Challenges in the anesthetic management of ambulatory patients in the MRI suites

Improving pediatric magnetic resonance imaging safety by enhanced non-technical skills and team collaboration

BACKGROUND

Safe pediatric magnetic resonance imaging (MRI) ideally relies on non-sedative techniques, as avoiding risky sedation is inherently safer. However, in practice, sedation often becomes unavoidable, particularly for younger children or those with anxiety, to ensure motion-free, high-quality imaging. This narrative review explores the current practices and proposes strategies to enhance safety in pediatric MRI examinations.

METHODS

We identified and analyzed 247 studies addressing various aspects of pediatric MRI safety, including sedation protocols, patient monitoring, and team-based management approaches.

RESULTS

Safe sedation requires careful drug selection tailored to individual needs, continuous monitoring, and robust emergency preparedness. While efforts are underway to minimize sedation, safer drug protocols and improved monitoring technologies remain essential. Assembling dedicated MRI teams trained in both technical and non-technical skills-such as situational awareness, communication, and teamwork-supports these strategies. Structured team briefings covering monitoring procedures, emergency scenarios, response protocols, and specific resuscitation roles are also critical. Developing a strong organizational culture that promotes patient safety and continuous learning from incident reports helps ensure ongoing improvements.

CONCLUSIONS

Achieving safe pediatric MRI examinations requires balancing the need for sedation with the goal of minimizing its use. Strengthening collaboration, refining sedation protocols, and implementing advanced safety monitoring systems are essential steps. Further advancements in imaging technologies are also necessary to reliably obtain high-quality scans without sedation, reducing risks and improving patient outcomes.

Pulmonary Atelectasis After Sedation With Propofol vs Propofol-Ketamine for Magnetic Resonance Imaging in Children: A Randomized Clinical Trial

Importance

Little is known about the impact of different anesthetic agents used for routine magnetic resonance imaging (MRI) sedation on pulmonary function in children.

Objective

To compare the incidence of pulmonary atelectasis after MRI sedation with propofol vs propofol-ketamine.

Design, Setting, and Participants

This double-masked randomized clinical trial screened 117 consecutive pediatric patients aged 3 to 12 years with American Society of Anesthesiologists physical status I to II undergoing elective MRI under deep sedation from November 2, 2022, to April 28, 2023, at a tertiary referral center. Four patients met the exclusion criteria, and 5 patients refused to participate. The participants and outcome assessors were masked to the group allocation.

Interventions

During the MRI, the propofol group received 0.2 mL/kg of 1% propofol and 2 mL of 0.9% saline followed by a continuous infusion of propofol (200 μg/kg/min) and 0.9% saline (0.04 mL/kg/min). The propofol-ketamine group received 0.2 mL/kg of 0.5% propofol and 1 mg/kg of ketamine followed by a continuous infusion of propofol (100 μg/kg/min) and ketamine (20 μg/kg/min).

Main Outcome and Measure

The incidence of atelectasis assessed by lung ultrasonography examination.

Results

A total of 107 children (median [IQR] age, 5 [4-6] years; 62 male [57.9%]), with 54 in the propofol group and 53 in the propofol-ketamine group, were analyzed in this study. Notably, 48 (88.9%) and 31 (58.5%) patients had atelectasis in the propofol and propofol-ketamine groups, respectively (relative risk, 0.7; 95% CI, 0.5-0.8; P < .001). The incidence of desaturation and interruption of the MRI due to airway intervention or spontaneous movement did not significantly differ between the groups. The propofol-ketamine group showed a faster emergence time than the propofol group (15 [9-23] vs 25 [22-27] minutes in the propofol-ketamine vs propofol group; median difference in time, 9.0 minutes; 95% CI, 6.0-12.0 minutes; P < .001). No patient was withdrawn from the trial due to adverse effects.

Conclusions and Relevance

In this randomized clinical trial, the propofol-ketamine combination reduced sedation-induced atelectasis while allowing for faster emergence compared with propofol alone.

Trial Registration

cris.nih.go.kr Identifier: KCT0007699.

Ultrasound-Guided Sacral Erector Spinae Plane Block: A Feasible Option for Pain Management During Magnetic Resonance Imaging: A Case Report

Inability to remain motionless owing to pain during magnetic resonance imaging (MRI) may increase the need for sedation and analgesia. Here, we present a case where ultrasound-guided sacral erector spinae plane block (ESPB) was used successfully for pain management during an MRI in a patient suffering from severe sacral pain. Sacral ESPB was performed with a total of 30 mL of 0.25% bupivacaine at the level of the intermediate sacral crest. The patient achieved sensory block in the L5-S4 dermatomes without motor block, resulting in complete pain relief. This case report highlights the feasibility of ultrasound-guided sacral ESPB as a potential pain management technique.

Perioperative management and drug selection for sedated/anesthetized patients undergoing MRI examination: A review

In recent years, magnetic resonance imaging (MRI) technology has become an indispensable imaging tool owing to significant improvements in MRI that have opened up new diagnostic perspectives. Due to the closed environment, long imaging time, and need to remain still during the examination process, the examiner may cannot cooperate with the completion of the examination of the procedure, which increases the need for deep sedation or anesthesia. Achieving this can sometimes be challenging, especially in the special nontraditional environment of MRI equipment (unfamiliar and narrow spaces, away from patients, strong magnetic fields) and in special populations requiring sedation/anesthesia during examinations, which pose certain challenges for the perioperative anesthesia management of MRI. A simple "checklist" is necessary because it allows the anesthesiologist to become familiar with the particular environment and human and material resources as quickly as possible. For the choice of sedative/anesthetic, the traditional drugs, such as midazolam and ketamine, are still used due to the ease of administration despite their low sedation success rate, prolonged recovery, and significant adverse events. Currently, dexmedetomidine, with respiratory drive preservation, propofol, with high effectiveness and rapid recovery, and sevoflurane, which is mild and nonirritating, are preferred for sedation/anesthesia in children and adults undergoing MRI. Therefore, familiarity with the perioperative management of patient sedation and general anesthesia and drug selection in the MRI environment is critical for successful surgical completion and for the safe and rapid discharge of MRI patients receiving sedation/anesthesia.

Pediatric Sedation/Anesthesia for MRI: Results From the Pediatric Sedation Research Consortium

BACKGROUND

Magnetic resonance imaging (MRI) is the most common imaging procedure requiring sedation/anesthesia in children. Understanding adverse events associated with sedation/anesthesia is important in making decisions regarding MRI vs. other imaging modalities. No large studies have evaluated the practice of pediatric sedation/anesthesia for MRI by a variety of pediatric specialists.

PURPOSE

Utilize a large pediatric sedation database to characterize the patients and adverse events associated with sedation/anesthesia for pediatric MRI.

STUDY TYPE

Retrospective analysis of prospectively collected data.

SUBJECTS

The Pediatric Sedation Research Consortium (PSRC) has 109,947 entries for sedations for MRI from November 10, 2011 through December 18, 2017.

ASSESSMENT

Patient demographics, sedative medications, interventions, and adverse events are described. Associations with adverse events were assessed. Trends in sedative medications used over time are examined.

STATISTICAL TESTS

Descriptive statistics, Chi-Squared and Fisher's Exact tests for categorical variables, logistic regression and assessment of trend using logistic regression and other method.

RESULTS

A total of 109,947 MRI-related sedations were examined. Most subjects (66.2%) were 5 years old or younger. Seizure or other neurologic issue prompted MRI in 63.7% of cases. Providers responsible for sedation/anesthesia included intensivists (49.3%), emergency medicine physicians (28.2%), hospitalists (10.2%), and anesthesiologists (9.8%). The most commonly used sedative agent was propofol (89.1%). The most common airway intervention was supplemental oxygen (71.7%), followed by head/airway repositioning (20.6%). Airway-related adverse events occurred in 8.4% of patients. Serious adverse events occurred in only 0.06% of patients, including three cases of cardiac arrest. No mortality was recorded. There was a statistically significant increase in the use of dexmedetomidine over time.

DATA CONCLUSIONS

Overall, adverse event rates were low. Sedation/anesthesia with propofol infusion and natural airway was the most common method used by this varied group of sedation providers. The use of dexmedetomidine increased over time.

EVIDENCE LEVEL

4 TECHNICAL EFFICACY: Stage 5.

State-of-the-art review of lung imaging in cystic fibrosis with recommendations for pulmonologists and radiologists from the "iMAging managEment of cySTic fibROsis" (MAESTRO) consortium

OBJECTIVE

Imaging represents an important noninvasive means to assess cystic fibrosis (CF) lung disease, which remains the main cause of morbidity and mortality in CF patients. While the development of new imaging techniques has revolutionised clinical practice, advances have posed diagnostic and monitoring challenges. The authors aim to summarise these challenges and make evidence-based recommendations regarding imaging assessment for both clinicians and radiologists.

STUDY DESIGN

A committee of 21 experts in CF from the 10 largest specialist centres in Italy was convened, including a radiologist and a pulmonologist from each centre, with the overall aim of developing clear and actionable recommendations for lung imaging in CF. An a priori threshold of at least 80% of the votes was required for acceptance of each statement of recommendation.

RESULTS

After a systematic review of the relevant literature, the committee convened to evaluate 167 articles. Following five RAND conferences, consensus statements were developed by an executive subcommittee. The entire consensus committee voted and approved 28 main statements.

CONCLUSIONS

There is a need for international guidelines regarding the appropriate timing and selection of imaging modality for patients with CF lung disease; timing and selection depends upon the clinical scenario, the patient's age, lung function and type of treatment. Despite its ubiquity, the use of the chest radiograph remains controversial. Both computed tomography and magnetic resonance imaging should be routinely used to monitor CF lung disease. Future studies should focus on imaging protocol harmonisation both for computed tomography and for magnetic resonance imaging. The introduction of artificial intelligence imaging analysis may further revolutionise clinical practice by providing fast and reliable quantitative outcomes to assess disease status. To date, there is no evidence supporting the use of lung ultrasound to monitor CF lung disease.

Dexmedetomidine sedation vs. inhaled general anesthesia for pediatric MRI: A retrospective cohort study: Dexmedetomidine sedation vs. inhaled general anesthesia for MRI

OBJECTIVES

The objective of this study was to evaluate the feasibility and the efficacy of a dexmedetomidine-based protocol followed by anesthesiologists unaccustomed to using dexmedetomidine during pediatric magnetic resonance imaging (MRI) examinations compared to conventional halogenated general anesthesia.

METHODS

This was a single-center retrospective cohort study including patients younger than 18 years who underwent sedation for MRI between August 1, 2018 and March 31, 2019. Patients who received dexmedetomidine were included in the DEX group and patients who had general anesthesia formed the GA group. Patients were matched with a ratio of 2 GA:1 DEX, based on age and type of MRI examination.

RESULTS

Overall, 78 patients were included (DEX=26; GA=52). Dexmedetomidine was significantly associated with a decrease in invasive ventilation (p<0.001) with no impact on image quality. The sedation failure rate was 42% with dexmedetomidine vs. 0% with general anesthesia (p<0.001). All cases of failure followed the intranasal administration of dexmedetomidine.

CONCLUSION

Dexmedetomidine seems to be a suitable sedation option for pediatric MRI. It provides an alternative to halogenated general anesthesia with the aim of limiting exposure to conventional anesthetic agents and invasive ventilation.

Radiographer's confidence in managing patients with claustrophobia during magnetic resonance imaging

INTRODUCTION

Claustrophobia is a major problem experienced by some patients referred for magnetic resonance imaging (MRI). This results in significant costs and delays to healthcare service provision due to appointment cancellations or patients' inability to complete MRI examinations. Radiographers may use several strategies to effectively manage patients with claustrophobia during MRI. This study aimed to determine radiographer's confidence in managing patients with claustrophobia and evaluate the perceived effectiveness of the intervention approaches employed.

METHODS

With institutional ethical approval, an online survey was conducted (15th September to 9th November 2020) among Kuwaiti MRI radiographers. The survey was designed to obtain information relating to participant demographics and the perceived confidence of radiographers in their use of interventions to manage claustrophobia during MRI procedures. Data obtained were analysed using the Statistical Package for the Social Sciences (v.26).

RESULTS

A total of 144 valid responses were obtained. Of the respondents, 82% (n = 118) were confident that they could support claustrophobic patients during MRI examinations. Almost all respondents (97.9%, n = 141) employed various claustrophobia reduction and relaxation techniques to improve patient experience and increase scan completion rates. There was a significant association between radiographer's level of education (r_s = +0.18, p = 0.028) and experience (r_s = +0.33, p < 0.001) with their confidence managing claustrophobic patients. While participating radiographers considered lectures and training the most effective methods to improve their skills in managing such patients, educating claustrophobic patients prior to their MRI scan was the most effective technique for facilitating scan completion.

CONCLUSION

Kuwaiti MRI radiographers are confident in applying different claustrophobic management techniques to improve patient compliance. Patient education, through supportive discussion, prior to their MRI examination was identified as the most effective intervention for managing claustrophobia.

IMPLICATIONS FOR PRACTICE

Patient education before MRI examination is necessary to enhance their experience and optimise scan completion rates. In addition, it is essential that MR radiographers develop their practical competence in supporting patients with claustrophobia during their scans.

Parental Experiences of the Pediatric Day Surgery Pathway and the Needs for a Digital Gaming Solution: Qualitative Study

BACKGROUND

The parents of hospitalized children are often dissatisfied with waiting times, fasting, discharge criteria, postoperative pain relief, and postoperative guidance. Parents' experiences help care providers to provide effective, family-centered care that responds to parents' needs throughout the day surgery pathway.

OBJECTIVE

The objective of our study was to describe parental experiences of the pediatric day surgery pathway and the needs for a digital gaming solution in order to facilitate the digitalization of these pathways.

METHODS

This was a descriptive qualitative study. The participants (N=31) were parents whose children were admitted to the hospital for the day surgical treatments or magnetic resonance imaging. The data were collected through an unstructured, open-ended questionnaire; an inductive content analysis was conducted to analyze the qualitative data. Reporting of the study findings adheres to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.

RESULTS

Parental experiences of the children's day surgery pathway included 3 main categories: (1) needs for parental guidance, (2) needs for support, and (3) child involved in his or her own pathway (eg, consideration of an individual child and preparation of child for treatment). The needs for a digital gaming solution were identified as 1 main category-the digital gaming solution for children and families to support care. This main category included 3 upper categories: (1) preparing children and families for the day surgery via the solution, (2) gamification in the solution, and (3) connecting people through the solution.

CONCLUSIONS

Parents need guidance and support for their children's day surgery care pathways. A digital gaming solution may be a relevant tool to support communication and to provide information on day surgeries. Families are ready for and are open to digital gaming solutions that provide support and guidance and engage children in the day surgery pathways.

Sex differential effect of dexmedetomidine on fear memory extinction and anxiety behavior in adolescent rats

Exposure to stressful stimuli, including fear and anxiety, modulates the central noradrenergic system. Dexmedetomidine is a commonly used α2-adrenoreceptor agonist. Because the effect of fear acquisition varies between sexes, the present study was designed to investigate sex-related differences in the effects of dexmedetomidine on fear memory and anxiety-like behavior. We conducted a fear test and an elevated plus maze test in 6-8-week-old male and female rats. Two doses of dexmedetomidine (20 and 40 μg/kg) were injected intraperitoneally three times at 24 h intervals after the tests: after fear expression, extinction 1, and extinction 2. The repeated administration of dexmedetomidine showed significant acceleration of fear memory extinction in female rats but not in male rats; the effect increased proportionally to concentrations of dexmedetomidine. Compared to male rats, female rats treated with both concentrations of dexmedetomidine showed significant anxiolytic behavior after 1 week. Dexmedetomidine accelerated the fear memory extinction and reduced anxiety; it was more effective in female rats than in male rats. Our results suggest that dexmedetomidine may exert protective effects against fear-related and anxiety-like behaviors in rats with fear memory after repeated administration, and the sex-specific effects of dexmedetomidine should be considered.