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Society of Nuclear Medicine Procedure Guideline for
Pediatric Sedation in Nuclear Medicine
version 3.0, approved January 25, 2003
Authors: Gerald A. Mandell, MD (DuPont Hospital for Children, Wilmington, DE); Massoud Majd, MD (Children’s Na-tional Medical Center, Washington, DC); Eglal I. Shalaby-Rana, MD (Children’s National Medical Center, Washington,DC); and Isky Gordon, MD (Great Ormond Street Hospital for Children NHS Trust, London, UK).
Introduction
must be prepared to manage all levels of sedationand general anesthesia, even if only conscious seda- The increasing complexity of pediatric nuclear medicine studies has led to a greater use of sedation.
These recommendations for sedation of selectedchildren undergoing nuclear medicine procedures III. Published Rules Concerning Pediatric Seda-
are generated to provide assistance to those institu- tions without pediatric sedation guidelines alreadyin place and are not intended to replace satisfactory The Joint Commission on Accreditation of Health existing policies. Sedation is no substitution for ade- Care Organizations mandates an institution-wide quate child and parent preparation. Friendly staff policy for pediatric sedation. It is advisable to follow geared to children, with sufficient time allocated for each institution’s established sedation policy, if such each pediatric examination, will reduce the need for a policy exists. Guidelines for the monitoring and se- sedation with many examinations such as dimercap- dation of children are published by the American tosuccinic acid and dynamic renography.
Academy of Pediatrics (AAP). These guidelines arequite extensive and include documentation, in- II. Definitions
formed consent, patient preparation, pre-sedationevaluation, monitoring, post-sedation care, dis- Sedation is a medically controlled state of depressed charge criteria, and instructions, as well as follow-up consciousness or unconsciousness. Sedation can bedivided into conscious sedation, deep sedation, and general anesthesia. In conscious sedation, the pa-tient maintains the ability to respond to external IV. Benefits of Sedation
stimulation. In deep sedation, patients are not easilyaroused. In general anesthesia, patients are not There are several uses of sedation in nuclear medicine. First, some procedures, such as SPECT or The important clinical distinction between these high-resolution pinhole imaging, require that the states revolves around the ability of the patient to child remain absolutely still for extended periods of maintain his or her protective reflexes. The con- time. Sedation can reduce patient motion during sciously sedated patient maintains protective re- these prolonged image acquisitions. The second use flexes, such as gagging and swallowing, and there- of sedation is to allow performance of a procedure fore can keep his or her airway patent without that requires the cooperation of an older child who assistance. The deeply sedated patient may lose refuses to cooperate. Typically, patients in this these reflexes and may not be able to maintain his or group have an exaggerated fear of the procedure be- her airway. The patient under general anesthesia has cause of a developmental disability, previous health lost protective reflexes and is unable to maintain hisor her airway.
care experiences, or a traumatic experience, such as There are no sharp boundaries between conscious physical or sexual abuse. Third, patient sedation can sedation, deep sedation, and general anesthesia.
enhance patient care by minimizing discomfort.
Furthermore, patients may rapidly move from con- These recommendations provide suggestions on scious sedation through deep sedation to general how to use sedation to maximize the quality of anesthesia. Therefore, clinics that sedate children imaging procedures while minimizing the risks.
V. Risks of Sedation
ATI continually monitors the patient with a pulseoximeter throughout the procedure. The patient is The risks of sedation include hypoventilation, ap- monitored until awakening and the institution’s dis- nea, airway obstruction, cardiopulmonary arrest, and the morbidity and mortality associated withthese events. Obtaining a medical history, includingallergies, as well as appropriate personnel and VII. Avoidance of Sedation
equipment, reduce the likelihood of such untoward For many pediatric nuclear procedures, sedation events. The providers of sedation must be able to and its attendant risks are avoidable by having an at- recognize these risks and respond rapidly with ap- tentive and caring approach to children. The pain of propriate and effective treatment. The decision to se- most nuclear medicine procedures is limited to a sin- date the child must involve a careful comparison of gle venipuncture or catheterization of the bladder.
the risks and the benefits. The patient should be as- For patients in whom the pain of venipuncture is a sessed by the physician supervising the sedation limiting factor, topical lidocaine preparations are and assigned an American Society of Anesthesiolo- available. These are best used 1–2 h before injection.
They may be prescribed before the procedure and ASA Classification
applied by a parent at home before arriving in the nuclear medicine clinic. Xylocaine jelly can be usedfor difficult urethral catheterizations (particularly in males). Giving full information about the examina- Severe systemic disease, but not incapacitating tion to the parents and child at the time the appoint-ment is made reduces anxiety levels in both parents Severe systemic disease that is a constant threat Many nonpharmacologic strategies are available to Moribund, not expected to live 24 h, irrespective help the child cooperate and hold still during a nu- clear medicine exam. Cooperation can be maximized An e is added to the status number to designate an emergency in many instances by allowing the parents to be with their child during the examination and letting thechild have the comfort of a pacifier, bottle, blanket, or An organ donor is usually designated as class 6.
stuffed animal. Depending on the age of the child, areassuring description of the procedure can be pro- gists (ASA) classification. If the patient is assigned vided before and during the procedure by a technol- an ASA classification of 3 or more, then this patient ogist who has good rapport with children. The room should probably be sedated by the anesthesiologist.
can be decorated to make it more interesting andcomfortable for the child. The distraction of a child’sattention by reading of a story or viewing television VI. Appropriate Personnel and Equipment
or a VCR allows reduction of patient motion. Parents Safe sedation requires an appropriately trained indi- can be instructed to schedule the procedure during vidual (ATI) with experience and training in pedi- the younger child’s nap time to maximize the atric sedation, pediatric airway maintenance, and chances that he or she will sleep during the proce- pediatric advanced life support (PALS). The ATI not dure. In addition, a “papoose,” sandbags, or adhe- only explains the sedation procedure to the family sive tape can be used to restrain infants and younger but also screens the child for negative outcome fac- children. Use of these strategies can avoid sedation tors, such as significant upper airway obstruction, while allowing acquisition of quality images.
apnea, reactive airway disease, risk for vomiting andaspiration, and uncontrolled seizures. A consulta- VIII. Choosing a Sedation Regimen
tion with a pediatric anesthesiologist or intensivistabout a child with risk factors may be necessary be- Sedation regimens vary greatly from one institution to another and even among physicians in the same An emergency cart with equipment and drugs department. There is no consensus on the best pro- suitable for children of all ages and sizes should be tocol for the sedation of children. The choice of readily available. Functioning suction apparatus drugs and route of administration depends on the with appropriate suction catheters, as well as a pos- patient’s age, history of underlying illness (e.g., itive-pressure oxygen delivery system capable of ad- mental deficiency, cardiac or respiratory illness), ex- ministering >90% oxygen, are also mandatory. The perience and familiarity with certain drugs, institu- SOCIETY OF NUCLEAR MEDICINE PROCEDURE GUIDELINES MANUAL MARCH 2003 tional protocols, length of procedure, and availabil- and Thorazine), is rarely necessary for most nuclear medicine procedures. Also, opiates may cause respira- In infants and young children, rectally or (more tory depression, especially if administered rapidly.
commonly) orally administered drugs are adequate Ketamine can cause hallucinations in older children.
for sedation. Rectal absorption tends to be erratic, Midazolam can be used alone or as an adjunct and the oral method is usually the preferred route of with other sedation drugs, such as opiates and bar- administration. Chloral hydrate is commonly used biturates, and may be used orally, intravenously, in infants and young children (usually up to 15 kg) rectally, or intranasally. Recently, there is a growing and is recommended by the AAP as an “effective enthusiasm for the use of intranasal midazolam with sedative with a low incidence of acute toxicity when its predominantly amnestic effect in children under- administered orally in the recommended dosage for going pre-anesthetic sedation, echocardiography, or short-term sedation.” Chloral hydrate in a dose of short surgical procedures. Nasally administered mi- 50–70 mg/kg (maximum total accumulated dose of dazolam in a dose of 0.2 mg/kg has been shown to 100 mg/kg) is usually adequate to achieve sedation.
have very minimal respiratory depression and a rel- The maximum total dose varies according to the atively short duration of sedation, approximately guidelines of the individual institution. 35–45 min. Orally administered midazolam in a dose In older patients and children with mental defi- of 0.5–0.75 mg/kg is available in flavored syrup. Al- ciencies, parenteral sedation, usually intravenous, though the rate of absorption is slower than in- may be the preferred method. Intravenous sedation tranasally administered midazolam, the unpleasant- allows for rapid induction and recovery, with better ness of the nasal drops is avoided and, in general, scheduling of sedation cases during high volume pe- the oral form is better accepted by patients. It obvi- riods. However, intravenous sedation must be ates the need for intravenous access and may be titrated for each patient, using the recommended suited for some nuclear medicine procedures. It also has a predominantly amnestic effect in children un- Pentobarbital sodium (Nembutal) is popular be- dergoing pre-anesthetic sedation, echocardiogra- cause it is a short-acting barbiturate with low inci- phy, urethral catheterization, and short surgical pro- dence of respiratory depression. It is commonly cedures. The exact dosages and preferred routes of used in dosages of 2–6 mg/kg. The maximum administration should be ascertained from the dosage varies according to the guidelines of the in- guidelines of the individual institution.
dividual institution. Nembutal is contraindicated The nuclear medicine physician should consult with in patients with porphyria and may require higher the anesthesiology department in each institution for doses in patients being treated for seizure disor- specific recommendations on dosages and combina- ders. Versed is often coupled with Nembutal in tions of sedative drugs. Consultation with an anesthe- doses of 0.1 mg/kg intravenously, for a maximum siologist is particularly important in patients with a total dose of 2.5 mg. Other intravenous sedation history of significant snoring, abnormal airway (i.e., regimens (opiates and benzodiazepines) are used micrognathia), congenital heart disease, reactive air- less frequently in the pediatric population. Rever- ways disease, and increased intracranial pressure.
sal drugs are required to treat overdoses, such asnaloxone (Narcan) for opiates and flumazenil (Ro- IX. Developing a Sedation Policy
Classes of drugs used for parenteral sedation: A written pediatric sedation policy is strongly rec- Dosages vary and can be generated by the pediatric ommended. The policy should follow institution- anesthesiology or critical care section of the individ- wide policy for pediatric sedation and also follow the guidelines of the AAP. Many institutions have •Barbiturates including pentobarbital sodium sedation committees with representation from anes- thesiology, nursing, intensive care, pediatrics, and •Opiates including meperidine (Demerol) and pediatric imaging. This committee can serve as a source of information for the development of the se- •Benzodiazepines including diazepam (Valium) Written medication protocols for sedation are also •Phenothiazines including chlorpromazine (Tho- strongly recommended. Many sedation protocols are available for pediatric sedation, not all of which •Neuroleptic agents including ketamine (Ketalar) are appropriate for nuclear imaging procedures. The Sedation protocols use drugs singly or in combina- exact protocol or set of protocols should be tailored tion. The use of analgesic opiates, such as fentanyl and to the age of the patient, the pain or discomfort level meperidine (as part of DPT––Demerol, Phenergan of the procedure, the length of the imaging proce- dure, and, most important, the experience of physi- Pereira JK, Burrows PE, Richards HM, et al. Com- cians in each clinic. The best source of specific seda- parison of sedation regimens for pediatric outpa- tion protocols is likely to be the institution’s anes- tient CT. Pediatr Radiol. 1993;23:341–344.
thesiologist or intensivist, or preferably, pediatric Diament MJ, Stanley P. The use of midazolam for se- anesthesiologist or pediatric intensivist. These indi- dation of infants and children. Am J Roentgenol.
viduals should have the greatest experience in seda- tion and should know the latest information on var- Burrows PE. Pediatric sedation for nuclear medicine procedures. In: Treves ST, ed. Pediatric Nuclear The AAP recommends that written informed con- Medicine. 2nd ed. New York, NY: Springer-Ver- sent be obtained from parents according to each in- stitution’s protocol. Consultation with the institu- Snodgrass WR, Dodge WF. Lytic/DPT cocktail: time tion’s legal counsel may be helpful to determine for rational and safe alternatives. Pediatr Clin guidelines for obtaining such consent.
North Am. 1989;36:1285–1291.
Adrian ER. Intranasal versed: the future of pediatric Issues Requiring Further Clarification
conscious sedation. Pediatr Nurs. 1994;20:287–292.
Latson LA, Cheatham JP, Gumbiner CH, et al. Mi- dazolam nose drops for outpatient echocardio-graphy sedation in infants. Am Heart J.
XI. Concise Bibliography
Louon A, Reddy VG. Nasal midazolam and ke- American Academy of Pediatrics, Committee on tamine for paediatric sedation during computer- Drugs. Guidelines for monitoring and manage- ized tomography. Acta Anaesthesiol Scand.
ment of pediatric patients during and after seda- tion for diagnostic and therapeutic procedures.
Pediatrics. 1992;89:1110–1115.
XII. Disclaimer
Keeter S, Benator RM, Weinberg SM, et al. Sedation in pediatric CT: national survey of current prac- The Society of Nuclear Medicine has written and tice. Radiology. 1990;175:745–752.
approved guidelines to promote the cost-effective American Academy of Pediatrics, Committee on use of high-quality nuclear medicine procedures.
Drugs and Committee on Environmental Health.
These generic recommendations cannot be applied Use of chloral hydrate for sedation in children.
to all patients in all practice settings. The guide- Pediatrics. 1993;92:471–473.
lines should not be deemed inclusive of all proper Greenberg SB, Faerber EN, Aspinall CL, et al. High- procedures or exclusive of other procedures rea- dose sedation for children undergoing MR imag- sonably directed to obtaining the same results. The ing: safety and efficacy in relation to age. Am J spectrum of patients seen in a specialized practice Roentgenol. 1993;161:639–641.
setting may be quite different from the spectrum of Greenberg SB, Faerber EN, Radke JL, et al. Sedation of patients seen in a more general practice setting.
difficult-to-sedate children undergoing MR imag- The appropriateness of a procedure will depend in ing: value of thioridazine as an adjunct to chloral part on the prevalence of disease in the patient hydrate. Am J Roentgenol. 1994;163:165–168.
population. In addition, the resources available to Strain JD, Harvey LA, Foley LC, et al. intravenously care for patients may vary greatly from one medi- administered pentobarbital sodium for sedation cal facility to another. For these reasons, guidelines in pediatric CT. Radiology. 1986;161:105–108.
Strain JD, Campbell JB, Harvey LA, et al. IV Nembu- Advances in medicine occur at a rapid rate. The tal: safe sedation for children undergoing CT.
date of a guideline should always be considered in Am J Roentgenol. 1988;151:975–979.
determining its current applicability.
SOCIETY OF NUCLEAR MEDICINE PROCEDURE GUIDELINES MANUAL MARCH 2003 ADDENDUM #1
Ambulatory Sedation Assessment & Flow Sheet
Sedation Order
________________________________________________________________________________________________ Flow Sheet
Medication
Comments
and Route
Time Study Completed
PSD Criteria For Outpatients TIME
Respiratory Status:
2=Spontaneous unassisted respirations
0=Assisted respirations
(chin support, oxygen, etc.)
Level Of Consciousness:
2=Awake and oriented to name and/or age
for child over 3 years
2=Awake and activity appropriate for age if
child under 3 years of age (as pre-sedation)
1=Lethargic but arousable
0=Nonarousable
Vital Signs (VS)
2=VS within 20% of pre-sedation value
1=VS within 20-30% of pre-sedation value
0=VS variance greater than ± 30%
of pre-sedation value
Vomiting
2=No vomiting
1=Vomiting more than 2 times
0=Persistent vomiting, requiring medication
Discharge Instructions To:
_______________________________________________________________________________
Verbalized Understanding?
_______________________________________________________________________________
Progress Note
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Discharge Date/Time
_______________________________________________________________________________
❒ Wheelchair
❒ Ambulatory
❒ Carried
_______________________________________________________________________________
Signature(s)
_______________________________________________________________________________
Ambulatory Sedation Assessment & Flow Sheet

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