Recommendations on painless imaging

Do not routinely use ketamine, or opioids for painless imaging procedures.

For children and young people who are unable to tolerate a painless procedure (for
example during diagnostic imaging) consider one of the following drugs, which have
a wide margin of safety:
-chloral hydrate for children under 15 kg
-midazolam
For children and young people who are unable to tolerate painless imaging with the
above drugs, consider one of the following, used in specialist techniques, which
have a narrow margin of safety (see section on personnel and training):
-propofol
-sevoflurane
Of all the imaging techniques MRI is the most common scenario in which sedation
may be needed. MRI usually lasts between 30 and 60 minutes and CT imaging is
much shorter. Chloral hydrate causes sleep lasting approximately one hour and is
therefore less appropriate for scans lasting a few minutes. An advantage of chloral
is that it does not require the services of an anaesthesia team. The GDG recognised
that chloral hydrate may not always be effective and that intravenous midazolam is
a drug commonly used to either increase the depth of sedation or prolong sedation.
Midazolam was shown to be one of the most cost-effective sedation techniques for
dental procedures (6.12.5.2) and the GDG believe this may well be the case for
painless imaging as well. CT scans and echocardiography can be done under
moderate sedation. Some children may need to be asleep in order to tolerate
complex or prolonged investigations. Examples include MRI and nuclear medicine
imaging that may involve the child keeping still for up to an hour. MRI can be
particularly frightening because it is noisy and involves lying still in an enclosed
space.
Recommendations on painful procedures
Examples of procedures usually carried out under dissociative or deep sedation are
suture of lacerations to the face and nail bed in young children, and orthopaedic
manipulations
For children and young people undergoing a painful procedure (for example suture
laceration or orthopaedic manipulation), when the target level of sedation is
minimal or moderate, consider:

- nitrous oxide (in oxygen) and/or

- midazolam (oral or intranasal)
For all children and young people undergoing a painful procedure, consider using a
local anaesthetic, as well as a sedative.
For children and young people undergoing a painful procedure (for example, suture
laceration or orthopaedic manipulation) in whom nitrous oxide (in oxygen) and/or
midazolam (oral or intranasal) are unsuitable consider:
-ketamine (intravenous or intramuscular), or
-intravenous midazolam with or without fentanyl (to achieve moderate sedation).
For children and young people undergoing a painful procedure (for example suture
laceration or orthopaedic manipulation) in whom ketamine (intravenous or
intramuscular) or intravenous midazolam with or without fentanyl (to achieve
moderate sedation) are unsuitable, consider a specialist sedation technique such as
propofol with or without fentanyl.
Nitrous oxide plus oxygen with or without iv midazolam are likely to be the two
lowest cost strategies for tooth extraction in children
For a child or young person who cannot tolerate a dental procedure with local
anaesthesia alone, to achieve conscious sedation consider:
-nitrous oxide (in oxygen) or
-midazolam.
If these sedation techniques are not suitable or sufficient, refer to a specialist team
for an alternative sedation technique.
Midazolam has a strong safety profile in inducing either minimal or moderate
sedation. For painful procedures midazolam should be combined with analgesia.
Ideally analgesia is achieved by local anaesthesia.
Ketamine is demonstrated to have a strong efficacy and safety profile in enabling
safe sedation and as an analgesic drug useful for painful procedures in children and
young people. Its main side effect is vomiting in approximately 10% of patients.
In clinical practice, midazolam is the most common sedative drug used
Fasting
2-4-6 rule, namely 2 hours for clear fluid, 4 hours for breast milk and 6 hours for
solids (including formula milk). The above recommendations are based on expert
opinions. Pooled general anesthesia data indicate that the risk of aspiration is low.
Aspirations occur primarily during intubation and extubation, both of which are

unlikely events during ED procedural sedation. To date, there have been no reported
cases of aspiration arising from the ED. Thus, the best course of action is based on
the risk and benefits of the procedure and sedation for the patient. adverse events
are extremely low regardless of NPO status and that risk is related more to the
depth of sedation
Fasting is not needed for:
-minimal sedation
-sedation with nitrous oxide (in oxygen)
-moderate sedation during which the child or young person will maintain verbal
contact with the
healthcare professional.
apply the 2-4-6 fasting rule for deep sedation and moderate sedation during which
the child or young person might not maintain verbal contact with the healthcare
professional
Inhalation of gastric contents can be fatal. Loss of consciousness is associated with
the loss of vital airway reflexes and inhalation of gastric contents is possible.
Consequently, fasting (in order to keep the stomach empty) is standard practice
before general anaesthesia and has become standard before any sedation
technique that may cause loss of consciousness.

Discharge criteria:
Ensure that all of the following criteria are met before the child or young person is
discharged:
- vital signs (usually body temperature, heart rate, blood pressure and respiratory
rate) have returned to normal levels
- the child or young person is awake (or returned to baseline level of
consciousness) and there is no risk of further reduced level of consciousness
-

nausea, vomiting and pain have been adequately managed.

The childs vital signs should be within 15% of admission readings (either above or
below)
The child should be ambulatory as appropriate for his or her age, without assistance
The child should be able to ingest and retain oral fluids
Fasting times should be as for general anesthesia:

2 hours for clear fluids

4 hours for breast milk
6 hours for solids.