Hostname: page-component-8448b6f56d-m8qmq Total loading time: 0 Render date: 2024-04-25T00:12:00.003Z Has data issue: false hasContentIssue false
  • English
  • Français

Comparison of intranasal midazolam, intranasal ketamine, and oral chloral hydrate for conscious sedation during paediatric echocardiography: results of a prospective randomised study

Published online by Cambridge University Press:  27 August 2019

Hayrullah Alp Open the ORCID record for Hayrullah Alp [Opens in a new window] ,
Ahmet M. Elmacı ,
Esma K. Alp  and
Bülent Say
Hayrullah Alp*
Affiliation:
Division of Pediatric Cardiology, Department of Pediatrics, Dr Ali Kemal Belviranlı Obstetrics and Children’s Hospital, Konya 42285, Turkey
Ahmet M. Elmacı
Affiliation:
Division of Pediatric Nephrology, Department of Pediatrics, Dr Ali Kemal Belviranlı Obstetrics and Children’s Hospital, Konya 42285, Turkey
Esma K. Alp
Affiliation:
Department of Pediatrics, Dr Ali Kemal Belviranlı Obstetrics and Children’s Hospital, Konya 42285, Turkey
Bülent Say
Affiliation:
Department of Anesthesiology, Dr Ali Kemal Belviranlı Obstetrics and Children’s Hospital, Konya 42285, Turkey
*
Author for correspondence: H. Alp, MD, Division of Pediatric Cardiology, Department of Pediatrics, Dr Ali Kemal Belviranlı Obstetrics and Children’s Hospital, Fatih Mah. Yeni İstanbul Cd. No: 32, Selçuklu, Konya 42285, Turkey. Phone: 090 332 223 6500 (2221); Fax: 0090 332 237 60 25; E-mail: drhayrullahalp@hotmail.com
Get access Rights & Permissions [Opens in a new window]

Abstract

Objective:

There are several agents used for conscious sedation by various routes in children. The aim of this prospective randomised study is to compare the effectiveness of three commonly used sedatives: intranasal ketamine, intranasal midazolam, and oral chloral hydrate for children undergoing transthoracic echocardiography.

Methods:

Children who were referred to paediatric cardiology due to a heart murmur for transthoracic echocardiography were prospectively randomised into three groups. Seventy-three children received intranasal midazolam (0.2 mg/kg), 72 children received intranasal ketamine (4 mg/kg), and 72 children received oral chloral hydrate (50 mg/kg) for conscious sedation. The effects of three agents were evaluated in terms of intensity, onset, and duration of sedation. Obtaining high-quality transthoracic echocardiography images (i.e. absence of artefacts) were regarded as successful sedation. Side effects due to medications were also noted.

Results:

There was no statistical difference in terms of sedation success rates between three groups (95.9, 95.9, and 94.5%, respectively). The median onset of sedation in the midazolam, ketamine, and chloral hydrate was 14 minutes (range 7–65), 34 minutes (range 12–56), and 40 minutes (range 25–57), respectively (p < 0.001 for all). However, the median duration of sedation in study groups was 68 minutes (range 20–75), 55 minutes (range 25–75), and 61 minutes (range 34–78), respectively (p = 0.023, 0.712, and 0.045). Gastrointestinal side effects such as nausea and vomiting were significantly higher in the chloral hydrate group (11.7 versus 0% for midazolam and 2.8% for ketamine, respectively, p = 0.002).

Conclusion:

Results of our prospectively randomised study indicate that all three agents provide adequate sedation for successful transthoracic echocardiography. When compared the three sedatives, intranasal midazolam has a more rapid onset of sedation while intranasal ketamine has a shorter duration of sedation. Intranasal ketamine can be used safely with fewer side effects in children undergoing transthoracic echocardiography.

Keywords

Sedativeechocardiographypaediatricintranasalmidazolamketamineoralchloral hydrateinfant
Type
Original Article
Information
Cardiology in the Young , Volume 29 , Issue 9 , September 2019 , pp. 1189 - 1195
Copyright
© Cambridge University Press 2019 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Ghaffar, S, Haverland, C, Ramaciotti, C, Scott, WA, Lemler, MS. Sedation for pediatric echocardiography: evaluation of preprocedure fasting guidelines. J Am Soc Echocardiogr 2002; 15: 980–983.CrossRefGoogle ScholarPubMed
Narendra, PL, Naphade, RW, Nallamilli, S, Mohd, S. A comparison of intranasal ketamine and intranasal midazolam for pediatric premedication. Anesth Essays Res 2015; 9: 213–218.CrossRefGoogle ScholarPubMed
Salehi, F, Riasi, HR, Ebrahimzadeh, A, Askari Janatabadi, S. The effect of oral midazolam and chloral hydrate before echocardiography in pediatric patients: a randomized double-blind clinical trial. Glob Pediatr Health 2017; 4: 1–6.Google ScholarPubMed
Yildirim, SV, Guc, BU, Bozdogan, N, Tokel, K. Oral versus intranasal midazolam premedication for infants during echocardiographic study. Adv Ther 2006; 23: 719–724.CrossRefGoogle ScholarPubMed
Napoli, KL, Ingall, CG, Martin, GR. Safety and efficacy of chloral hydrate sedation in children undergoing echocardiography. J Pediatr 1996; 129: 287–291.CrossRefGoogle ScholarPubMed
Conway, A, Rolley, J, Sutherland, JR. Midazolam for sedation before procedures. Cochrane Database Syst Rev 2016; 20: CD009491.Google Scholar
Buonsenso, D, Barone, G, Valentini, P, Pierri, F, Riccardi, R, Chiaretti, A. Utility of intranasal ketamine and midazolam to perform gastric aspirates in children: a double-blind, placebo controlled, randomized study. BMC Pediatr 2016; 14: 67.CrossRefGoogle Scholar
Gutstein, HB, Johnson, KL, Heard, MB, Gregory, GA. Oral ketamine preanesthetic medication in children. Anesthesiology 1992; 76: 28–33.CrossRefGoogle ScholarPubMed
Grant, IS, Nimmo, WS, Clements, JA. Pharmacokinetics and analgesic effects of i.m. and oral ketamine. Br J Anaesth 1981; 53: 805–810.CrossRefGoogle ScholarPubMed
Payne, K, Mattheyse, FJ, Liebenberg, D, Dawes, T. The pharmacokinetics of midazolam in paediatric patients. Eur J Clin Pharmacol 1989; 37: 267–272.CrossRefGoogle ScholarPubMed
American Society of Anesthesiologists Task Force on Sedation, Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 2002; 96: 1004–1007.CrossRefGoogle Scholar
Wilson, ME, Karaoui, M, Al Djasim, L, Edward, DP, Al Shamrani, M, Friedman, DS. The safety and efficacy of chloral hydrate sedation for pediatric ophthalmic procedures: a retrospective review. J Pediatr Ophthalmol Strabismus 2014; 51: 154–159.CrossRefGoogle ScholarPubMed
Kao, SC, Adamson, SD, Tatman, LH, Berbaum, KS. A survey of post-discharge side effects of conscious sedation using chloral hydrate in pediatric CT and MR imaging. Pediatr Radiol 1999; 29: 287–290.CrossRefGoogle ScholarPubMed
Pershad, J, Palmisano, P, Nichols, M. Chloral hydrate: the good and the bad. Pediatr Emerg Care 1999; 15: 432–435.CrossRefGoogle ScholarPubMed
Geva, T, Powell, AJ. Sedation and monitoring. In: Allen, HD, Gutgesell, HP, Clark, EB, Driscoll, DJ (eds). Moss and Adams’ Heart Disease in Infants, Children, and Adolescents, 7th edn. Lippincott Williams & Wilkins, Philadelphia, 2008: 165–166.Google Scholar
Sessler, CN, Gosnell, MS, Grap, MJ, et al. Richmond agitation-sedation scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med 2002; 166: 1338–1344.CrossRefGoogle ScholarPubMed
Lopez, L, Colan, SD, Frommelt, PC, et al. Recommendations for quantification methods during the performance of a pediatric echocardiogram: a report from the Pediatric Measurements Writing Group of the American Society of Echocardiography Pediatric and Congenital Heart Disease Council. J Am Soc Echocardiogr 2010; 23: 465–495.CrossRefGoogle ScholarPubMed
Zilberman, MV. How best to assure patient co-operation during a pediatric echocardiography examination? J Am Soc Echocardiogr 2010; 23: 43–45.CrossRefGoogle ScholarPubMed
Miller, JW, Ding, L, Gunter, JB, et al. Comparison of intranasal dexmedetomidine and oral pentobarbital sedation for TTE in infants and toddlers: a prospective, randomized, double-blind trial. Anesth Analg 2018; 126: 2009–2016.CrossRefGoogle Scholar
Yu, Q, Liu, Y, Sun, M, et al. Median effective dose of intranasal dexmedetomidine sedation for TTE in pediatric patients with noncyanotic congenital heart disease: an up-and-down sequential allocation trial. Paediatr Anaesth 2017; 27: 1108–1114.CrossRefGoogle Scholar
Wheeler, DS, Jensen, RA, Poss, WB. A randomized, blinded comparison of chloral hydrate and midazolam sedation in children undergoing echocardiography. Clin Pediatr (Phila) 2001; 40: 381–387.CrossRefGoogle ScholarPubMed
Heistein, LC, Ramaciotti, C, Scott, WA, Coursey, M, Sheeran, PW, Lemler, MS. Chloral hydrate sedation for pediatric echocardiography: physiologic responses, adverse events, and risk factors. Pediatrics 2006; 117: e434–e441.CrossRefGoogle ScholarPubMed
Fantacci, C, Fabrizio, GC, Ferrara, P, Franceschi, F, Chiaretti, A. Intranasal drug administration for procedural sedation in children admitted to pediatric Emergency Room. Eur Rev Med Pharmacol Sci 2018; 22: 217–222.Google ScholarPubMed
Akçay, ME, Kılıç, ET, Akdemir, MS. The comparison of the efficacy and safety of midazolam, ketamine, and midazolam combined with ketamine administered nasally for premedication in children. Anesth Essays Res 2018; 12: 489–494.Google ScholarPubMed
Stephen, MC, Mathew, J, Varghese, AM, Kurien, M, Mathew, GA. A randomized controlled trial comparing intranasal midazolam and chloral hydrate for procedural sedation in children. Otolaryngol Head Neck Surg 2015; 153: 1042–1050.CrossRefGoogle ScholarPubMed