Akinsola Fakolujo

Sedating a child with “cold”—features of airway infection — is one of the most technically demanding pediatric anesthesia procedures in resource-poor environments. Before seating a child for an MRI, both the anesthetists and the radiology team must understand that there are two-in-one tasks ahead. Two tasks that are conflicting in one procedure. The radiology team would want a child who is very calm and still so as to produce the best quality images. They try to achieve this by placing the child in the “MRI chamber,” beyond the immediate reach or communication range of the anesthetist. But the anesthetists want a child who is healthy, potentially active and communicative throughout the procedure. Two or three drug options are often available for sedation in such environments. Keramine, midazolam or propofol-based. Ketamine and propofol are like words and opposites in the art of pediatric sedation. Ketamine sedates moderately and preserves the airway and reflexes—the child continues to breathe normally on his own, while also ensuring his airway does not get blocked by anything including his own saliva and airway secretions. One would think this is the best option if a child had to be sent into an enclosed chamber for an investigation after the sedation. But children don't usually keep still or calm while on ketamine. Ketamine has a side effect that has to do with dissociative symptoms. The child remains aware of his environment while under sedation—aware of being enclosed in a chamber—and feels he is emerging out of his body. Such a child would naturally refuse to stay calm without movements, a condition that is all-necessary if the radiologist must take good images. Many times, the whole procedure would have to be abandoned if the child continues to move in agitation. Propofol on the other hand is a magical drug of sedation. As soon as it is injected, everything changes rapidly in the child. He sleeps very deeply, as if he has missed his sleep for two weeks, and unlike ketamine, propofol also causes muscle relaxation and calmness which is an advantage for the MRI procedures. However, propofol causes loss of airway reflexes, respiratory depression or even an overt respiratory arrest. Loss of airway reflexes means even when the child is breathing normally, he may become drowned (aspiration) in his own saliva/airway secretions while sleeping (being sedated) with propofol. Either respiratory depression or the loss of airway reflexes (aspiration) in a sedated child can quickly result in low blood oxygen levels and brain injury in children who are not closely monitored. This is why any child under propofol sedation must be CONTINUALLY monitored till they are FULLY AWAKE, which is about one hour after the last injection. You must have the means to continually monitor the SPO2 (oxygen saturation in the blood), the heart rate, and the blood pressure. Otherwise, you may have a dead child in your hand in just ten minutes of no monitoring. But we know that some resource-poor centres in Africa still sedate people (kids) without proper monitoring. This is a wake-up call for parents to ask questions about how their kids' oxygen saturation, blood pressure and heart rate would be monitored before they are subjected to any form of sedation. It is always a painful thing when a child suffers an avoidable injury or death, especially when everything happens rapidly. May the Lord console this family and grant them the fortitude to bear the loss.