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1 All authors: Department of Radiology, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, 3333 Burnet Ave., Cincinnati, OH 45229-3039.
Received February 26, 2002;
accepted after revision June 19, 2002.
Address correspondence to L. F. Donnelly.
Abstract
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MATERIALS AND METHODS. Radiology reports, medical records, and department incident reports were reviewed for the past 5 years from all patients who required sedation for abdominal CT. Patient age and sex, type of sedation, and complications (defined as vomiting with aspiration) related to enteric contrast material before the sedation were recorded. For routine oral contrast material, diluted Hypaque (meglumine diatrizoate) was administered in an age-based amount 1-2 hr before scanning. For sedation, depending on the patient's age, either oral chloral hydrate (70-100 mg/kg) or IV pentobarbital (3 mg/kg with repeated doses of up to 7 mg/kg) was used.
RESULTS. Three hundred sixty-seven patients who received oral contrast material before sedation for abdominal CT were identified (200 boys, 167 girls; age range, 1 month-19 years; mean age, 2.9 years). Chloral hydrate was used in 30 patients and IV pentobarbital in 337 patients. No complications related to the administration of oral contrast material before sedation were identified.
CONCLUSION. The practice of administering oral contrast material in children before sedation for abdominal CT appears to be safe when using the sedation drugs and protocols in place at our institution. Further study of the safety of this practice should be undertaken.
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Abdominal CT was performed for various clinical indications. Children being evaluated for trauma do not receive oral contrast material at our institution and therefore were not included in the study population.
All sedation procedures were performed and monitored in accordance with our departmental structured sedation program. With the exception of the administration of oral contrast material, the patients receive nothing by mouth for a defined time before sedation. In accordance with our hospital sedation guidelines, all patients cannot receive clear liquids for 2 hr before sedation. Patients younger than 6 months cannot receive solid food or nonclear liquids for 4 hr before the procedure. Patients between 6 months and 3 years old cannot receive solid food or nonclear liquids for 6 hr before sedation. Patients more than 3 years old cannot receive solid food or nonclear liquids for 8 hr before sedation.
Immediately before each sedation, the sedation nurse obtained a history from the patient or the parent or guardian and performed a physical examination that was supervised by the pediatric radiologist. Patients were sedated with either oral chloral hydrate (70-100 mg/kg) or IV pentobarbital (3 mg/kg with repeated doses if the patient remained awake for up to a total of 7 mg/kg). Drug choice was based on the patient's age (guideline: chloral hydrate for patients < 1 year, pentobarbital for patients > 1 year). During the entire procedure and sedation recovery, respiratory rate, heart rate and rhythm, and blood oxygen saturation levels were monitored using transcutaneous pulse oximetry. All children were breathing spontaneously without any form of assisted ventilation.
Enteric contrast material was administered in accordance with our department protocols. Contrast material was administered by mouth or nasogastric tube. In all cases, diluted Hypaque (meglumine diatrizoate; Nycomed, Princeton, NJ) was used as the contrast agent. The diluted contrast material was created by adding a dilutent to Hypaque (1.5% meglumine diatrizoate, in-house pharmacy preparation). The 1.5% meglumine diatrizoate was diluted 30:1 with a dilutent (sterile water in cases of nasogastric administration and noncarbonated flavored drink in cases of oral administration). The volume of oral contrast material administered was determined according to patient age (Table 1). This volume of contrast material was administered in one of two protocols concerning the timing of administration: a 1-hr or a 2-hr preparation. The 1-hr preparation is routine, and the 2-hr preparation is used in patients in whom opacification of pelvic bowel loops is preferred, such as in suspected periappendiceal abscess. For the 1-hr preparation, one half of the volume of enteric contrast material is administered 1 hr before sedation, and CT and the other half of the volume is administered 15 min before sedation and CT. For the 2-hr preparation, one half of the volume is administered 2 hr before, one fourth of the volume is administered 1 hr before, and one fourth of the volume is administered 15 min before sedation and CT.
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Radiology reports and medical records were reviewed for evidence of complications related to the administration of enteric contrast material before sedation. These complications were defined as vomiting with evidence of aspiration. Aspiration was considered to have occurred if any of the following events were documented: aspiration was described in the medical record, chest radiographs were obtained after the procedure to rule out aspiration and showed acute lung opacification, oxygen desaturation or respiratory distress occurred after an episode of vomiting, or the patient required unanticipated admission to the hospital or had other unanticipated changes in therapy related to changes in respiratory status after CT was performed. In addition to the individual medical records, the list of patients who underwent sedation for CT after administration of enteric contrast material was checked against the list of names recorded in our radiology incident report log for cases of vomiting with aspiration. The radiology incident report log is managed by the radiology nurses and the pediatric radiologists and contains records of all adverse reactions and complications that were documented in the radiology report. Complications or adverse reactions related to sedation, including vomiting and aspiration, are among those events recorded. It is the policy in our department to document any complications or adverse effects in the radiology report as well as to file an incident report.
Our hospital internal review board approved the review of these records. Because the review of these records was retrospective and did not influence patient care, informed consent was not required.
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No complications related to the administration of oral contrast material before sedation were identified. Specifically, no patients showed findings suspicious for aspiration after the administration of enteric contrast material and a sedative. Four cases (1%) of vomiting occurred without associated events as the patient was awaking from sedation. All four patients had been sedated with pentobarbital. The ages of the patients, all of whom were boys, were 1 year, 2 years, 2 years, and 15 years; the 15-year-old patient was developmentally delayed. In all four patients, the vomiting was reported to have occurred after the CT examination was complete and while the patient was awaking from sedation.
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The major complication for which the nothing-by-mouth guidelines are designed to minimize is the potential risk of vomiting and aspiration. Nausea and vomiting often occur in patients who undergo sedation [8, 9]. Because of delayed gag reflexes associated with sedation, sedated patients who vomit are thought to be at increased risk of aspiration. Several cases of aspiration from contrast material leading to adverse affects in children who underwent CT have been well documented [10, 11]. These described cases have occurred in patients who were being imaged for trauma [10, 11] and spurred much debate concerning the safety of administering enteric contrast material for the CT examination of trauma patients [10,11,12,13].
Debate exists concerning the degree of sedation and the associated depression of pharyngeal function and the resulting aspiration risk [14,15,16,17,18]. There is even controversy concerning the terminology, such as conscious sedation, used to describe the degree of sedation [19]. A number of health care professionals consider the degree of pharyngeal depression and the risk of vomiting and aspiration to be less with drugs such as pentobarbital than with a general anesthetic [14,15,16,17,18]. Certainly, the incidence of vomiting, degree of pharyngeal depression, and risk of aspiration are different for different sedatives [15]. In this sense, our data apply to the use of only pentobarbital and choral hydrate. Because we have few patients who were sedated with choral hydrate, our data mainly pertain to patients sedated with pentobarbital. Concerning the incidence of vomiting, pharyngeal depression, and risk of aspiration related specifically to pentobarbital administration, we could find no published data except the mention of vomiting as a potential adverse effect in the package insert (Nembutal; Abbott Laboratories, North Chicago, IL).
To our knowledge, no cases have been published of aspiration from enteric contrast material leading to complications in pediatric patients who were sedated. In our review of 5 years of experience concerning the administration of enteric contrast material before sedation in a busy pediatric body imaging service, no cases were discovered in which aspiration was noted or led to clinically significant adverse effects.
Our study is limited by a number of factors. The study is retrospective in nature, and the detection of aspiration was dependent on the policy that all adverse events be recorded in the medical record and incident reports be filed. Although none of the pediatric radiologists in our body imaging section or the radiology sedation nurses recall a case of aspiration related to enteric contrast material, and we think that it is unlikely that a significant incident of aspiration could occur without documentation, the inclusion of such an event is dependent on the reporting policies of the department. Second, a control group was not included in our study. In future studies, a control group composed of children who were sedated for IV contrast-enhanced CT studies but did not require oral contrast material (CT of the chest, neck, or head) could be used to determine whether oral contrast material does or does not contribute to a higher degree of aspiration. Third, despite a large number of abdominal CT examinations that were performed at our institution during the 5-year period of the study, only 367 were performed with sedation. This finding shows that most children who undergo CT of the abdomen do not require sedation. A multicenter study may be advantageous in providing a larger number of subjects. Finally, as previously mentioned, the conclusions from this study can be applied strictly to only those drugs used in our sedation program. Future studies may be needed to see whether the same conclusions can be drawn concerning other sedatives. All patients in our study also received IV contrast material, which can lead to nausea and vomiting. CT examinations that require oral but not IV contrast material are uncommon but may have an even more decreased risk of aspiration than scans obtained with IV contrast material.
In conclusion, the practice of administering oral contrast material before sedation for abdominal CT in children appears to be safe when using the sedation drugs and protocols in place at our institution. Further study into the safety of this practice should be undertaken.
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