrate was used for MRI
sedation. The success rate for MRI was 86%. No respir-
atory complications occurred [18].
In conclusion chloral hydrate seems to be a safe sedative,
but its side effects such as nausea and vomiting, long
recovery times and postoperative agitation have to be
considered. High failure rates of successful MRI scanning
could not prove this substance to be cost effective and
time saving in this context.
PentobarbitalPentobarbital is a short-acting barbiturate. Its reputation
has suffered as it was involved in euthanasia discussions.
Oral or rectal dosing is 3–6 mg/kg. Time until onset of
sedation is 15–60 min, and duration is 60–240 min [15].
Rooks et al. [19] compared pentobarbital and chloral
hydrate sedation for MRI in 498 children. No relevant
differences were observed between the groups. In further
studies pentobarbital showed a better acceptance by
children and parents [20], fewer adverse events [21]
but more paradoxical reactions and motion artefacts
[22] than those in the chloral hydrate group. When using
pentobarbital, potential relevant cardiovascular and
respiratory depression and the contraindications in
patients with porphyria have to be considered.
KetamineKetamine is commonly ignored as a sedative for MRI as it
has an analgesic component which is not necessary for
MRI. Dosing is 1–1.5 mg/kg when applied intravenously
or 4–5 mg/kg when injected intramuscularly. Onset time
is 1–3 min, and duration is 15–30 min [15].
In 2009 Green et al. [23��] reviewed the airway and
respiratory adverse events when ketamine was used as
opyright © Lippincott Williams & Wilkins. Unauth
sedative. In 8282 cases an overall risk of airway problems
for ketamine of 3.9% was reported. Risk factors for these
problems were age below 2 and over 13 years, high
intravenous dosing, coadministration of anticholinergics
or benzodiazepines [23��].
Vardy et al. [24] compared ketamine with midazolam and
propofol for procedural sedation. In this investigation
there was a similar overall complication rate, but in the
case of ketamine more hypertonicity, hypertension and
re-emerge phenomena occurred [24]. This characterizes
the special attribute of this drug that distinguishes it from
most other sedatives. In conclusion, ketamine used alone
may be useful for sedation in patients with respiratory
risk factors.
MidazolamMidazolam used alone is not suitable for MRI sedation
as its duration is too short for a successful procedure of
20–30 min. It has to be either re-injected or used in
combination with fentanyl or pentobarbital or ketamine.
As shown in the review by Green et al. [23��] the com-
bination of sedatives is a risk factor for respiratory com-
plications.
Combined sedation drug use in children is not acceptable
because the effects are hardly predictable and therefore
risky.
PropofolPropofol seems to be a perfect drug for sedation because
it is effective, has a short recovery time and can easily be
titrated to the required sedation level. Dosing is normally
2–5 mg/kg/h intravenous. Machata et al. [25] observed 53
infants and 447 children for an ambulatory MRI pro-
cedure. In 1% mild respiratory complications occurred
(no intubation). Short induction and a recovery time of
8 min are convincing advantages of propofol use [25].
Dalal [26] compared chloral hydrate and pentobarbital
with propofol for MRI sedation use. In this investigation
propofol was associated with shortest ready to scan and
discharge times. But in 13.6% cardiorespiratory events
were reported [26]. Patel et al. [27] evaluated the success
and dosing requirements of propofol in children for
prolonged procedural sedation by a nonanaesthesiol-
ogy-based sedation service. Two hundred and forty-nine
patients with a mean age of 4.8 years were included. All
sedations were successful and unanticipated adverse
effects rare (<1%) [2].
When using propofol only for sedation purposes the low
therapeutic tolerance has to be stressed. Consequently the
physician must monitor the respiratory rate and manage
the paediatric airway. Under these circumstances, propofol
orized reproduction of this article is prohibited.
C
516 Anesthesia outside the operating room
can be used to provide comfortable and adequate sedation
for MRI scanning.
DexmedetomidineDexmedetomidine is a selective alpha-2 agonist which is
declared by the ASA to be sedative which can be used by
nonanaesthesiologists. No relevant respiratory effects of
this drug are known. Haemodynamic side-effects such as
low blood pressure and low heart rate are common.
A loading dose of 2–3 mg/kg over 10 min followed by
1–2 mg/kg/h as an infusion for sedation maintenance is
recommended. Life-threatening complications have to
be expected if dexmedetomidine is used in combination
with digoxin [28,29]. Because of these side-effects the
drug is not suitable for patients with cardiac compromise.
Several studies investigating dexmedetomidine for seda-
tion have been published recently. Mason and colleagues
[30] reported MRI procedures for 747 children and
showed successful imaging in 97.6%. Cardiovascular si-
de-effects (bradycardia never exceeding a 20% range
from standard values) were seen in 16%. Oxygen satur-
ation was always above 95% [30]. In children with
obstructive sleep apnoea syndrome a comparison
between dexmedetomidine and propofol for MRI sleep
induction revealed effective sedation without the need
for additional airway equipment in 88.5 versus 70% of
scans [31��]. Some other investigations found no differ-
ence in successful scanning between dexmedetomidine
and propofol in 60 children between 1 and 7 years old but
propofol showed advantages in induction, recovery and
discharge time. No oxygen desaturation was seen in the
dexmetedomidine-sedated children [32]. Similar results
were reported by Heard and collegues [33], who com-
pared a midazolam–dexmedetomidine combination with
propofol for sedation. Lubisch et al. [34] published a
retrospective study of children with autism and other
neurobehavioural disorders. Three hundred and fifteen
patients with a mean age of 3.9 years were sedated with
dexmedetomidine, most commonly for MRI, while 90%
of patients received concomitant midazolam. Seven
patients required intervention for cardiac events and
one for a respiratory event. There were two episodes
of recovery-related agitation; 98.7% of sedations were
successfully completed [34].
In summary, dexmedetomidine could, if one takes
account of the contraindication of cardiovascular comor-
bidity, be a favourable sedative drug for MRI scanning.
Anaesthesia for MRIAn apparent advantage of general anaesthesia for MRI
scanning is that it is independent of a child’s ability to
cooperate. The whole process, including preparation and
scan time, is more predictable, and the scan quality may
opyright © Lippincott Williams & Wilkins. Unautho
benefit because the child is immobilized and scan inter-
ruptions due to sedation side-effects are minimized.
In addition, it is possible to perform breath-holding
manoeuvres for images that need complete immobiliz-
ation. Anaesthesia is an effective and quality-guarantee-
ing method in this setting [35]. In newborns and infants at
risk from very short times of respiratory insufficiency due
to hypoxia and bradycardia general anaesthesia should be
performed for safety reasons.
In principle all types of general anaesthesia techniques
can be used in MRI. If the ventilator is equipped with a
vaporizer, sevoflurane is an ideal inhalative narcotic for
children. On the other hand, propofol can be used for
total intravenous anaesthesia. Laryngeal masks and
tracheal tubes can be used in the MRI setting. The
decision should depend on comorbidities, anatomy and
fasting status in the individual case.
In a group of 200 children with neurodevelopmental
disorders and comedication with anticonvulsive and psy-
chotropic drugs sevoflurane was compared with propofol
for successful MRI procedures. In the sevoflurane group a
92% scan success rate was achieved compared with an
80% success rate in the propofol group. No difference in
respiratory complications was noted [36�].
Compared with propofol sedation using this drug as a
narcotic in combination with tracheal intubation, atelec-
tasis was seen more often in intubated children after the
MRI scan. In 26 young patients at the end of anaesthesia
the difference in the atelectasis rate was 82–94%. Atelec-
tasis had already occurred in the early stage of scanning
in intubated children and in those who were ventilated
with intermittent positive-pressure ventilation [37,38].
ConclusionAnaesthesia or sedation for MRI procedures in children is
the question we help to answer here. It is obvious that the
decision has to be made on a case-by-case basis, taking
into account all characteristics of the individual child.
A fully equipped anaesthesia workstation is strictly
required for both sedation and anaesthesia. Airway
management and resuscitation equipment have to be
prepared and directly available. Adequate training in
paediatric airway and emergency management in this
setting with a restricted view of and access to the patient
is essential for anaesthesiologists or paediatric ICU
physicians. As drug permission is variable in different
countries, off-label use is performed in some situations.
In children older than 3 years or with a body weight of
more than 10 kg sedation might be a safe alternative to
anaesthesia if no specific airway abnormalities or comor-
bidities are present. In infants younger than 3 years or in
the presence of major comorbidities that may aggravate
rized reproduction of this article is prohibited.
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Anaesthesia or sedation for MRI in children Schulte-Uentrop and Goepfert 517
airway management or the clinical procedure, general
anaesthesia is the preferred choice and implies a pre-
dictable clinical process.
AcknowledgementThe authors affirm that there does not exist any conflict of interestor sponsorship.
References and recommended readingPapers of particular interest, published within the annual period of review, havebeen highlighted as:� of special interest�� of outstanding interest
Additional references related to this topic can also be found in the CurrentWorld Literature section in this issue (p. 537).
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orized reproduction of this article is prohibited.
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