DOI: 10.7860/JCDR/2020/45140.

14196
Original Article

Effectiveness of Dexmedetomidine vs Ketamine

Anaesthesia Section

in Paediatric Patients Undergoing MRI

Debashish Paul1, Kaminder Bir Kaur2, Arijit Ray3, Alok Jaiswal4, Shreyas Kate5, Anshu Mala Bhengra6

ABSTRACT mcg/kg/h). Ramsay sedation score of five was considered as

Introduction: Magnetic Resonance Imaging (MRI) is not painful, onset of sedation. Midazolam 0.1 mg/kg IV was decided as
but frightening especially in children leading to movement rescue sedation. Unpaired t-test was applied for the continuous
and artefacts causing prolongation of the procedure. Though variables.
analgesia is not required, but being a noisy suite, deep sedation Results: Sixty-one patients were analysed, 31 in Group K, and
is a prerequisite for it. Dexmedetomidine (DEX) and Ketamine 30 in Group D. The onset time for sedation in Group K was
both anaesthetic drugs can achieve the sedation in the children 6.30±1.32 minutes and 12.20±SD=2.01 minutes in Group D
but never had been compared. which was significantly shorter in Group K (p=0.001). However,
Aim: To compare the effect of DEX and Ketamine in paediatric the time to Modified Aldrete Score of 10/10 was higher in
patients undergoing MRI under sedation. Group K (21.10±1.84 minutes) vs (13.73±1.89 minutes) in
Group D which is statistically significant. (Mean±SD; p=0.001).
Materials and Methods: This was a cross-sectional study
No adverse events were reported in both the groups.
carried out from August 2017 to July 2018 included 74 patients.
All patients were separated into Group K for Ketamine (loading Conclusion: Ketamine and DEX can both be used for MRI
dose of 1 mg/kg, intravenous over 10 min followed by infusion sedation in children successfully without any adverse effects.
of 10-15 mcg/kg/min) and Group D for DEX (loading dose of The onset of sedation is faster in Ketamine, but discharge and
1 mcg/kg over 10 min followed by infusion of DEX at 0.2-0.7 recovery are significantly delayed with Ketamine as compared

Keywords: Adverse effects, Deep sedation, Recovery

INTRODUCTION DEX is an imidazole derivative that is highly selective for the α2

In children, most of the diagnostic and therapeutic procedures adrenergic receptor. It is structurally related to clonidine. Activation
require sedation or analgesia or both to achieve the degree of of the alfa (α2A) adrenergic receptor by DEX produces both sedation
cooperation or immobilisation. Sedation of children for imaging and analgesia without respiratory depression but does not reliably
procedures like MRI is often challenging. Procedure like MRI which provide general anaesthesia, even at maximal doses. As a sedative
is conducted in a tunnel or duct in a noisy environment can frighten agent, DEX has been widely used in the ICU for sedation and
the child leading to movement artefact causing repetition of the postoperative analgesia. It has distribution half-life of eight minutes
sequences, prolonging the procedure and therefore mandates for (approximately) and a terminal half-life of 3.5 hours [7].
deep or conscious sedation [1,2]. Hence, sedation is essential for Ketamine is an N-Methyl-D-Aspartate (NMDA) receptor antagonist
children aged between 01 (one) to 12 years. used as an anaesthetic, sedative and analgesic. It is commonly
Sedation required in the MRI suite is different than what we practice ignored as a sedative for MRI as it has an analgesic component
in the operation theatre or in the Intensive Care Unit (ICU). Thus, a which is not necessary for MRI. Ketamine can be a suitable option
deep level of sedation is required during MRI, which is medically for procedures like MRI with an onset time of one to three minutes
induced state of unconsciousness. Patients remain unresponsive and duration of 15-30 minutes. It has been recommended as a
to the external stimuli like verbal command; essentially remain useful agent for sedation in patients with respiratory risk factors [8].
motionless during the procedure with posing less risk to the potential Both these drugs have been used in various studies in combination
complications of deep sedations [3]. for day care procedures and have provided promising results
Sedation of children for MRI is challenging due to limited [9-11]. In this study, these drugs were proposed to be compared
access to the patient when imaging is on, the nature of the MRI amongst for monitored anaesthesia care in a paediatric population
hardware which precludes easy access to head and airway undergoing non invasive procedure.
and the incompatibility of monitoring devices inside MRI suite The aim of the study was to compare the sedative effects, cardiac
leading to inadequate or failed sedation, difficulty in maintaining effects {Heart Rate (HR)} and respiratory effects {Respiratory Rate
haemodynamic and respiratory stability along with the potential (RR) and saturation} of DEX in comparison to Ketamine in children
complications like hypoventilation, apnoea, aspiration, increased undergoing MRI. Primary objective was to compare the onset time
intra cranial pressure, hypotension [4]. The success of sedation of sedation and the recovery time with either of the drugs. Also,
for MRI is measured by its safety (lack of adverse events like the secondary objective was decided to compare the need to
bradycardia) and the effectiveness [3,5]. There is always an supplement sedation during the procedure and adverse events like
argument over the suitable drug and it’s dosage for MRI sedation apnoea and desaturation associated in both the groups.
in children. Keeping in mind the goals of sedation in the paediatric
patient by American Academy of Paediatrics Committee on Drugs MATERIALS AND METHODS
for diagnostic and therapeutic procedures, various drugs have It was a cross sectional study carried out in a large teaching hospital
been used till date [6]. from August 2017 to July 2018 after obtaining clearance from the
Journal of Clinical and Diagnostic Research. 2020 Nov, Vol-14(11): UC01-UC05 1
 Debashish Paul et al., Comparison of Dexmedetomedine with Ketamine as a Sedative in Paediatric www.jcdr.net

hospital ethics committee (IEC 72| 2017 dated 23 May 2017) and titrated accordingly. Once the procedure was over, patients were
written, informed parents consent. shifted out to the recovery room following discontinuation of the
Children between the age groups six month to six years in American study drug infusion.
society anaesthesiologist category (ASA) I and II undergoing elective The time period from the discontinuation of the study drug infusion
diagnostic MRI were included in the study. to spontaneous eye opening and recorded modified Aldrate score
Children having congenital heart disease, history of (H/O) upper of 10/10 of the patient in the recovery room followed by the time
respiratory tract infection, pneumonia or episode of acute severe to discharge from the Post-Anesthesia Care Unit (PACU) were
asthma in the preceding four weeks, H/O recent use of digoxin, recorded.
alpha 2-agonist or psychotropic medications were excluded from Circulation was judged by HR instead of BP. The time intervals from
the study. Also, children with H/O allergies to the study drugs PACU discharge were determined.
predicted, anatomical difficult airway and procedures taking time of
less than 45 minutes were excluded from the study. STATISTICAL ANALYSIS
Total 74 patients were registered for the study. Two groups were For the purpose of sample size calculation, the statisitically significant
decided as Group “K” for children receiving Ketamine and Group difference in the time of onset of sedation between the two groups, a
“D” for children receiving DEX. Group allocation was done randomly previous study was referred to [13]. To detect an observed difference
based on the odd and even number of the reporting date for pre of 20% in between the groups, with a power of study 80% and a
anaesthetic check-up in the Institution. Allocation of patients to type I error of 0.05, the minimum sample size required was 26 in
either group was done by a clinician not involved in the study and each group. Total number of allocation of patients in various groups
same was kept concealed until data collection and analysis were were kept more than 30, assuming a drop out of 10% patients.
completed. All children were allowed to take clear liquids up to two Nominal data (number of subjects with apnoea, saturation and rescue
hour before sedation but food (including breast milk) intake was with
medication etc.,) were presented as number (n) and percentage (%).
held as per standard guideline for Nil Per Os. (NPO)
Continuous variables (e.g., age, weight, HR, RR etc.,) were expressed
Baseline values were recorded for all children upon arrival in the as mean (Mean) and Standard Deviation (±SD). Chi-Square test was
preparation room in the MRI suite. A 22G (gauge/size) or 24G applied for comparison of nominal data. For continuous variable,
venous cannula was inserted in the dorsum of the hand which was unpaired t-test was applied to compare between groups. Paired
prepared one hour prior with the application of the Eutectic Mixture t-test was applied to compare within group findings (Pre Vs Post).
of Lignocaine and Prilocaine (EMLA) cream. If the procedure was Additional parametric as well as nonparametric analysis of the data
delayed IV fluids was administered as per maintenance rate in the was performed as deemed essential. The p-value of <0.05 was
pre-anaesthesia care unit at the MRI suite. considered as statistically significant. The analysis of the data was
A loading dose of DEX (1 mcg/kg was given over 10 min) or ketamine performed using Microsoft excel and Statistical Package for Social
(1 mg/kg) with glycopyrrolate 10 mcg/kg) was given intravenously Sciences (SPSS) (software version 13.0).
(IV) followed by continuous infusion of DEX (0.2-0.7 mcg/kg /h) in
Group D or ketamine (10-15 mcg/kg/min) in Group K. RESULTS
Response to sound, verbal commands or tactile stimulation were A total of 61 patients were analysed in the present study, 31
evaluated and sedation level of children was measured after every in Group K and 30 children in Group D [Table/Fig-1]. Both the
10 minutes with the help of Ramsay sedation scale [12]. groups were comparable in demographical distribution and the
diagnosis for which an MRI was undertaken [Table/Fig-2]. Bilateral
The Ramsay scale assigns a score of 1-6 based on the clinical
Sensorineural Hearing Loss (SNHL) and seizure disorder were the
assessment of the level of sedation (1=anxious, agitated, restless;
most common diagnoses in both the groups [Table/Fig-3]. HR
2=awake, but cooperative, tranquil, orientated; 3=responds to
and RR in both the groups prior to start of sedation (at 00 min)
verbal commands only). Scores 4-6 apply to sleeping patients and
were comparable and not statistically significant. During sedation
are graded according to the response to loud noise or a glabellar
a decrease in both HR and RR from baseline was observed in
tap (4=brisk response; 5=sluggish response; 6=no response).
both the groups. However, this decrease in both HR and RR
The children were taken into the MRI suite when reflecting stable when compared between the two groups were not statistically
haemodynamic and respiratory parameters with a Ramsay sedation significant [Table/Fig-4].
score of five. Time starting from drug infusion till achieving Ramsay
score of five is defined as onset of sedation.
If a Ramsay score of six was not achieved after 15 minutes of study
drug infusion to the maximum dose determined in the study protocol
or inadequate sedation occurred during MRI examination, a single
rescue dose of midazolam 0.1 mg/kg IV was administered (to a
maximum of 3 mg by titration) to the patients in both the groups.
Inadequate sedation was defined as difficulty in achieving the
desired level of sedation and not able to complete the procedure
because of movement during MRI examination. HR, SpO2 and
RR were monitored continuously and recorded at 5-minutes
intervals during the study period by the observer inside the
MRI suite. All patients were maintained on spontaneous
respiration with a target SpO2>90%. Oxygenation was done
via a transparent face mask fitted adequately. If there was a
drop in SpO2 below 90% for 30 seconds, patient was taken
out of the MRI tunnel and target SpO2 was achieved by various
techniques of maintaining airway patency, titration of oxygen
flow and with the help of airway adjuncts. Once settled down,
the procedure was continued and the study drug infusion was [Table/Fig-1]: Flow diagram of patient distribution.

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www.jcdr.net Debashish Paul et al., Comparison of Dexmedetomedine with Ketamine as a Sedative in Paediatric

Group K (n=31) Group D (n=30) 00-05 Min 20.97 2.98 19.93 2.85 0.18
Significance
Parameter Mean SD Mean SD (p-value) 00 Min 22.43 2.86 21.80 3.93 0.47
Age (years) 4.64 3.16 4.88 2.83 0.76 05 Min 20.17 2.93 19.90 3.74 0.76
Weight (Kg) 17.62 6.00 19.33 5.84 0.27
10 Min 18.50 3.16 17.70 3.82 0.38
Sex (M/F) 18/13 21/9 0.5
15 Min 16.67 3.34 19.27 17.66 0.43
[Table/Fig-2]: Comparison of demographic variables.
Un-paired t test is applied. p-value is significant if <0.05 20 Min 16.00 3.83 15.37 4.27 0.55

Respiratory 25 Min 15.93 3.68 15.33 3.86 0.54

Group K Group D
Diagnosis (n=31) (n=30) Grand total rate 30 Min 15.90 3.37 15.27 3.67 0.49
Arnold chiarri malformation 1 0 1 35 Min 16.20 2.31 15.63 2.76 0.39
B/L SNHL 7 6 13 40 Min 16.40 2.14 15.93 2.30 0.42
Cerebellar ataxia 0 1 1
45 Min 16.47 2.49 16.10 3.06 0.61
Cerebral palsy 2 2 4
50 Min 16.57 2.40 16.63 2.47 0.92
Congenital hearing loss 2 2 4
55 Min 17.40 2.49 17.43 2.49 0.96
Congenital short stature 1 1 2
60 Min 18.13 2.15 18.13 2.34 1.00
Epilepsy 0 1 1
[Table/Fig-4]: Comparison of Heart Rate (HR) and Respiratory Rate (RR) between
Facial nerve palsy 1 1 2
Group K and Group D.
Floppy infant 1 1 2 *Un-paired t-test is applied. p-value is significant if <0.05

Haemangioma-thorax abdomen 0 1 1
Adequate sedation, as defined by obtaining a Ramsay Sedation
Hemiplagia 0 1 1 Score of 6, was attained in all the patients in both the study groups.
Hydrocephalus 1 0 1 There were no cases of sedation failure or requirement for rescue
Impaired hearing 1 1 2 sedation in any of the study subjects.
Meduloblastoma 1 2 3 Group K (n=31) Group D (n=30)
Significance
Meningomyocoele 1 1 2
Parameter Time points Mean SD Mean SD (p-value)
Obstructive jaundice 1 0 1
Saturation 00-05 Min 99.10 0.88 98.83 1.02 0.28
Ophthalmic neuritis 1 1 2
00 Min 98.67 1.03 98.57 1.10 0.72
Post meningitis sequlae 0 1 1
05 Min 94.33 16.23 94.00 16.21 0.94
Precocious puberty 1 0 1
10 Min 93.07 16.77 93.00 16.79 0.99
Seizure disorder 5 5 10
15 Min 95.57 1.59 95.40 1.81 0.71
Short stature, failure to thrive 2 1 3
20 Min 95.20 1.81 95.10 1.77 0.83
Spontaneous pneumthorax 1 0 1
25 Min 95.17 1.95 95.37 2.06 0.70
Undescended testis 1 1 2
30 Min 94.87 1.98 95.00 2.15 0.80
Grand total 31 30 61
35 Min 95.47 1.78 95.63 1.99 0.73
[Table/Fig-3]: Comparison of diagnosis between Group K and Group D.
Un-paired t test is applied. p-value is significant if <0.05 40 Min 95.47 1.89 95.43 1.81 0.94
45 Min 95.47 1.91 95.27 1.93 0.69
Event of adverse reaction like desaturation and apnoea was not
50 Min 94.80 1.65 95.17 1.95 0.43
observed in any patient in either group. The saturation level from
0-60 minutes in both the groups, recorded at every 05 minutes 55 Min 95.97 1.54 96.17 1.60 0.62

interval, showed no statistically significant differences [Table/Fig-5]. 60 Min 96.40 1.50 96.70 1.29 0.41
00-60 Min Significance
Group K (n=31) Group D (n=30) Group K (n=31) Group D (n=30)
Significance Events of (recorded (p-value)
Parameter Time points Mean SD Mean SD (p-value) Apnoea at every 05
min interval ) NIL NIL 1.00
minus 05
[Table/Fig-5]: Comparison of saturation and events of apnoea between Group K
Min 107.10 10.41 105.10 9.89 0.45
and Group D.
00 Min 114.63 10.74 112.86 12.10 0.55 *Un-paired t-test is applied. p-value is significant if <0.05

05 Min 106.10 8.55 104.87 9.41 0.60 All the patients completed their MRI scan without any interruption.
10 Min 103.30 7.63 101.67 9.26 0.46 However, the onset of sedation (Mean±SD) in Group K was
6.30±1.32 minutes and 12.20±SD=2.01 minutes in Group D
15 Min 101.53 8.92 99.10 8.37 0.28
(p=0.001). The time to Modified Aldrete Score of 10/10 was
20 Min 99.07 7.63 95.77 9.68 0.15 higher in Group K. (Mean±SD; 21.10±1.84 minutes in Group K vs
Heart rate 25 Min 98.03 6.54 95.30 8.98 0.18 13.73±1.89 minutes in Group D [Table/Fig-6]. This difference in
(b/min) between the groups was statistically significant (p=0.001).
30 Min 98.43 7.33 96.03 9.33 0.27

35 Min 97.70 6.78 95.87 8.79 0.37 Group K Group D

(n=31) (n=30)
40 Min 98.07 6.94 95.57 9.39 0.25 Significance
Parameter Mean ±SD Mean ±SD (p-value)
45 Min 98.00 7.09 95.30 9.67 0.22
Time To Ramsay Sedation Scale
6.30 1.32 12.20 2.01 0.001
50 Min 97.97 7.07 96.67 9.56 0.55 Score of Six (in Min )

Time To Aldrete Score 10/10 (in min) 21.10 1.84 13.73 1.89 0.001
55 Min 99.57 8.40 97.60 9.39 0.40
[Table/Fig-6]: Comparison of induction and recovery between Group K and Group D.
60 Min 99.70 7.56 98.40 9.64 0.56 Un-paired t test is applied. p-value is significant if <0.05

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 Debashish Paul et al., Comparison of Dexmedetomedine with Ketamine as a Sedative in Paediatric www.jcdr.net

DISCUSSION doses of DEX. Ketamine preserves ventilation, pharyngeal and

The study results indicated that the patients’ demographic were not laryngeal reflexes and does not create transient apnoea [23]. In this
statistically different between groups. Both groups had adequate study, RR did decrease from the baseline in both the groups however
procedural sedation (Ramsay sedation score of five) for MRI scan this was not clinically significant and required no intervention during
and 100% of the children in both the groups completed their scan the two treatments.
without any interruption, interference or any complications. It had Thus, together with the absence of any episodes of apnoea,
shown that both sedative drugs (DEX vs. ketamine) can be used bradycardia or desaturation suggests that neither DEX nor Ketamine
safely in sedation for MRI. This finding is similar to the studies done depresses respiration excessively in children when used in the
using these drugs [14-16]. In a previous study, it was noted that the dose range and manner used in this study. None of the patients in
onset of sedation time was 19 minutes for DEX in MRI sedation [15]. this study had an episode of oxygen desaturation. This finding is
In this study, the faster onset of sedation time by the study drugs consistent with other studies using DEX for sedation in paediatric
(Mean±SD; 12.20±2.01 minutes) could be explained by the fact patients [16,24,25].
that here the accepted Ramsay score of five (5) was considered for
the time to onset of sedation as opposed to the accepted Ramsay
Limitation(s)
score of six (6) in the previous study [16].
MRI scans with a longer duration (approximately >45 minutes)
In the present study, ketamine provided faster onset of sedation were chosen. This exclusion of scanning procedures of smaller
than DEX. The time to Ramsay Sedation Scale=5 was significantly duration might have lead to a selection bias. In this study, the
higher in Group D (12.20±2.01 minutes) as compared to Group K pre-procedural behaviour before administering drugs were not
(6.30 min±1.32 minutes) with a p-value=0.001 which is statistically monitored or the blood pressure before, during or after the scan.
significant. This finding is similar to previous study [14]. One thought was that paediatric patients are more dependent
In the present study while analysing the recovery and achieving on HR than on blood pressure to maintain cardiac output, hence
discharge criteria in both the groups it was observed that the time monitoring of blood pressure would have been inconsequential.
to Modified Aldrete Score 10/10 was significantly higher in Group K Some observations like no incidence of sedation failure in both
(21.10±1.84 minutes) as compare to Group D (13.73±1.89 minutes) the groups could not be explained. A larger study population can
(p-value=0.001). This finding is similar to the study by Eldeek AM testify this finding.
et al., [14]. They reported that the recovery and the discharge time
were longer in the DEX group [14]. Arian and colleagues reported a
CONCLUSION(S)
recovery time of 34 min with DEX in adults [17]. The recovery time
Ketamine shows early onset of adequate sedation but statistically
was shorter in this study. This could be explained by the fact that the
significant delayed recovery and discharge as compared to DEX,
subjects were children and that the duration of infusion was shorter
thus making DEX a better alternative. However, both DEX and
in present study.
ketamine provide adequate sedation in procedures like MRI without
Use of ketamine in paediatric age group was first published by any adverse events or requirement of rescue sedation.
Dachs and Innes in 1997 [18]. They have mentioned about similar
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PARTICULARS OF CONTRIBUTORS:
1. Reader, Department of Anaesthesiology and Critical Care, AFMC, Pune, Maharastra, India.
2. Assistant Professor, Department of Anaesthesiology and Critical Care, AFMC, Pune, Maharastra, India.
3. Assistant Professor, Department of Anaesthesiology and Critical Care, INHS, Ashwini, Mumbai, Maharastra, India.
4. Reader, Department of Anaesthesiology and Critical Care, AFMC, Pune, Maharastra, India.
5. Resident, Department of Anaesthesiology and Critical Care, AFMC, Pune, Maharastra, India.
6. Resident, Department of Anaesthesiology and Critical Care, AFMC, Pune, Maharastra, India.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: PLAGIARISM CHECKING METHODS: [Jain H et al.] Etymology: Author Origin
Alok Jaiswal, • Plagiarism X-checker: May 23, 2020
402, Shellar Heights, Wanowarie, Pune, Maharastra, India. • Manual Googling: Jul 24, 2020
E-mail: [email protected] • iThenticate Software: Oct 10, 2020 (22%)

Author declaration:
• Financial or Other Competing Interests: None Date of Submission: May 22, 2020
• Was Ethics Committee Approval obtained for this study? Yes Date of Peer Review: Jun 27, 2020
• Was informed consent obtained from the subjects involved in the study? Yes, (from guardians) Date of Acceptance: Jul 29, 2020
• For any images presented appropriate consent has been obtained from the subjects. NA Date of Publishing: Nov 01, 2020

Journal of Clinical and Diagnostic Research. 2020 Nov, Vol-14(11): UC01-UC05 5