Anaesthesia or sedation for mri in children

Anaesthesia or sedation for MRI in children
Leonie Schulte-Uentrop and Matthias S. Goepfert
Department of Anaesthesiology, University Medical Purpose of review
Center Hamburg-Eppendorf, Hamburg, Germany
The purpose of this review is to focus on recent literature about sedation or anaesthesia
Correspondence to Leonie Schulte-Uentrop, in paediatric MRI. Special features of the MRI working environment, recent studies
Department of Anaesthesiology, University Medical
Center Hamburg-Eppendorf, Martinistrasse 52, 20246 about sedation or anaesthesia, and success rates and risk profiles in this setting are
Hamburg, Germany presented. Finally, information for physicians to decide between sedation or
Tel: +49 40 15222816109;
e-mail: lschulte@uke.uni-hamburg.de anaesthesia in individual situations is presented.
Recent findings
Current Opinion in Anaesthesiology 2010,
23:513–517
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
ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
0952-7907

specialized respective needs. Nevertheless, it also has to
Introduction perform as any other anaesthesia unit with a ventilator,
MRI is a noninvasive, radiation-free diagnostic procedure. anaesthetic gas measurement, capnography, pulse oxime-
A magnetic field with strength of 1.5–7 T (140 000 times try, ECG monitor, blood pressure measurement and respir-
the Earth’s natural magnetic field) is used to perform MRI atory frequency monitor.
clinically. These magnetic forces orient all protons in the
magnetic field in a longitudinal direction and create a spin. For paediatric anaesthesia, the ventilator in the MRI
A high-frequency radio impulse is then applied with the setting has to be equipped with compliance compen-
same frequency as the spin. This triggers the protons to sation, and resuscitation material has to be within reach.
absorb energy. After stopping the radio frequency, the Finally it must be pointed out that an MRI emergency
protons return to their initial position and emit radio waves stop takes some minutes to be effective and is expensive.
that serve as raw material for the MRI [1,2].
The frequency of MRI scans in children has increased in
Depending on the diagnostic needs an MRI scan takes recent years owing to significant improvements in MRI
about 10–30 min, is quite noisy and the patient is moved opening up new diagnostic perspectives [3]. If young
into a narrow pipe with limited access. For optimum image patients are unable to cooperate or to be at rest, either
quality enabling precise diagnosis patients have to remain sedation or anaesthesia is required. Most children who
motionless. Metallic materials have to be removed as they need MRI diagnostic procedures have neurological dis-
impair image quality and may induce undesirable side eases, vascular malformation or oncological tumour
effects, e.g. warming. The high-frequency radio impulses growth. Epilepsy and spastic or mental retardation are
can cause damage to or dysfunction of medical devices. For common symptoms in these patients [4,5]. These facts
this reason an anaesthesia workstation in an MRI environ- must be taken into account when sedation or anaesthesia
ment has to fulfil specific criteria to meet the highly for MRI in children is required. In the end, however, the
0952-7907 ß 2010 Wolters Kluwer Health | Lippincott Williams Wilkins DOI:10.1097/ACO.0b013e32833bb524

Copyright © Lippincott Williams Wilkins. Unauthorized reproduction of this article is prohibited.

514 Anesthesia outside the operating room

main goals to be achieved are maximum patient safety, modern medical centres. In 2008 Beauve and colleagues
successful scanning and paramount image quality. 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
Sedation for MRI shorter for chloral hydrate sedation [8]. As still only a few
Usually the Observer’s Assessment of Alertness and studies exist on the exact mode of action of different
Sedation (OAAS) scale or the Ramsey score are used to sedative drugs in paediatric patients and off-label use has
describe sedation depth clinically [6]. For children the to be performed in many cases the feed and scan tech-
American Academy of Pediatrics defined four sedation nique has to be considered as a relevant alternative [9].
steps: anxiolysis, conscious sedation, deep sedation and
anaesthesia [7]. Goals of sedation in the paediatric patient In another investigation melatonin was used for sleep
for diagnostic and therapeutic procedures are defined as: induction before MRI. The success of this sleep induc-
guard the patient’s safety and welfare; minimize physical tion concept was not convincing. Nevertheless high doses
discomfort and pain; control anxiety, minimize psycho- of this substance combined with sleep withdrawal might
logical trauma, and maximize the potential for amnesia; have an effect but needs further proof [10,11].
control behaviour and/or movement to allow the safe
completion of the procedure; and return the patient to a Who should perform sedation, a physician or a specially
state in which safe discharge from medical supervision, as trained nurse? In most countries in Europe and overseas,
determined by recognized criteria, is possible. These goals anaesthesiologists are responsible or indispensable owing
can be achieved by selecting the lowest dose of one drug to regulatory frameworks. In the UK or France, however,
with the highest therapeutic index for the procedure. sedation is also provided by trained nurses. This topic has
been discussed controversially [12]. Krauss et al. [13]
Concerning children and MRI, because of noise and tube described the advantages and disadvantages of the US
narrowness, deep sedation is the required depth for model, which has helped to make sedation and analgesia
examination in most cases. Stopping an MRI scan is significantly safer and more professional than procedures
expensive and ineffective, thus the failure rate has to performed 20 years ago in the United States.
be minimized.
The Paediatric Sedation Research Consortium recently
Prerequisites for sedation are the same as for general reported on 49 836 sedation or anaesthesia cases involving
anaesthesia: fasting, intravenous access, vital signs propofol over a 3-year period. Two cardiac arrests, four
monitoring, emergency equipment and physicians who aspiration events, and no deaths were among this cohort.
are experienced in using the technical equipment and One in 65 sedations was associated with stridor or lar-
trained in paediatric airway management. yngospasm or airway obstruction or expiratory wheezing
or central apnea [14].
In this context it must be pointed out that disabled
children do not need higher doses of sedatives but are In this context it has to be pointed out that chest excursions
three times more at risk of hypoxia under sedation [5]. cannot be observed easily and saturation might fall late
As the view of and access to the patient are limited in the after cessation of breathing, particularly if oxygen is insuf-
MRI setting, the physician has to be very experienced in flated. For this reason end-tidal CO2 monitoring is indis-
paediatric medication and airway management in new- pensable in MRI sedation and anaesthesia procedures.
borns and children. If hypoventilation occurs, stopping Long-distance ventilator or capnometry tubes are often
the scan, pulling the scan desk outside the tube and used in the MRI setting. Therefore there are significant
attending to the patient in this special surrounding is time drawbacks in using these devices. Another alternative to
consuming and needs to be practised. In newborns and measure respiratory excursions is a special respiratory belt
infants immediately after oxygen desaturation occurs that monitors chest excursions during MRI scanning.
bradycardia starts. This has to be kept in mind when
choosing a suitable procedure and monitoring for our There is a variety of drugs available for sedation. Which
paediatric patients. of these substances are favourable for MRI sedation?
When choosing an adequate sedative for MRI in children
A very safe and simple technique for newborns is the the review of Krauss et al. [15] about procedural sedation
‘feed and scan’ technique in which children are fed and and analgesia is helpful.
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 Chloral hydrate
of the scanning procedure. This time-consuming pro- Chloral hydrate is a sedative and hypnotic drug with
cedure therefore seems not to be practicable in most barbiturate-like features. Onset time if applied orally is


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- sedative. In 8282 cases an overall risk of airway problems
peutic doses it has only a slight effect on ventilation and for ketamine of 3.9% was reported. Risk factors for these
blood pressure, but its therapeutic index is small. Dosing problems were age below 2 and over 13 years, high
is between 25 and 100 mg/kg [15]. intravenous dosing, coadministration of anticholinergics
or benzodiazepines [23].
A recent review analysed chloral hydrate sedations
in term and preterm infants. The occurrence of post- Vardy et al. [24] compared ketamine with midazolam and
procedural oxyhaemoglobin desaturation was directly propofol for procedural sedation. In this investigation
correlated with younger chronological age in term infants there was a similar overall complication rate, but in the
and younger postconceptional age in preterm infants case of ketamine more hypertonicity, hypertension and
[16]. re-emerge phenomena occurred [24]. This characterizes
the special attribute of this drug that distinguishes it from
Cortellazzi et al. [17] reported on 1104 chloral hydrate most other sedatives. In conclusion, ketamine used alone
sedations. In 20% MRI scan could not be ﬁnished suc- may be useful for sedation in patients with respiratory
cessfully, airway obstruction was seen in 2.8%, oxygen risk factors.
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 Midazolam
sedation. The success rate for MRI was 86%. No respir- Midazolam used alone is not suitable for MRI sedation
atory complications occurred [18]. as its duration is too short for a successful procedure of
20–30 min. It has to be either re-injected or used in
In conclusion chloral hydrate seems to be a safe sedative, combination with fentanyl or pentobarbital or ketamine.
but its side effects such as nausea and vomiting, long As shown in the review by Green et al. [23] the com-
recovery times and postoperative agitation have to be bination of sedatives is a risk factor for respiratory com-
considered. High failure rates of successful MRI scanning plications.
could not prove this substance to be cost effective and
time saving in this context. Combined sedation drug use in children is not acceptable
because the effects are hardly predictable and therefore
risky.
Pentobarbital
Pentobarbital is a short-acting barbiturate. Its reputation
has suffered as it was involved in euthanasia discussions. Propofol
Oral or rectal dosing is 3–6 mg/kg. Time until onset of Propofol seems to be a perfect drug for sedation because
sedation is 15–60 min, and duration is 60–240 min [15]. it is effective, has a short recovery time and can easily be
titrated to the required sedation level. Dosing is normally
Rooks et al. [19] compared pentobarbital and chloral 2–5 mg/kg/h intravenous. Machata et al. [25] observed 53
hydrate sedation for MRI in 498 children. No relevant infants and 447 children for an ambulatory MRI pro-
differences were observed between the groups. In further cedure. In 1% mild respiratory complications occurred
studies pentobarbital showed a better acceptance by (no intubation). Short induction and a recovery time of
children and parents [20], fewer adverse events [21] 8 min are convincing advantages of propofol use [25].
but more paradoxical reactions and motion artefacts Dalal [26] compared chloral hydrate and pentobarbital
[22] than those in the chloral hydrate group. When using with propofol for MRI sedation use. In this investigation
pentobarbital, potential relevant cardiovascular and propofol was associated with shortest ready to scan and
respiratory depression and the contraindications in discharge times. But in 13.6% cardiorespiratory events
patients with porphyria have to be considered. were reported [26]. Patel et al. [27] evaluated the success
and dosing requirements of propofol in children for
prolonged procedural sedation by a nonanaesthesiol-
Ketamine ogy-based sedation service. Two hundred and forty-nine
Ketamine is commonly ignored as a sedative for MRI as it patients with a mean age of 4.8 years were included. All
has an analgesic component which is not necessary for sedations were successful and unanticipated adverse
MRI. Dosing is 1–1.5 mg/kg when applied intravenously effects rare (1%) [2].
or 4–5 mg/kg when injected intramuscularly. Onset time
is 1–3 min, and duration is 15–30 min [15]. When using propofol only for sedation purposes the low
therapeutic tolerance has to be stressed. Consequently the
In 2009 Green et al. [23] reviewed the airway and physician must monitor the respiratory rate and manage
respiratory adverse events when ketamine was used as the paediatric airway. Under these circumstances, propofol


516 Anesthesia outside the operating room

can be used to provide comfortable and adequate sedation benefit because the child is immobilized and scan inter-
for MRI scanning. ruptions due to sedation side-effects are minimized.
In addition, it is possible to perform breath-holding
manoeuvres for images that need complete immobiliz-
Dexmedetomidine ation. Anaesthesia is an effective and quality-guarantee-
Dexmedetomidine is a selective alpha-2 agonist which is ing method in this setting [35]. In newborns and infants at
declared by the ASA to be sedative which can be used by risk from very short times of respiratory insufficiency due
nonanaesthesiologists. No relevant respiratory effects of to hypoxia and bradycardia general anaesthesia should be
this drug are known. Haemodynamic side-effects such as performed for safety reasons.
low blood pressure and low heart rate are common.
A loading dose of 2–3 mg/kg over 10 min followed by In principle all types of general anaesthesia techniques
1–2 mg/kg/h as an infusion for sedation maintenance is can be used in MRI. If the ventilator is equipped with a
recommended. Life-threatening complications have to vaporizer, sevoflurane is an ideal inhalative narcotic for
be expected if dexmedetomidine is used in combination children. On the other hand, propofol can be used for
with digoxin [28,29]. Because of these side-effects the total intravenous anaesthesia. Laryngeal masks and
drug is not suitable for patients with cardiac compromise. tracheal tubes can be used in the MRI setting. The
Several studies investigating dexmedetomidine for seda- decision should depend on comorbidities, anatomy and
tion have been published recently. Mason and colleagues fasting status in the individual case.
[30] reported MRI procedures for 747 children and
showed successful imaging in 97.6%. Cardiovascular si- In a group of 200 children with neurodevelopmental
de-effects (bradycardia never exceeding a 20% range disorders and comedication with anticonvulsive and psy-
from standard values) were seen in 16%. Oxygen satur- chotropic drugs sevoflurane was compared with propofol
ation was always above 95% [30]. In children with for successful MRI procedures. In the sevoflurane group a
obstructive sleep apnoea syndrome a comparison 92% scan success rate was achieved compared with an
between dexmedetomidine and propofol for MRI sleep 80% success rate in the propofol group. No difference in
induction revealed effective sedation without the need respiratory complications was noted [36].
for additional airway equipment in 88.5 versus 70% of
scans [31]. Some other investigations found no differ- Compared with propofol sedation using this drug as a
ence in successful scanning between dexmedetomidine narcotic in combination with tracheal intubation, atelec-
and propofol in 60 children between 1 and 7 years old but tasis was seen more often in intubated children after the
propofol showed advantages in induction, recovery and MRI scan. In 26 young patients at the end of anaesthesia
discharge time. No oxygen desaturation was seen in the the difference in the atelectasis rate was 82–94%. Atelec-
dexmetedomidine-sedated children [32]. Similar results tasis had already occurred in the early stage of scanning
were reported by Heard and collegues [33], who com- in intubated children and in those who were ventilated
pared a midazolam–dexmedetomidine combination with with intermittent positive-pressure ventilation [37,38].
propofol for sedation. Lubisch et al. [34] published a
retrospective study of children with autism and other
neurobehavioural disorders. Three hundred and fifteen Conclusion
patients with a mean age of 3.9 years were sedated with Anaesthesia or sedation for MRI procedures in children is
dexmedetomidine, most commonly for MRI, while 90% the question we help to answer here. It is obvious that the
of patients received concomitant midazolam. Seven decision has to be made on a case-by-case basis, taking
patients required intervention for cardiac events and into account all characteristics of the individual child.
one for a respiratory event. There were two episodes A fully equipped anaesthesia workstation is strictly
of recovery-related agitation; 98.7% of sedations were required for both sedation and anaesthesia. Airway
successfully completed [34]. management and resuscitation equipment have to be
prepared and directly available. Adequate training in
In summary, dexmedetomidine could, if one takes paediatric airway and emergency management in this
account of the contraindication of cardiovascular comor- setting with a restricted view of and access to the patient
bidity, be a favourable sedative drug for MRI scanning. is essential for anaesthesiologists or paediatric ICU
physicians. As drug permission is variable in different
countries, off-label use is performed in some situations.
Anaesthesia for MRI In children older than 3 years or with a body weight of
An apparent advantage of general anaesthesia for MRI more than 10 kg sedation might be a safe alternative to
scanning is that it is independent of a child’s ability to anaesthesia if no specific airway abnormalities or comor-
cooperate. The whole process, including preparation and bidities are present. In infants younger than 3 years or in
scan time, is more predictable, and the scan quality may the presence of major comorbidities that may aggravate


Anaesthesia or sedation for MRI in children Schulte-Uentrop and Goepfert 517

airway management or the clinical procedure, general 17 Cortellazzi P, Lamperti M, Minati L, et al. Sedation of neurologically impaired
children undergoing MRI: a sequential approach. Paediatr Anaesth 2007;
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19 Rooks V, Chung T, Connor L, et al. Comparison of oral pentobarbital sodium
Acknowledgement (Nembutal) and oral chloral hydrate for sedation of infants during radiologic
The authors affirm that there does not exist any conflict of interest imaging: preliminary results. Am J Roentgenol 2003; 180:1125–1128.
or sponsorship. 20 Chung T, Hoffer FA, Connor L, et al. The use of oral pentobarbital sodium
(Nembutal) versus oral chloral hydrate in infants undergoing CT and MR
imaging: a pilot study. Pediatr Radiol 2000; 30:332–335.
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