Agrawal et al.

Sedation in Pediatric Radiology

Review Article
Sedation during Imaging in Children: A Narrative Review
Amit Agrawal1, Shweta Sharma1, Jyotsna Shrivastava2
From, 1Associate Professor, 2Professor and Head, Department of Pediatrics, Gandhi Medical College and Kamla Nehru Hospital,
Madhya Pradesh, India.

ABSTRACT
Radiographic imaging, along with clinical signs and symptoms, go hand in hand to arrive at a diagnosis and formulate a proper treat-
ment plan. These imaging techniques require the child to stay in one position, for a variable duration of time. The last two decades
have, thus, seen an increase in procedures involving the use of sedatives in pediatric radiology. The use of sedatives ensures that the
child complies throughout the procedure until the necessary data is collected. There are numerous classes of drugs used as sedatives
in children, having their set of advantages and adverse effects. The need to follow a systematic protocol, proper monitoring and as-
sessment, and selecting the drug after ruling out contraindications becomes manifold around children. This review hence, attempts
to highlight the various sedative drugs in use, their adverse effects, protocols in place, and problems associated with the imaging
modalities and sedative drugs in pediatric radiology.

Key words: Sedation, Sedatives, Pediatric Imaging, Magnetic Resonance Imaging, Computed Tomography

P
ediatric imaging as a technology is expanding its remember the experience. The American Academy of Pediat-
horizons by the day with advancements like three- rics (AAP) defines the goals of sedation in the pediatric pa-
dimensional tomography, functional magnetic reso- tient for diagnostic and therapeutic procedures as follows: to
nance imaging (MRI), and interventional radiology guard the patient’s safety and welfare; to minimize physical
applications [1-3]. As a result, the need for sedation continues discomfort and pain; to control anxiety, minimize psychologi-
to increase, as high as 60%, as reported by the Pediatric Seda- cal trauma, and maximize the potential for amnesia; to control
tion Research Consortium [4]. Therefore, it becomes essential behavior and/or movement to allow for the safe completion of
for sedation providers to be familiar with radiological ad- the diagnostic/interventional procedure; and to return the pa-
vancements so they may be able to adapt to the technology to tient to a state from which safe discharge is possible [6]. This
help facilitate smooth and effective data collection. review thus, aims to discuss the standard definitions, protocol,
and personnel required for the safe administration of seda-
The physiologic effects of sedatives are described through tives, various drugs in use, and their adverse effects and prob-
the terms “sedation”, “conscious sedation” and “deep seda- lems associated with imaging techniques on sedation.
tion”. These terms may be misleading as they incorrectly im-
ply that sedation is a static process. On one hand ‘conscious History and Evolution
sedation’ is a pharmacologically induced state of depressed There were no guidelines for pediatric sedation up until 1985.
consciousness wherein a patient can respond to verbal com- Due to rising adverse events in dental offices, a need for
mands and an intact airway and protective reflexes are main- awareness regarding pediatric sedation hazards was felt.
tained. Whereas, on the other hand, deep sedation is a phar- Thus, AAP in 1985 formulated guidelines for elective use of
macologically induced depressed state where a patient is una- sedatives and anesthesia, by a committee composed of Dr.
ble to respond to verbal commands and needs external assis- Charles Coté and Dr. Theodore Striker [7]. The very same
tance in maintaining an intact airway and protective reflexes. guidelines were modified in 1992 by the AAP Committee on
This implies that the level of consciousness is not always pre- Drugs wherein it was acknowledged that a deeper level of
dictable and a sedated child may fluctuate between different sedation can be easily achieved and that the use of a pulse
levels of consciousness during the procedure. Therefore, se- oximeter was recommended in all patients undergoing seda-
dation may be considered a dynamic process that demands tion [8]. Gradually the guidelines underwent modifications in
continuous evaluation of patient status [5]. 1998, 2002, and 2006 according to BIR Publications. The
Joint Commission on Accreditation of Healthcare Organiza-
The two main aims of sedation are control of anxiety and tions (JCAHO) made certain modifications stating that the
prevention of movement to ensure patient compliance and the Department of Anesthesiology is responsible for developing
successful collection of optimal images during the proce- ‘within-institution’ guidelines, which consequently led to the
dure.Another reason for choosing sedation could be to abide involvement of the American Academy of Anesthesiology
by the wishes of the parents to ensure the child does not (ASA) with sedation safety.
Access this article online Correspondence to: Amit Agr awal, Associate Pr ofessor ,
rd
Received – 23 Apr 2024 Quick Response Code 49-B, Sector B, Indrapuri, Bhopal, Madhya Pradesh, India.
th
Initial Review – 12 May 2024 Email: [email protected].

Accepted – 15th May 2024

© 2024 Creative Commons Attribution-Non Commercial
DOI: 4.0 International License (CC BY-NC-ND 4.0).

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Agrawal et al. Sedation in Pediatric Radiology

The ASA was then successful in changing the terminology (reflex withdrawal from a painful stimulus is not a purposeful
from ‘conscious sedation’ to a more precise term - ‘sedation/ response)”. No interventions are required to maintain a patent
analgesia’. Revised sedation guidelines were published by airway. Spontaneous ventilation is adequate. Cardiovascular
ASA in 2002, addressing all depths of sedation [9]. ASA in function is usually maintained.
close association with JCAHO developed a new language to Deep Sedation: In this plane of sedation patients ar e
describe sedation’s process. Currently, three stages are de- asleep and cannot easily be roused but do respond purposeful-
scribed, apart from General Anesthesia (GA) - minimal seda- ly to repeated or painful stimulation. The ability to maintain
tion, moderate sedation, and deep sedation. These definitions ventilatory function independently may be impaired. Patients
by ASA were recently adopted by AAP and released in may require assistance to maintain a patent airway.
‘Discharge Criteria for Children Sedated by Non-
anesthesiologists: Is “safe” really safe enough?’. General Anesthesia: This is a dr ug-induced loss of con-
sciousness during which patients are not arousable, even by
The Neuroanesthesia and Neurointensive Study Group of painful stimulation. The ability to maintain independent ven-
the Italian Society of Anesthesia, Analgesia, Resuscitation, tilatory function is often impaired. They need assistance with
and Intensive Care (SIAARTI) with the Italian Society of maintaining their airway and positive pressure ventilation is
Neonatal and Pediatric Anesthesia and Resuscitation often required to maintain adequate gas exchange. Cardiovas-
(SARNePI) published the SIAARTI-SARNePI Guidelines in cular function may also be impaired.
2004 for sedation in pediatric neuroradiology [10]. However,
Dissociative Sedation: Another categor y has been added
all these studies failed to establish a standard set of defini-
by European pediatricians. This is defined as a trance-like
tions that could be followed throughout the pediatric fraterni-
cataleptic state induced by the dissociative agent ketamine or
ty. They also failed to highlight the adverse effects due to
s-ketamine and characterized by profound analgesia and am-
sedation and anesthesia.
nesia with retention of protective airway reflexes, spontane-
Finally, an attempt to standardize the terminologies that ous respiration, and cardiopulmonary stability [17].
could be adopted by all sedation providers was made in 2008,
Care should be taken not to adhere strictly to these defini-
with the release of ‘Quebec Guidelines’ by a Consensus Panel tions while selecting and administering sedative drugs as one
on Sedation Research of Pediatric Emergency Research Cana- drug might induce moderate sedation in one child, and the
da and the Pediatric Emergency Care Applied Research Net- same might induce deep sedation in another. Therefore, the
work [11]. The World Society of Intravenous Anesthesia in correct protocol should always be followed [18].
2010 established the International Sedation Task Force
(ISTF) (‘Sedation/anesthesia in Pediatric Radiology Report’). Sedation Protocol and Personnel
It was composed of members from different countries and
backgrounds. This was done in an attempt to standardize Personnel: Local licensing boar ds and individual institu-
globally the definitions of adverse events which were objec- tions decide the scope of practice and access of qualified
practitioners, registered nurses, non-anesthesiologist physi-
tive, reproducible, and applicable to all settings worldwide
cians, and anesthesiologists for administering sedation. The
focusing on events of clinical significance. They have also
criteria for a sedation provider to be eligible to administer the
developed a standardized sedation outcome reporting tool
drug include being able to identify the depth of sedation
outlining its aims, to establish an international consensus to
achieved or being skilled enough to rescue or reverse the se-
produce a sedation monitoring record for performing and doc-
dation in case a level deeper than the intended depth is
umenting pre-procedure assessment, monitoring, and dis-
achieved or rapidly identify loss of airway patency/ventilatory
charge of any sedation patient [12].
function and to provide artificial respiratory support. Famili-
Sedation - Definition and Classification arity with the pharmacology of the sedative is also necessary
for the provider including the dose, route of administration,
Sedation is a “medically controlled state of depressed con- adverse effects, contraindications, and potential drug reac-
sciousness or unconsciousness”. The level of sedation can be tions. The providers should have access to potential antago-
categorized as per the ASA [13]. These levels include (1) nists and be adept at intervening should any adverse event
minimal sedation (anxiolysis), (2) moderate sedation/ occur [19,20].
analgesia (conscious sedation), (3) deep sedation/analgesia Pre-sedation Assessment: This step is necessar y as it helps
and (4) General Anesthesia (GA). The classification is based to determine the fitness of the patient for sedation. It primari-
on the decreased levels of response, airway protection, and ly involves a detailed assessment of the child’s current health,
increased need for cardiovascular support, the most important presence or history of any chronic illnesses, medication histo-
being the child’s ability to maintain protective reflexes [14]. ry to rule out potential drug interactions, and emphasis on the
Successful levels of sedation are said to be achieved when the airway and respiratory status [21]. Modified Mallampati scor-
child can stay still, throughout the procedure and the required ing may be used for physically examining and assessing the
data is easily achieved [15,16]. upper airway tract for any obstructions or intubation difficul-
ties, in children old enough to spontaneously open their
Minimal Sedation: A state dur ing which patients ar e
mouth for pharyngeal structure assessment [22]. A score of 3
awake and calm and respond normally to verbal commands.
or 4 indicates airway obstruction and intubation difficulty,
Although cognitive function and coordination may be im-
directing the need for the lightest depth of sedation to avoid
paired, ventilatory and cardiovascular functions are unaffected.
any adverse events. On the other hand, the opinion of an anes-
Moderate Sedation: A state dur ing which patients ar e thesiologist can be considered. Confirming the NPO status of
sleepy but respond purposefully to verbal commands (known the patient is necessary. History of any previous sedation/
as conscious sedation in dentistry) or light tactile stimulation anesthesia administration should be discussed to recognize

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Agrawal et al. Sedation in Pediatric Radiology

any adverse reactions and complications or sources of anxiety Table 2: Method for equipment check and monitoring
that need further assistance. Pre-assessment, thus, helps de-
vise a sedation plan customized for that individual including Acro- Full Form How to Monitor
arrangements to be made for skilled professionals, specific nym
equipment, transport, or premedications.
S Suction Suction catheters and/or Yankau-
Monitoring and Equipment: According to the ASA and the er’s suction with a functioning suc-
AAP, guidelines for monitoring during procedural sedatives tion apparatus.
have been provided. They direct the continuous monitoring of
the heart rate, respiratory rate, oxygen saturation, and inter- O Oxygen Adequate oxygen supply with opti-
mittent monitoring of blood pressure, while monitoring of end mal backup and functioning flow
-tidal CO2 is encouraged [7,8,23,24]. While ECG is preferred meters/other devices to allow its
to monitor the heart rate, a pulse oximeter may also be appro- delivery
priate, provided the wavelength is reliable. Impedance ple-
thysmography via ECG leads may be considered for monitor- A Airway Nasopharyngeal and oropharyngeal
ing respiratory rate, but the use of capnography is more relia- airways, laryngoscope blades, en-
ble and thus highly encouraged. AAP recommends the fre- dotracheal (ET) tubes, supraglottic
quency of at least every 5 minutes for monitoring the vital airway devices, stylets, bougie, face
signs during deep sedation [8]. According to ASA guidelines mask, bag–valve–- mask/AMBU,
[7] certain equipment is to be present starting from induction or equivalent device.
through recovery as mentioned in (Table 1). According to
P Pharmacy All the basic drugs needed to sup-
AAP [8] recommendation the acronym SOAPME is widely
port life during an emergency, in-
followed for equipment and monitoring (Table 2).
cluding antagonists as indicated.
Table 1: Equipment to be present from induction through M Monitor Functioning pulse oximeter with
recovery size-appropriate probes and other
Category Equipment monitors (noninvasive blood pres-
sure, end-tidal carbon dioxide mon-
Airway Suction apparatus and catheters itors, electrocardiogram [ECG],
stethoscopes)
Oral/nasal airways
Oxygen delivery devices (nasal cannula, E Equipment Special equipment or drugs for both
facemask) anesthesia and resuscitation (e.g.,
defibrillator).
Bag–valve–mask system (self-inflating or
anesthesia type)
Sedation Candidates: The need for sedation in a child
Laryngoscope handles/blades depends on various factors like developmental, technical, or
Endotracheal tubes and stylets patient health-related. Children who are above the age of 6-8
years and healthy have been shown to cooperate in non-
IV access supplies including catheters, tour- invasive studies like ultrasounds, CT scans, and shorter MRIs
niquets, tape, arm boards without sedation. Furthermore, techniques that are of shorter
Intraosseous needle and IV fluid tubing, T- duration might not require sedation in children even younger
than 6-8 years. Infants 3-4 months old can also complete a
connectors, 3-way stopcocks
brief non-invasive scan if allowed to fall asleep after feeding,
just before the study. Children assessed as borderline for co-
Medications operation can be made to comply during a scan by distraction
Oxygen techniques, infant immobilizers, with the help of child life
Albuterol therapists, audiovisual projections, and music therapy instead
of taking the aid of sedation [25-27]. Although non-
Atropine/glycopyrrolate
pharmacological aids are present, certain children require
Calcium chloride/gluconate sedation for almost all kinds of scanning procedures. In in-
Dextrose 10 %/50 % stances where the child has constant underlying pain may be
unable to stay still during scans and thus require sedation.
Diphenhydramine Children having developmentally delayed/behavior disorders,
Epinephrine particularly anxiety, may require deep sedation. Finally, some
children are poor candidates for sedation like the ones having
Flumazenil baseline airway obstruction, central apnea disorders, active
Methylprednisolone respiratory infection, or cyanotic/unrepaired congenital heart
disease, and thus, be considered for GA or their procedure
Naloxone should be deferred till the health-related issue is resolved [28-33].
Racemic epinephrine Drugs used for Sedation
Sodium bicarbonate Highlights the various classes of drugs, their route of admin-
Neuromuscular blocker (succinylcholine/ istration, onset, and duration of action, and adverse effects
rocuronium) used on children during imaging techniques (Table 3)
[5,18,34, 35,36].

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Agrawal et al. Sedation in Pediatric Radiology

Table 3: Drugs used as sedatives in pediatric radiology

Dosage Onset/ Duration of Adverse effects Remarks

action (min)

1. Benzodiazepines

A. Chloral hydrate (Oral/Rectal) - Sedative

50-100 mg/kg, up to 120 mg/ 3-5/ 45-60 Unpleasant taste, Gastric Unpredictable onset, long duration, lack of
kg, max single dose 2 g irritation, Airway obstruc- reversal drugs, and the possibility of the
tion, Vomiting, Paradoxical child waking up in the middle have led to
reactions, Death in unattend- its discontinuation in a lot of countries
ed patients

B. Midazolam (Oral/Rectal/IV/IN) - Sedative anxiolytic, amnestic

- 0.02-0.05 mg/kg IV, titrate IV: 2–5/ 30–45 Respiratory depression, ap- Co-administration of opioids increases the
using 1/2 original dose (2-4 Oral: 15–20/ Up to 60 nea, paradoxical reactions risk of apnoea while co-administration of
mm) based on effect and IN: 5–10/ 30–45 like aggressiveness and cry- macrolide antibiotics may result in pro-
oxygen saturation, max bolus ing longed unconsciousness due to inhibition
dose 1 mg of hepatic metabolism.
- 0.5–0.7 mg/kg (Oral)
- 0.2–0.4 mg/kg(IN)
300–500 µg/kg(rectal)

C. Diazepam (IV/Oral) - Sedative, Anxiolytic, Amnestic

0.05-0.1 mg/kg IV, max cu- IV: 5-15/ 30-120 Respiratory depression, hy- IV diazepam is 4–5 times less potent than
mulative dose 5 mg; 0.2-0.3 potension, syncope, para- midazolam. Despite a longer elimination
mg/kg PD, max cumulative doxical reactions, bradycar- half-life, recovery profiles are similar
dose 10mg dia, cardiovascular collapse (usually by 2 h).

2. Barbiturates

A. Pentobarbital (IV/Oral/IM) - Sedative

2-3 mg/kg doses titrated q 5- 5-10/ 40-60 airway obstruction or para- For painless imaging, pentobarbital 2–6
7 mm until sedated or max doxical reactions mg kg1 i.v. is very successful. Pentobarbi-
cumulative amount of 8 mg/ tal is not available in the UK.
kg not to exceed 200mg

B. Methohexital (Rectal) - Sedative

20 mg/kg in 10% solution 10-15/ 45 Respiratory depression, ap- Methohexital is contraindicated in acute
nea, hiccoughs, cardiovascu- intermittent porphyria (AIP).
lar depression, laryn-
gospasm

C. Thiopental sodium (IV/Rectal) - Sedative

1 to 2 mg /kg IV every 3 to Less than 1/ 15-60 Respiratory depression, ap- Rarely used now due to the availability of
5 min up to maximum of 6 nea, bradycardia, hypoten- better drugs
mg/kg sion

3. Opioids

A. Morphine (IV/IM) - Analgesic with Sedative Properties

0.1-0.2 mg/kg, max dose 3-4 3-5/ Analgesia max 4 Hypotension, IVH, PVL, Usually given in combination with midazo-
mg hr; sedation varies but respiratory depression, car- lam
is shorter diovascular collapse
B. Fentanyl (IV) - Analgesic with Sedative Properties
1 to 2 mcg/kg as induction 5 to 10/ 30 to 60 Vomiting, respiratory de- Usually given in combination with
dose and 0.5 to 1 mcg per kg pression, chest wall rigidity propofol
as maintenance dose

C. Meperidine (IV/IM) - Analgesic with Sedative Properties

1-2 mg/kg, max dose 100 mg 5-10/ Analgesia 1-2 hr; Oxygen desaturation has been Given in combination with midazolam
sedation varies but is reported in 5% of cases.
shorter

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Agrawal et al. Sedation in Pediatric Radiology

3. Anesthetics
A. Propofol (IV) - GA
6 mo to 2 y: 1 to 2 mg/kg IV Within a minute/ 5 to Pain on injection, respirato- One of the most used agents, excellent
> 2 y of age: 0.5 to 1 mg/kg 15 min after a single ry depression, apnea, airway recovery profile
IV bolus dose; Additional IV dose obstruction hypotension,
bolus dose 0.5 mg/kg every 3 and/or rapid transition to
to 5 min, up to 3 mg/kg deeper levels of sedation
B. Ketamine (IM/IV) - GA
1–2 mg/kg (IV); 0.5 to 1 mg/ 1 to 2 min (IV) 5 to Emergence reactions, vomit- Lesser respiratory adverse effects than
kg, repeated every 5 to 10 10 min (IM)/ 15 to 30 ing propofol produce dissociative anesthesia
min with IV induction min (IV) 30 to 60 min
4–5 mg/kg (IM) (IM)
4. Inhalational agents
A. Nitrous Oxide (IN) - Analgesic, Sedative
50 to 70% N2O administered Within a minute Nausea, vomiting, dysphoria Provides anxiolysis, amnesia, and loss of
with oxygen through a de- consciousness can occur when combined
mand valve system with with other sedatives or when used alone in
scavenging capability; Con- concentrations over 50%.
tinuous use in the same con-
centration
B. Sevoflurane (IN) - Analgesic, Sedative
0.5% increased slowly to up Depends on the con- Respiratory depression Smooth induction
to 8% in oxygen; Requires centration used within might occur with higher
continuous administration 2 to 3 min concentrations

*IV: Intr avenous, IN: Intranasal, IM: Intr amuscular , GA: Gener al Anesthesia.

Drugs used for the reversal of Sedatives CT Imaging: The major challenge attached to this imaging
modality is that the sedation provider cannot be in the same
Reversal of benzodiazepine sedation: Flumazenil in the room due to the risk of radiation exposure and has to monitor
dose of 0.01–0.01 mg/kg through IV route can be used to re- the vitals through the readings on the monitor. Therefore, it is
verse benzodiazepine sedation. As the half-life of flumazenil the responsibility of the provider before leaving the room, to
is less than that of some benzodiazepines, there is a risk of first assess and closely monitor the vitals after administering
resonation. The onset of action is 1–2 mins and lasts for 30– the drug and ensure that there are no movements that may
45 minutes. prevent acquisition of the correct data before the CT is started [18].
Reversal of opioid-induced sedation and respiratory de- CONCLUSION
pression: Opioid-induced respiratory depression can be re-
versed with Naloxone. Administered via IV route, in the dose The need for imaging in children as a diagnostic tool is in-
of 0.01–0.02 mg/kg. The onset of action is 1–2 minutes and creasing along with the need for sedation during imaging.
lasts for up to 30–45 mins. Nalmefene may also be used. Ad- Hence, the need of the hour is to train more professionals and
ministered by IV route, in the dosage of 0.25 μg/kg nurses as sedation providers; especially, in smaller imag-
(maximum 1 μg/kg). The onset of action is 2–3 min and lasts ingcenters. As there are various adverse effects related to the
for up to 120–180 mins [5]. sedation drugs, the centers need to be well-equipped to handle
any complications and have the necessary monitoring and
Problems due to imaging modalities on sedation assessment tools. The skilled professional should be qualified
enough to precisely assess and differentiate adequately pa-
MRI: As a r adiogr aphic modality MRI has its sets of ad-
tients suitable for sedation or anesthesia or need deferred
vantages as it uses a powerful magnetic field and also is free
treatment.
from radiation but it also comes with its own set of hazards as
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