Adverse cardiovascular and respiratory events during sedation of pediatric patients for imaging examinations

An innovative approach for coordinating multiple sedated procedures in medically complex pediatric patients

Children and youth with special health care needs often undergo a higher frequency of sedated procedures, increasing their risk for complications, prolonged hospitalizations, as well as increased time and cost burdens. By consolidating multiple procedures requiring anesthetic sedation, the risk and cost can be reduced for both families and health care systems. In this paper, we discuss an innovative model to coordinate procedures across internal and external providers to improve quality of care for this vulnerable patient population. Although preliminary, our findings suggest this approach may be beneficial to both the patient, family, and health system.

Robust retrospective motion correction of head motion using navigator-based and markerless motion tracking techniques

PURPOSE

This study investigated the artifacts arising from different types of head motion in brain MR images and how well these artifacts can be compensated using retrospective correction based on two different motion-tracking techniques.

METHODS

MPRAGE images were acquired using a 3 T MR scanner on a cohort of nine healthy participants. Subjects moved their head to generate circular motion (4 or 6 cycles/min), stepwise motion (small and large) and "simulated realistic" motion (nodding and slow diagonal motion), based on visual instructions. One MPRAGE scan without deliberate motion was always acquired as a "no motion" reference. Three dimensional fat-navigator (FatNavs) and a Tracoline markerless device (TracInnovations) were used to obtain motion estimates and images were separately reconstructed retrospectively from the raw data based on these different motion estimates.

RESULTS

Image quality was recovered from both motion tracking techniques in our stepwise and slow diagonal motion scenarios in almost all cases, with the apparent visual image quality comparable to the no-motion case. FatNav-based motion correction was further improved in the case of stepwise motion using a skull masking procedure to exclude non-rigid motion of the neck from the co-registration step. In the case of circular motion, both methods struggled to correct for all motion artifacts.

CONCLUSION

High image quality could be recovered in cases of stepwise and slow diagonal motion using both motion estimation techniques. The circular motion scenario led to more severe image artifacts that could not be fully compensated by the retrospective motion correction techniques used.

The effect of playing music and mother's voice to children on sedation level and requirement during pediatric magnetic resonance imaging

BACKGROUND

Magnetic resonance imaging examinations frequently cause anxiety and fear in children. The objective of this study was to investigate the effects of listening to music sound, the mother's voice, and sound isolation on the depth of sedation and need for sedatives in pediatric patients who would undergo MRI.

METHODS

Ninety pediatric patients aged 3 to 12 years who were planned for imaging in the MRI unit were randomly assigned to isolation group (Group I), musical sound group (Group II), and mother's voice group (Group III). We evaluated patients' anxiety and sedation levels via the Observer's Assessment of Alertness/Sedation (OAA/S) RESULTS: Heart rate, oxygen saturation, OAA/S, and Ramsey scores during the procedure were not significantly different among the groups (p>0.05). The mean amount of propofol and total propofol consumption was statistically lower in the mother's voice group than in the isolation and music sound groups (p<0.001). Mean propofol amount and total propofol consumption were not significantly different in isolation and music sound groups (p>0.05). No difference was found between the groups regarding the time it took for the patients' Modified Aldrete score to reach 9 (p>0.05).

CONCLUSIONS

In pediatric patients, listening to the mother's voice during MRI decreased the total sedative requirement consumed without increasing the depth of sedation.

French survey of sedation practices for pediatric magnetic resonance and computed tomography imaging

BACKGROUND

Pediatric magnetic resonance imaging (MRI) and computed tompgraphy (CT) require patient immobility and therefore often require sedation or general anesthesia of patients. Consensus on these procedures is lacking in France.

OBJECTIVE

Thus, the aim of this study was to describe the current sedation practices for pediatric MRI and CT in France.

MATERIAL AND METHODS

From January 2019 to December 2019, an online questionnaire was delivered by electronic mail to a representative radiologist in 60 pediatric radiology centers registered by the French-speaking pediatric and prenatal imaging society. Questions included protocols, drugs used, monitoring and side effects.

RESULTS

Representatives of 40 of the 60 (67%) radiology centers responded to the survey. Among them, 31 performed sedation including 17 (55%) centers where radiologists performed sedation without anesthesiologists present during the procedure. The premedication drugs were hydroxyzine (n = 8, 80%) and melatonin (n = 2, 20%), Sedation drugs used for children ages 0 to 6 years old were pentobarbital (n = 9, 60%), midazolam (n = 2, 13%), chloral hydrate (n = 2, 13%), diazepam (n = 1, 6.5%) and chlorpromazine (n = 1, 6.5%). A written sedation protocol was available in 10/17 (59%) centers. In 6/17 (35%) centers, no monitoring was used during the procedures. Blood pressure monitoring and capnography were rarely used (< 10%) and post-sedation monitoring was heterogeneous. No life-threatening adverse effect was reported, but 6 centers reported at least one incident per year.

CONCLUSION

For half of the responding radiology centers, radiologists performed sedation alone in agreement with the local anesthesiology team. Sedation procedures and monitoring were heterogenous among centers. Adjustment and harmonization of the practices according to the capacity of each center may be useful.

Effectiveness of training before unsedated MRI scans in young children: a randomized control trial

BACKGROUND

Young children requiring clinical magnetic resonance imaging (MRI) may be given general anesthesia. General anesthesia has potential side effects, is costly, and introduces logistical challenges. Thus, methods that allow children to undergo awake MRI scans are desirable.

OBJECTIVES

To compare the effectiveness of mock scanner training with a child life specialist, play-based training with a child life specialist, and home book and video preparation by parents to allow non-sedated clinical MRI scanning in children aged 3-7 years.

MATERIALS AND METHODS

Children (3-7 years, n=122) undergoing clinical MRI scans at the Alberta Children's Hospital were invited to participate and randomized to one of three groups: home-based preparation materials, training with a child life specialist (no mock MRI), or training in a mock MRI with a child life specialist. Training occurred a few days prior to their MRI. Self- and parent-reported functioning (PedsQL VAS) were assessed pre/post-training (for the two training groups) and pre/post-MRI. Scan success was determined by a pediatric radiologist.

RESULTS

Overall, 91% (111/122) of children successfully completed an awake MRI. There were no significant differences between the mock scanner (89%, 32/36), child life (88%, 34/39), and at-home (96%, 45/47) groups (P=0.34). Total functioning scores were similar across groups; however, the mock scanner group had significantly lower self-reported fear (F=3.2, P=0.04), parent-reported sadness (F=3.3, P=0.04), and worry (F=3.5, P=0.03) prior to MRI. Children with unsuccessful scans were younger (4.5 vs. 5.7 years, P<0.001).

CONCLUSIONS

Most young children can tolerate awake MRI scans and do not need to be routinely anesthetized. All preparation methods tested, including at-home materials, were effective.

The beneficial effect of medical clowns on performance of EEG in young children: a randomized controlled study

Electroencephalography (EEG) is an important test in the diagnosis of epilepsy. To perform the test, many electrodes are placed on the child's scalp, a stressful situation that may contribute to uncooperative behavior. The aim of our study was to investigate the effects provided by a close collaboration with medical clowns on the performance of EEG in young children. A prospective randomized control study was conducted between July 2020 and September 2021. The study included children aged 1-5 years who were scheduled to undergo EEG testing at the Bnai Zion Medical Center. The children were randomly allocated to each group (study group with medical clowns and control group without medical clowns) according to the day of the test. The medical clowns, the EEG technician, and the children's caregivers all independently rated the entire process in designated questionnaires composed of items rated on a 5-point Likert scale. In addition, the technical quality of all EEG tests was evaluated and rated by one neurologist (G.J.) in a blinded manner. One hundred children participated in the study. Fifty children underwent the EEG accompanied by one of two medical clowns (study group), and fifty children underwent routine EEG, without medical clowns (control group). The physician-rated technical score of the EEG recording was significantly higher in the study group (p < 0.001). Among parents of the study group, 96% were highly satisfied from the presence of the medical clowns during the EEG (median 5). Both the EEG technician and the parents denoted a significantly higher cooperation rate in the study group children, of 72% and 82%, respectively, compared to the control group. The rating of child/parent's cooperation was not correlated with age, sex, or ethnicity of the child. There was no need for sedation in the study group.

CONCLUSION

Performing EEG in young children in collaboration with medical clowns can increase the quality of the EEG recording possibly due to higher cooperation rates, which in turn lead to mutual satisfaction of both parents and technicians with the procedure.

TRIAL REGISTRATION

NCT05257096.

WHAT IS KNOWN

• Performing EEG in young children may be a stressful experience. • Use of sedation during EEG may cause side effects. To avoid need for sedation various methods are used to overcome the stressful experience: Natural daytime nap, partial sleep deprivation, oral melatonine and reassurance of parents.

WHAT IS NEW

• Performing EEG in young children in collaboration with medical clowns can increase the quality of the EEG recording. • Medical clown intervention led to mutual satisfaction of both parents and technicians with the EEG test procedure.

Screening of cancer predisposition syndromes

Pediatric patients with cancer predisposition syndromes are at increased risk of developing malignancies compared with their age-matched peers, necessitating regular surveillance. Screening protocols differ among syndromes and are composed of a number of elements, imaging being one. Surveillance can be initiated in infants, children and adolescents with a tumor known or suspected of being related to a cancer predisposition syndrome or where genetic testing identifies a germline pathogenic gene variant in an asymptomatic child. Pre-symptomatic detection of malignant neoplasms offers potential to improve treatment options and survival outcomes, but the benefits and risks of screening need to be weighed, particularly with variable penetrance in many cancer predisposition syndromes. In this review we discuss the benefits and risks of surveillance imaging and the importance of integrating imaging and non-imaging screening elements. We explore the principles of surveillance imaging with particular reference to whole-body MRI, considering the strategies to minimize false-negative and manage false-positive whole-body MRI results, the value of standardized nomenclature when reporting risk stratification to better guide patient management, and the need for timely communication of results to allay anxiety. Cancer predisposition syndrome screening is a multimodality, multidisciplinary and longitudinal process, so developing formalized frameworks for surveillance imaging programs should enhance diagnostic performance while improving the patient experience.

Using intranasal dexmedetomidine with buccal midazolam for magnetic resonance imaging sedation in children: A single-arm prospective interventional study

OBJECTIVE

Although numerous intravenous sedative regimens have been documented, the ideal non-parenteral sedation regimen for magnetic resonance imaging (MRI) has not been determined. This prospective, interventional study aimed to investigate the efficacy and safety of buccal midazolam in combination with intranasal dexmedetomidine in children undergoing MRI.

METHODS

Children between 1 month and 10 years old requiring sedation for MRI examination were recruited to receive buccal midazolam 0.2 mg⋅kg^-1 with intranasal dexmedetomidine 3 μg⋅kg^-1. The primary outcome was successful sedation following the administration of the initial sedation regimens and the completion of the MRI examination.

RESULTS

Sedation with dexmedetomidine-midazolam was administered to 530 children. The successful sedation rate was 95.3% (95% confidence interval: 93.5-97.1%) with the initial sedation regimens and 97.7% (95% confidence interval: 96.5-99%) with a rescue dose of 2 μg⋅kg^-1 intranasal dexmedetomidine. The median sedation onset time was 10 min, and a significant rising trend was observed in the onset time concerning age (R = 0.2491, P < 0.001). The wake-up and discharge times significantly correlated with the duration of the procedure (R = 0.323, P < 0.001 vs. R = 0.325, P < 0.001). No oxygen deficiency nor medication intervention due to cardiovascular instability was observed in any of the patients. History of a prior failed sedation was considered a statistically significant risk factor for failed sedation in the multivariate logistic regression model [odds ratio = 4.71 (95% confidence interval: 1.24-17.9), P = 0.023].

CONCLUSION

In MRI examinations, the addition of buccal midazolam to intranasal dexmedetomidine is associated with a high success rate and a good safety profile. This non-parenteral sedation regimen can be a feasible and convenient option for short-duration MRI in children between 1 month and 10 years.

Incidence and Causes of Adverse Events in Diagnostic Radiological Studies Requiring Anesthesia in the Wake-Up Safe Registry

OBJECTIVES

General anesthesia or sedation can facilitate the completion of diagnostic radiological studies in children. We evaluated the incidence, predictors, and causes of adverse events (AEs) when general anesthesia is provided for diagnostic radiological imaging.

METHODS

Deidentified data from 24 pediatric tertiary care hospitals participating in the Wake-Up Safe registry during 2010-2015 were obtained for analysis. Children 18 years or younger receiving general anesthesia for radiological procedures were identified using Current Procedural Terminology codes, and reported AEs were analyzed if they were associated with anesthetic care at magnetic resonance imaging or computed tomography locations. Logistic regression was used to determine predictors of AE occurrence in cases with complete covariate data.

RESULTS

We identified 175,486 anesthetics for diagnostic radiological exams, compared with 83 AEs in magnetic resonance imaging or computed tomography locations (AE incidence of 0.05%). In multivariable analysis, AEs were more likely among patients with American Society of Anesthesiologists physical status IV compared with American Society of Anesthesiologists physical status I patients (adjusted odds ratio, 8.9; 95% confidence interval, 2.8-28.0; P < 0.001). Twenty-three AEs resulted in harm to the patient, whereas 32 AEs required unplanned hospital or intensive care unit admission. Anesthetic complications or issues were the most common cause of AEs (n = 52).

CONCLUSIONS

Anesthesia provided for pediatric radiological studies is very safe and with an overall low AE incidence. The contribution of anesthetic complications to reported AEs suggests opportunities for further process improvement in this setting.

Medical guidelines for Li-Fraumeni syndrome 2019, version 1.1

Li–Fraumeni syndrome (LFS) is a hereditary tumor that exhibits autosomal dominant inheritance. LFS develops in individuals with a pathogenic germline variant of the cancer-suppressor gene, TP53 (individuals with TP53 pathogenic variant). The number of individuals with TP53 pathogenic variant among the general population is said to be 1 in 500 to 20,000. Meanwhile, it is found in 1.6% (median value, range of 0–6.7%) of patients with pediatric cancer and 0.2% of adult patients with cancer. LFS is diagnosed by the presence of germline TP53 pathogenic variants. However, patients can still be diagnosed with LFS even in the absence of a TP53 pathogenic variant if the familial history of cancers fit the classic LFS diagnostic criteria. It is recommended that TP53 genetic testing be promptly performed if LFS is suspected. Chompret criteria are widely used for the TP53 genetic test. However, as there are a certain number of cases of LFS that do not fit the criteria, if LFS is suspected, TP53 genetic testing should be performed regardless of the criteria. The probability of individuals with TP53 pathogenic variant developing cancer in their lifetime (penetrance) is 75% for men and almost 100% for women. The LFS core tumors (breast cancer, osteosarcoma, soft tissue sarcoma, brain tumor, and adrenocortical cancer) constitute the majority of cases; however, various types of cancers, such as hematological malignancy, epithelial cancer, and pediatric cancers, such as neuroblastoma, can also develop. Furthermore, approximately half of the cases develop simultaneous or metachronous multiple cancers. The types of TP53 pathogenic variants and factors that modify the functions of TP53 have an impact on the clinical presentation, although there are currently no definitive findings. There is currently no cancer preventive agent for individuals with TP53 pathogenic variant. Surgical treatments, such as risk-reducing bilateral mastectomy warrant further investigation. Theoretically, exposure to radiation could induce the onset of secondary cancer; therefore, imaging and treatments that use radiation should be avoided as much as possible. As a method to follow-up LFS, routine cancer surveillance comprising whole-body MRI scan, brain MRI scan, breast MRI scan, and abdominal ultrasonography (US) should be performed immediately after the diagnosis. However, the effectiveness of this surveillance is unknown, and there are problems, such as adverse events associated with a high rate of false positives, overdiagnosis, and sedation used during imaging as well as negative psychological impact. The detection rate of cancer through cancer surveillance is extremely high. Many cases are detected at an early stage, and treatments are low intensity; thus, cancer surveillance could contribute to an improvement in QOL, or at least, a reduction in complications associated with treatment. With the widespread use of genomic medicine, the diagnosis of LFS is unavoidable, and a comprehensive medical care system for LFS is necessary. Therefore, clinical trials that verify the feasibility and effectiveness of the program, comprising LFS registry, genetic counseling, and cancer surveillance, need to be prepared.

Thoracic CTA in infants and young children: Image quality of dual-source CT (DSCT) with high-pitch spiral scan mode (turbo flash spiral mode) with or without general anesthesia with free-breathing technique

PURPOSE

To determine whether diagnostic quality thoracic computed tomography angiography (CTA) studies can be obtained without general anesthesia (GA) in infants and young children using dual-source computed tomography (DSCT) with turbo flash spiral mode (TFSM) and free-breathing technique.

MATERIALS AND METHODS

All consecutive infants and young children (≤ 6 years old) who underwent thoracic CTA studies from January 2018 to October 2020 for suspected congenital thoracic disorders were categorized into two groups: with GA (Group 1) and without GA (Group 2). All thoracic CTA studies were performed on a DSCT scanner using TFSM and free-breathing technique. Two pediatric thoracic radiologists independently evaluated motion artifact in three lung zones (upper, mid, and lower). Degree of motion artifact was graded 0-3 (0, none; 1, mild; 2, moderate; and 3, severe). Logistic models adjusted for age and gender were used to compare the degree of motion artifact between lung zones. Interobserver agreement between reviewers was evaluated with kappa statistics.

RESULTS

There were a total of 73 pediatric patients (43 males (59%) and 30 females (41%); mean age, 1.4 years; range, 0-5.9 years). Among these 73 patients, 42 patients (58%) underwent thoracic CTA studies with GA (Group 1) and the remaining 31 patients (42%) underwent thoracic CTA studies without GA (Group 2). Overall, the degree of motion artifact was higher for Group 2 (without GA). However, only a very small minority (1/31, 3%) of Group 2 (without GA) thoracic CTA studies had severe motion artifact. There was no significant difference between the two groups with respect to the presence of severe motion artifact (odds ratio [OR] = 6, p = .222). When two groups were compared with respect to the presence of motion artifact for individual lung zones, motion artifact was significantly higher in the upper lung zone for Group 2 (without GA) (OR = 20, p = .043). Interobserver agreement for motion artifact was high, the average Kappa being 0.81 for Group 1 and 0.95 for Group 2.

CONCLUSION

Although the degree of motion artifact was higher in the group without GA, only a small minority (3%) of thoracic CTA studies performed without GA had severe motion artifact, rendering the study nondiagnostic. Therefore, the results of this study support the use of thoracic CTA without GA using DSCT with TFSM and free-breathing in infants and young children. In addition, given that motion artifact was significantly higher in the upper lung zone without GA, increased stabilization in the upper chest and extremities should be considered.

Virtual Reality vs. Tablet Video as an Experiential Education Platform for Pediatric Patients Undergoing Chest Radiography: A Randomized Clinical Trial

Virtual reality (VR), which offers an immersive experience, has been implemented into the education of pediatric patients to reduce peri-procedural anxiety. This randomized clinical trial evaluated the effect of VR, compared with standard video, on reducing anxiety and distress in pediatric patients undergoing chest radiography. A total of 120 children aged 4 to 8 years with scheduled chest radiography appointments were randomized into either the tablet or the VR group. Children in the tablet group experienced chest radiography indirectly with a 3 min tablet video, whereas those in the VR group received the same content via a VR experience. The distress of children was measured using the Observational Scale of Behavioral Distress (OSBD) scale. Parental presence and procedural outcomes were also recorded. The number of less distressed children (OSBD score < 5) was significantly higher in the VR group than in the tablet group (49 [81.7%]) vs. 32 [53.3%]) (p = 0.001). The OSBD scores, the need for parental presence, the procedure time, and the number of repeated procedures were all lower in the VR group. The immersive VR experience appears to decrease the degree of anxiety in children and increase the efficiency of the procedures compared with the tablet video with the same content.

Ultrasound-Guided Core Biopsy for Tissue Diagnosis in Pediatric Oncology: 16-Year Experience With 597 Biopsies

OBJECTIVE. Percutaneous imaging-guided core needle biopsies (CNBs) for cancer diagnosis in pediatric patients are gaining interest because of their availability, lower rate of complications, and high diagnostic power compared with traditional surgical biopsies. Nevertheless, their precise role in the diagnostic algorithm of pediatric oncology is still unknown. The purpose of this study was to report our accumulated 16-year experience with CNB; discuss the availability, safety, and diagnostic accuracy of the procedure and the adequacy of ancillary testing; and compare our findings with the available literature. MATERIALS AND METHODS. Pediatric ultrasound-guided CNBs performed in our hospital between November 2003 and December 2019 were retrospectively studied. Data collection included demographics, clinical and procedural parameters, complications, and final diagnosis. RESULTS. A total of 597 biopsies were performed in 531 patients (132 performed in known oncologic patients and 465 performed to establish diagnosis). The median time between the biopsy request and the procedure was 1 day. Of 432 biopsies performed in patients with malignancies, 12 (2.8%) had false-negative results. In 165 cases of benign pathologic findings, all had true-negative results. Ancillary testing was adequate in all malignant cases. Overall sensitivity, specificity, and accuracy rates were 97.2%, 100%, and 98.0%, respectively. Five biopsies (0.8%) resulted in complications, including one major bleed and one track seeding. CONCLUSION. Our experience shows that ultrasound-guided CNB for suspected malignancy in pediatric patients has a high safety profile, availability, and accuracy rate compared with surgical biopsy. Our fast-track strategy enables early initiation of designated therapy and has the potential to become the procedure of choice.

MEG-PLAN: a clinical and technical protocol for obtaining magnetoencephalography data in minimally verbal or nonverbal children who have autism spectrum disorder

BACKGROUND

Neuroimaging research on individuals who have autism spectrum disorder (ASD) has historically been limited primarily to those with age-appropriate cognitive and language performance. Children with limited abilities are frequently excluded from such neuroscience research given anticipated barriers like tolerating the loud sounds associated with magnetic resonance imaging and remaining still during data collection. To better understand brain function across the full range of ASD there is a need to (1) include individuals with limited cognitive and language performance in neuroimaging research (non-sedated, awake) and (2) improve data quality across the performance range. The purpose of this study was to develop, implement, and test the feasibility of a clinical/behavioral and technical protocol for obtaining magnetoencephalography (MEG) data. Participants were 38 children with ASD (8-12 years) meeting the study definition of minimally verbal/nonverbal language. MEG data were obtained during a passive pure-tone auditory task.

RESULTS

Based on stakeholder feedback, the MEG Protocol for Low-language/cognitive Ability Neuroimaging (MEG-PLAN) was developed, integrating clinical/behavioral and technical components to be implemented by an interdisciplinary team (clinicians, behavior specialists, scientists, and technologists). Using MEG-PLAN, a 74% success rate was achieved for acquiring MEG data, with a 71% success rate for evaluable and analyzable data. Exploratory analyses suggested nonverbal IQ and adaptive skills were related to reaching the point of acquirable data. No differences in group characteristics were observed between those with acquirable versus evaluable/analyzable data. Examination of data quality (evaluable trial count) was acceptable. Moreover, results were reproducible, with high intraclass correlation coefficients for pure-tone auditory latency.

CONCLUSIONS

Children who have ASD who are minimally verbal/nonverbal, and often have co-occurring cognitive impairments, can be effectively and comfortably supported to complete an electrophysiological exam that yields valid and reproducible results. MEG-PLAN is a protocol that can be disseminated and implemented across research teams and adapted across technologies and neurodevelopmental disorders to collect electrophysiology and neuroimaging data in previously understudied groups of individuals.

Safety challenges related to the use of sedation and general anesthesia in pediatric patients undergoing magnetic resonance imaging examinations

The use of sedation and general anesthesia has facilitated the significant growth of MRI use among children over the last years. While sedation and general anesthesia are considered to be relatively safe, their use poses potential risks in the short term and in the long term. This manuscript reviews the reasons why MRI examinations require sedation and general anesthesia more commonly in the pediatric population, summarizes the safety profile of sedation and general anesthesia, and discusses an amalgam of strategies that can be implemented and can ultimately lead to the optimization of sedation and general anesthesia care within pediatric radiology departments.

Evidence base for point-of-care ultrasound (POCUS) for diagnosis of skull fractures in children: a systematic review and meta-analysis

BACKGROUND

Blunt head trauma is a common presentation to emergency departments (EDs). Identifying skull fractures in children is important as they are known factor of risk for traumatic brain injury (TBI). Currently, CT is the reference standard for diagnosing skull fractures and TBIs in children. Identifying skull fractures with point-of-care ultrasound (POCUS) may help risk-stratify children for TBI following blunt trauma. The purpose of this study is to evaluate the sensitivity, specificity, positive predictive value and negative predictive value of POCUS in identifying skull fractures in children.

METHODS

A systematic search was performed on 17 July 2020 in Ovid Medline, Cochrane Library, Google Scholar, Web of Science and Embase. Prospective studies reporting skull fractures diagnosed with ultrasound in children younger than 18 years due to blunt head injury were included. Studies that did not confirm the fracture with CT were excluded. The quality of studies was evaluated using the QUADAS-2 tool. Data were extracted from the eligible studies to calculate outcomes such as sensitivity and specificity; when possible overall outcomes were calculated.

RESULTS

Seven studies were included. All eligible studies included patients for whom the decision to perform a CT scan was made in advance. Overall, the included studies demonstrated low risk of bias or had minor concerns regarding risk of bias. The pooled data (n=925) demonstrated a sensitivity of 91%, specificity of 96%, positive predictive value of 88% and negative predictive value of 97%.

CONCLUSION

The included studies demonstrate minor methodological limitations. Overall, the evidence suggests that POCUS is a valid option for diagnosing skull fractures in children visiting the ED after blunt head injury.

Adverse Drug Events due to Central Nervous System Depressant Drugs in Pediatric Patients With or Without Surgery

OBJECTIVES

To identify differences in the incidence and severity of adverse drug events (ADEs) due to CNS depressant drugs among pediatric patients with and without surgery.

METHODS

The Japan Adverse Drug Events Study was a cohort study enrolling pediatric inpatients. Potential ADEs were identified by onsite review of medical charts, incident reports, and prescription queries. Two independent physicians classified ADEs and severity. We compared the incidence and characteristics of ADEs between pediatric patients with surgery (surgery group) and without surgery (non-surgery group). We evaluated severity of ADEs due to CNS depressant drugs among both groups.

RESULTS

We enrolled 944 patients, 234 in surgery group and 710 in non-surgery group. A total of 480 ADEs due to any drugs occurred in 225 patients. Among 81 ADEs due to CNS depressant drugs, 42 ADEs were in surgery group, whereas 39 were in non-surgery group. The risk of fatal or life-threatening ADEs due to CNS depressant drugs was significantly higher than other drugs (12% vs. 2%, p < 0.001). In the surgery group, anesthetics led to 2 fatal or life-threatening, 8 serious, and 30 significant ADEs, whereas in the non-surgery group anesthetics led to 2 fatal or life-threatening, 5 serious, and 4 significant ADEs. Anesthetics were higher risk in the non-surgery group (p = 0.049).

CONCLUSIONS

The risks of fatal and life-threatening ADEs were significantly higher with CNS depressant drugs than other drugs. Pediatric patients without surgery have higher risks of fatal or life-threatening ADEs due to anesthetics than those with surgery.

Drug selection for sedation and general anesthesia in children undergoing ambulatory magnetic resonance imaging

The demand for drug-induced sedation for magnetic resonance imaging (MRI) scans have substantially increased in response to increases in MRI utilization and growing interest in anxiety in children. Understanding the pharmacologic options for deep sedation and general anesthesia in an MRI environment is essential to achieve immobility for the successful completion of the procedure and ensure rapid and safe discharge of children undergoing ambulatory MRI. For painless diagnostic MRI, a single sedative/anesthetic agent without analgesia is safer than a combination of multiple sedatives. The traditional drugs, such as chloral hydrate, pentobarbital, midazolam, and ketamine, are still used due to the ease of administration despite low sedation success rate, prolonged recovery, and significant adverse events. Currently, dexmedetomidine, with respiratory drive preservation, and propofol, with high effectiveness and rapid recovery, are preferred for children undergoing ambulatory MRI. General anesthesia using propofol or sevoflurane can also provide predictable rapid time to readiness and scan times in infants or children with comorbidities. The selection of appropriate drugs as well as sufficient monitoring equipment are vital for effective and safe sedation and anesthesia for ambulatory pediatric MRI.

Impact on child and parent anxiety level of a teddy bear-scale mock magnetic resonance scanner

BACKGROUND

Pediatric magnetic resonance imaging (MRI) can be stressful. Mock MR scanners have been proven to be effective in avoiding the use of general anesthesia.

OBJECTIVES

We prospectively evaluated the impact of a teddy bear-scale model of a mock MR scanner on the anxiety experienced by parents and their children during MRI without general anesthesia .

MATERIALS AND METHODS

A 1-year prospective study before and after the installation of a mock scanner in a Pediatric Radiology Department of a university hospital. Anxiety levels were self-estimated by children ages 4 to 16 years and by the parents with a visual analogue scale (from 0, completely relaxed, to 100, extremely stressed) at three moments: in the waiting room, in the preparation room after an explanation by the MRI technologists, and at the issue of the MR acquisition images. Two groups were tested: one with a mock MR scanner, the other without. Analysis of variance (ANOVA) and Fisher exact tests were performed. Motion artifacts were studied.

RESULTS

Ninety-one children and their parents were included. The median age was 8 years (standard deviation [SD]=2). In the post mock period, the ambiance of the preparation room was considered by children as significantly more relaxing in 50% vs. 20% (P=0.004) and the anxiety level of children was significantly lower after the explanation, particularly in girls, but unchanged for their parents. The anxiety levels at the end of the examination were significantly lower for parents. The motion artifacts rate was lower (1.7% vs. 4.7%, P=0.04).

CONCLUSION

A mock scanner was an efficient tool to improve efficiency of the explanation and to decrease anxiety in children and motion artifacts in pediatric MRI.

An international multidisciplinary consensus statement on fasting before procedural sedation in adults and children

The multidisciplinary International Committee for the Advancement of Procedural Sedation presents the first fasting and aspiration prevention recommendations specific to procedural sedation, based on an extensive review of the literature. These were developed using Delphi methodology and assessment of the robustness of the available evidence. The literature evidence is clear that fasting, as currently practiced, often substantially exceeds recommended time thresholds and has known adverse consequences, for example, irritability, dehydration and hypoglycaemia. Fasting does not guarantee an empty stomach, and there is no observed association between aspiration and compliance with common fasting guidelines. The probability of clinically important aspiration during procedural sedation is negligible. In the post-1984 literature there are no published reports of aspiration-associated mortality in children, no reports of death in healthy adults (ASA physical status 1 or 2) and just nine reported deaths in adults of ASA physical status 3 or above. Current concerns about aspiration are out of proportion to the actual risk. Given the lower observed frequency of aspiration and mortality than during general anaesthesia, and the theoretical basis for assuming a lesser risk, fasting strategies in procedural sedation can reasonably be less restrictive. We present a consensus-derived algorithm in which each patient is first risk-stratified during their pre-sedation assessment, using evidence-based factors relating to patient characteristics, comorbidities, the nature of the procedure and the nature of the anticipated sedation technique. Graded fasting precautions for liquids and solids are then recommended for elective procedures based upon this categorisation of negligible, mild or moderate aspiration risk. This consensus statement can serve as a resource to practitioners and policymakers who perform and oversee procedural sedation in patients of all ages, worldwide.

Results from the Adverse Event Sedation Reporting Tool: A Global Anthology of 7952 Records Derived from >160,000 Procedural Sedation Encounters

Background: The incidence of sedation-related adverse events, inclusive of both adults and children, administered by multiple specialty providers from different countries and venues, using standardized definitions, has never been reported on an international level. We are reporting the outcome data of the adverse event sedation reporting tool as an important step toward a more complete risk assessment of sedation-related morbidity, mortality, and etiology. The analysis of the AE sedation reporting data include descriptive measures to evaluate the characteristics of the provider, the patient, sedations performed, adverse events, interventions, and outcomes. The primary outcome was the rate and nature of adverse events. Between 12/14/2010 and 12/11/2018 there were 7952 sedations, from an estimated total of 164,114 sedations administered, of which 622 were reported as adverse events. The mean age of the entire patient population is 33.0 years (0.02–98.7). The providers represented 39 countries across six continents. Oxygen desaturation (75%–90%) for <60 s is the most prevalent adverse event with a rate of 7.8 per 10,000, followed by airway obstruction at a rate of 5.42 per 10,000. Apnea occurred at a rate of 4.75 per 10,000. Significant predictors of adverse events are ≥ ASA score III (p = 0.0003), procedure time (6:00 pm–12:00 am: p < 0.0001, 12:00–6:00 am: p = 0.0003), and non-hospital location (p < 0.0001). The AE sedation reporting tool has demonstrated that the majority of adverse events in children and adults who receive procedural sedation from multi-specialists internationally required minor interventions and had outcomes of minor risk.

[Practical aspects of sedation in dentistry]

In modern dental practice, the use of sedation to eliminate the fear and anxiety of the patient has become frequent. Unfortunately, according to the legislation, the concept of sedation is inseparable from anesthesia and it can only be performed by an anesthesiologist in a group or Department of Anesthesiology and Resuscitation. The article is devoted to a detailed comprehensive review of sedation in dental and surgical interventions in the maxillofacial area. It details the physiological and pathophysiological data of stress and psycho-emotional discomfort. The article indicates drugs for sedation, methods of their administration, features of application, possible complications. Such methods of parenteral sedation as intranasal, inhalation, intravenous are described in detail. Specific problems of sedation, for example, psychomotor agitation in the application of propofol or cough in deep sedation are indicated. It describes the modern data on intraoperative monitoring as an important component of patient safety during sedation. In addition to the Harvard standard the use of capnography and monitoring the depth of sedation by using bispectral index (BIS) is recommended.

Prediction of cervical spine injury in young pediatric patients: an optimal trees artificial intelligence approach

BACKGROUND

Cervical spine injuries (CSI) are a major concern in young pediatric trauma patients. The consequences of missed injuries and difficulties in injury clearance for non-verbal patients have led to a tendency to image young children. Imaging, particularly computed tomography (CT) scans, presents risks including radiation-induced carcinogenesis. In this study we leverage machine learning methods to develop highly accurate clinical decision rules to predict pediatric CSI.

METHODS

The PEDSPINE I registry was used to investigate CSI in blunt trauma patients under the age of three. Predictive models were built using Optimal Classification Trees, a novel machine learning approach offering high accuracy and interpretability, as well as other widely used machine learning methods.

RESULTS

The final Optimal Classification Trees model predicts injury based on overall Glasgow Coma Score (GCS) and patient age. This model has a sensitivity of 93.3% and specificity of 82.3% on the full dataset. It has comparable or superior performance to other machine learning methods as well as existing clinical decision rules.

CONCLUSIONS

This study developed a decision rule that achieves high injury identification while reducing unnecessary imaging. It demonstrates the value of machine learning in improving clinical decision protocols for pediatric trauma.

TYPE OF STUDY

Retrospective Prognosis Study.

LEVEL OF EVIDENCE

II.

Effect of Immersive Virtual Reality Education Before Chest Radiography on Anxiety and Distress Among Pediatric Patients: A Randomized Clinical Trial

IMPORTANCE

Pediatric patients often encounter anxiety and distress in hospital settings, and virtual reality education, providing a vivid, immersive, and realistic experience, has been introduced to mitigate these anxiety responses.

OBJECTIVE

To evaluate whether virtual reality education for pediatric patients before chest radiography could reduce anxiety and distress in children and improve the radiographic process.

DESIGN, SETTING, AND PARTICIPANTS

This prospective randomized clinical trial was conducted in a tertiary academic hospital in Seongnam, Republic of Korea. Participants (n = 112) were children aged 4 to 8 years who underwent chest radiography between July 20, 2018, and September 11, 2018. Analysis was performed from October 2, 2018, to April 23, 2019.

INTERVENTIONS

Children were randomized to simple verbal instruction (control group) or 3-minute virtual reality education explaining the process of chest radiography in detail and leading to appropriate cooperation (virtual reality group).

MAIN OUTCOMES AND MEASURES

The primary outcome was anxiety and distress among pediatric patients based on behavioral observations using the amended version of the Observational Scale of Behavioral Distress scale for radiology procedures (total score of 30, with a score <5 indicating less distressed and a score ≥5 indicating more distressed). Secondary outcomes were the need of parental presence, parental satisfaction score, procedure time, number of repeated images, and process difficulty score.

RESULTS

Of 99 children included in the final analysis, 50 (50.5%) were allocated to the control group (mean [SD] age, 5.6 [1.2] years; 26 boys [52.0%]) and 49 (49.5%) to the virtual reality group (mean [SD] age, 5.8 [1.3] years; 32 boys [65.3%]). The mean (SD) score for anxiety and distress (2.0 [3.7] vs 5.0 [6.1]; mean difference, 3.0 [95% CI, 1.0-5.0]; P = .004), need for parental presence (8 cases with parents present [16.3%] vs 18 cases with parents present [36.0%]), and mean (SD) procedure time (55.1 [21.6] seconds vs 75.0 [42.0] seconds) were lower in the virtual reality group than in the control group. The mean (SD) score for parental satisfaction (9.4 [1.4] vs 8.6 [2.0]) was higher in the virtual reality group than in the control group.

CONCLUSIONS AND RELEVANCE

Virtual reality education before chest radiography improved the radiography experience among pediatric patients by reducing anxiety, distress, and procedure time while increasing parents' satisfaction.

TRIAL REGISTRATION

UMIN Clinical Trials Registry: UMIN000030663.

Contrast-enhanced ultrasound of liver lesions in children

Initial pediatric imaging of the liver heavily relies on ultrasonography (US) because it is free of ionizing radiation, easily portable and readily available. Although conventional US (gray-scale and color Doppler) is often an excellent screening tool, its relative low specificity compared to CT/MRI limits liver lesion characterization. The United States Food and Drug Administration's recent approval of an intravenous US contrast agent for pediatric liver lesion characterization (sulfur hexafluoride lipid-type A microspheres) and its excellent safety profile have spurred increased interest in contrast-enhanced US for definitive diagnosis of pediatric liver lesions. This review focuses on the safety of contrast-enhanced US, role of contrast-enhanced US in the evaluation of focal liver lesions, basic contrast-enhanced US technique for liver imaging, and interpretation principles. The authors review common focal liver lesions, with special attention to the role of contrast-enhanced US in the pediatric oncology population.

Initial clinical experience with high-pitch dual-source CT as a rapid technique for thoraco-abdominal evaluation in awake infants and young children

AIM

To evaluate dual-source high-pitch computed tomography (HPCT) imaging of the chest and abdomen as a rapid scanning technique to obtain diagnostic-quality imaging evaluation of infants and young children without sedation.

MATERIALS AND METHODS

Fifty-three paediatric patients (age 24.1±2 months) who underwent chest or abdomen HPCT (≥1.5) and standard pitch CT (SPCT, <1.5) on a dual-source 128-row multidetector CT system were included in the study. Image quality assessment was performed by two paediatric radiologists for diagnostic confidence, image artefacts, and image noise. Objective image noise was measured.

RESULTS

Most of the CT examinations were performed in children who were >1 year old (n=15 and n=20) followed by ≤1 year old (n=8 and n=10) in SPCT and HPCT, respectively. The mean radiation dose (SSDE) from HPCT was 1.96±1 mGy compared to 2.2±1 mGy for SPCT (p=0.3). No major artefacts were reported and overall image quality of all HPCT examinations was acceptable diagnostically. In addition, objective image noise values were not significantly different between HPCT compared with SPCT (11±3 versus 11±5, p=0.7).

CONCLUSION

Ultra-fast, HPCT can be performed without the need for sedation as a potential alternative to anaesthetised magnetic resonance imaging in infants and young children.

Transforming the Imaging Experience While Decreasing Sedation Rates

OBJECTIVE

To evaluate the effect of the MRI-am-a-Hero program on sedation utilization for outpatient pediatric MRI studies.

METHODS

The MRI-am-a-Hero program, which utilizes multimedia educational material and popular comic book characters to educate and support pediatric patients during MRI scan, was implemented at the radiology facility of a single tertiary care, academic medical center. The effect of the MRI-am-a-Hero program on sedation utilization for pediatric MRI was retrospectively evaluated using multivariate regressions yielding odds ratio of sedation before and after program implementation. The institutional review board approved the study with HIPAA compliancy. Effectiveness of the program was evaluated while controlling for age, neurological MRI examination, number of examinations in the case, and use of intravenous contrast. Further analysis was performed in subgroups categorized by age, neurological MRI versus nonneurological MRI, and the use of contrast.

RESULTS

The percent of MRI cases with sedation decreased from 22.9% to 17.3% after the MRI-am-a-Hero program was implemented. When controlling for other variables, including patient age, neurological MRI, number of examinations in a case, and use of intravenous contrast, the odds of a study being performed with sedation after program implementation are 40% less than the odds before program implementation (odds ratio [OR] 0.60, P < .001). The effect of the program was greatest for patients aged 4 to 7 (OR 0.56, P < .001), followed by patients aged 8 to 11 (OR 0.64, P = .019). It was not statistically significant for patients aged 12 to 15 (OR 0.97, P = .919).

CONCLUSION

MRI-am-a-Hero is a generalizable and inexpensive program for reducing sedation utilization for outpatient pediatric MRI studies, especially for patients aged 4 to 11.

Falling through the worm hole: an exploration of the imaging workup of the vermiform appendix in the pediatric population

Despite the thousands of articles discussing appendicitis in the literature, the dilemma of how to best diagnosis and manage pediatric appendicitis remains unsettled. Over the past decade, evidence has been mounting about the use of antibiotics as the sole therapy in uncomplicated appendicitis in the adult population. This debate has even recently bled over into the lay press. While this change in practice pattern is still in its infancy for the pediatric population, radiologists should be aware of this change in therapy and how it can impact the imaging work-up and relevant findings. This article concisely summarizes the imaging findings and various imaging pathways to arrive at the diagnose of appendicitis with an emphasis of how to best be of use to our surgical colleagues in this evolving paradigm. It also highlights venues for further research, namely increasing accuracy of differentiating complicated from uncomplicated appendicitis.

Clinical predictors of adverse cardiovascular events for acute pediatric drug exposures

Context: Risk factors for adverse cardiovascular events (ACVE) from drug exposures have been well-characterized in adults but not studied in children. The objective of the present study is to describe the incidence, characteristics, and risk factors for in-hospital ACVEs among pediatric emergency department (ED) patients with acute drug exposures.Methods: This is a prospective cohort design evaluating patients in the Toxicology Investigators Consortium (ToxIC) Registry. Pediatric patients (age <18 years) who were evaluated at the bedside by a medical toxicologist for a suspected acute drug exposure were included. The primary outcome was in-hospital ACVE (myocardial injury, shock, ventricular dysrhythmia, or cardiac arrest). The secondary outcome was in-hospital death. Multiple logistic regression analyses were performed to examine novel clinical risk factors and extrapolate adult risk factors (bicarbonate <20 mEq/L; QTc ≥500 ms), for the primary/secondary outcomes.Results: Among the 13,097 patients (58.5% female), there were 278 in-hospital ACVEs (2.1%) and 39 in-hospital deaths (0.3%). Age and drug class of exposure (specifically opioids and cardiovascular drugs) were independently associated with ACVE. Compared with adolescents, children under 2 years old (OR: 0.41, 95% CI: 0.21-0.80), ages 2-6 (OR: 0.37, 95% CI: 0.21-0.80), and ages 7-12 (OR: 0.51, 95% CI: 0.27-0.95) were significantly less likely to experience an ACVE. Serum bicarbonate concentration <20 mEq/L (OR: 2.31, 95% CI: 1.48-3.60) and QTc ≥ 500 ms (OR: 2.83, 95% CI: 1.67-4.79) were independently associated with ACVE.Conclusion: Previously derived clinical predictors of ACVE from an adult drug overdose population were successfully extrapolated to this pediatric population. Novel associations with ACVE and death included adolescent age and opioid drug exposures. In the midst of the opioid crisis, these findings urgently warrant further investigation to combat adolescent opioid overdose morbidity and mortality.

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures

The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of appropriately trained staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.

The pearls of pediatric sedation: polish the old and embrace the new

Over the past decade, as the complexity and breadth of pediatric procedures increases, the actual choices of approved sedatives have remained relatively stagnant. Since the introduction of midazolam, there has not been a sedative approved for pediatric labelling until December 2018. This December, the European approval of ADV6209 (Ozalin) for pediatric usage marked the newest addition to the pediatric sedative armamentarium in over a decade. This review is timely and significant because it will provide a balanced evaluation of the most common sedatives in use today, the most recent sedative to be approved and, most importantly, a critical look at the literature supporting the latest approaches to the most commonly performed procedures.

Future of paediatric sedation: towards a unified goal of improving practice

This review offers a perspective on the future of paediatric sedation. This future will require continued evaluation of adverse events, their risk factors, and predictors. As the introduction of new sedatives with paediatric applications will remain limited, the potential role of mainstay sedatives administered by new routes, for new indications, and with new delivery techniques, should be considered. The role of non-pharmacological strategies for anxiolysis, along with the application of non-mainstay physiologic monitoring, may aid in the improvement of targeted sedation delivery. Understanding the mechanism and location of action of the different sedatives will remain an important focus. Important developments in paediatric sedation will require that large scale studies with global data contribution be conducted in order to support changes in sedation practice, improve the patient experience, and make sedation safer.

A non-randomized controlled study of total intravenous anesthesia regimens for magnetic resonance imaging studies in children

Background and Aims:

We studied the efficacy and safety of different total intravenous anesthesia used for pediatric magnetic resonance imaging (MRI).

Material and Methods:

Children of 1–7 years age (n = 88), undergoing MRI received a loading dose of dexmedetomidine 1 μg/kg over 10 min, ketamine 1 mg/kg, and propofol 1 mg/kg in sequence. University of Michigan Sedation Scale (UMSS) of 3 was considered an acceptable level for starting the scan. Rescue ketamine 0.25–0.5 mg/kg was given if UMSS remained <3. After the loading dose of drugs, some children attained UMSS = 4 or progressive decline in heart rate, therefore, did not receive any infusion. The rest received either dexmedetomidine (0.7 μg/kg/h) (n = 35) or propofol (3 mg/kg/h) (n = 38) infusion for maintenance. Ketamine 0.25 mg/kg was used as rescue. Sedation failure was considered if either there was inability to complete the scan at the pre-set infusion rate, or there was need for >3 ketamine boluses or serious adverse events occurred. Statistical Package for Social Sciences 20 was used for analysis.

Results:

Initiation of scan was 100% successful with median induction time of 10 min. Maintenance of sedation was successful in 100% with dexmedetomidine and 97.4% with propofol infusion. Recovery time (25 min v/s 30 min), discharge time (35 min v/s 60 min), and total care duration (80 min v/s 105 min) were significantly less with propofol as compared to dexmedetomidine (P = 0.002, 0.000, and 0.000, respectively). There were no significant adverse events observed.

Conclusion:

Dexmedetomidine 1μg/kg, ketamine 1 mg/kg, and propofol 1 mg/kg provide good conditions for initiation of MRI. Although dexmedetomidine at 0.7μg/kg/h and propofol at 3 mg/kg/h are safe and effective for maintenance, propofol provides faster recovery.

Pulmonary aspiration during procedural sedation: a comprehensive systematic review

Background

Although pulmonary aspiration complicating operative general anaesthesia has been extensively studied, little is known regarding aspiration during procedural sedation.

Methods

We performed a comprehensive, systematic review to identify and catalogue published instances of aspiration involving procedural sedation in patients of all ages. We sought to report descriptively the circumstances, nature, and outcomes of these events.

Results

Of 1249 records identified by our search, we found 35 articles describing one or more occurrences of pulmonary aspiration during procedural sedation. Of the 292 occurrences during gastrointestinal endoscopy, there were eight deaths. Of the 34 unique occurrences for procedures other than endoscopy, there was a single death in a moribund patient, full recovery in 31, and unknown recovery status in two. We found no occurrences of aspiration in non-fasted patients receiving procedures other than endoscopy.

Conclusions

This first systematic review of pulmonary aspiration during procedural sedation identified few occurrences outside of gastrointestinal endoscopy, with full recovery typical. Although diligent caution remains warranted, our data indicate that aspiration during procedural sedation appears rare, idiosyncratic, and typically benign.

Children centered care: Minimizing the need for anesthesia with a multi-faceted concept for MRI in children aged 4-6

PURPOSE

To evaluate the need for general anesthesia (GA) in MRI in children aged 4-6 years, using a multi-faceted concept, Children Centered Care (CCC), compared to a standard setup.

MATERIALS AND METHODS

In this prospective study of 81 children, we developed and tested a multi-faceted concept, CCC, for MRI in children aged 4-6 without GA, comparing it to a standard setup. The CCC included: 1) an interactive app, 2) a trained pediatric team, 3) a children's lounge with a toy-scanner, and 4) a child-friendly multimedia environment in the MRI room. Patients were included from February-September 2016 and 2017. The use of GA was evaluated, image quality was assessed and a cost-benefit analysis was done.

RESULTS

We included 40 children in the control group and 41 in the CCC group. Mean age was 5.8 years and 48 (59%) were males. Neuro and orthopedic imaging accounted for 58 (72%) and 22 (27%), respectively. With the CCC setup 39/41 (95%) completed a diagnostic MRI without GA compared to 17/40 (43%) in the control group (p < 0.001). Image quality was not different between the groups (p = 0.37). The setup proved cost-effective with a payback time of two years in a Danish setting with 250 eligible patients per year.

CONCLUSION

With the multi-faceted concept CCC, the use of GA for MRI in children aged 4-6 was markedly reduced to 5%, image quality was maintained and the setup was cost-effective.

Pediatric anesthesia and neurotoxicity: what the radiologist needs to know

The use of cross-sectional imaging in the pediatric population continues to rise, particularly the use of MRI. Limiting motion artifact requires cooperative subjects who do not move during imaging, so there has been an increase in the need for pediatric sedation or anesthesia. Over the last decade, concern has increased that exposure to anesthesia might be associated with long-term cognitive deficits. In this review we report current understanding of the effects of anesthesia on the pediatric population, with special focus on long-term developmental and cognitive outcomes, and suggest how radiologists can use new technologies or imaging strategies to mitigate or minimize these potential risks.

Identification of quality improvement areas in pediatric MRI from analysis of patient safety reports

BACKGROUND

Analysis of safety reports has been utilized to guide practice improvement efforts in adult magnetic resonance imaging (MRI). Data specific to pediatric MRI could help target areas of improvement in this population.

OBJECTIVE

To estimate the incidence of safety reports in pediatric MRI and to determine associated risk factors.

MATERIALS AND METHODS

In a retrospective HIPAA-compliant, institutional review board-approved study, a single-institution Radiology Information System was queried to identify MRI studies performed in pediatric patients (0-18 years old) from 1/1/2010 to 12/31/2015. The safety report database was queried for events matching the same demographic and dates. Data on patient age, gender, location (inpatient, outpatient, emergency room [ER]), and the use of sedation/general anesthesia were recorded. Safety reports were grouped into categories based on the cause and their severity. Descriptive statistics were used to summarize continuous variables. Chi-square analyses were performed for univariate determination of statistical significance of variables associated with safety report rates. A multivariate logistic regression was used to control for possible confounding effects.

RESULTS

A total of 16,749 pediatric MRI studies and 88 safety reports were analyzed, yielding a rate of 0.52%. There were significant differences in the rate of safety reports between patients younger than 6 years (0.89%) and those older (0.41%) (P<0.01), sedated (0.8%) and awake children (0.45%) (P<0.01), and inpatients (1.1%) and outpatients (0.4%) (P<0.01). The use of sedation/general anesthesia is an independent risk factor for a safety report (P=0.02). The most common causes for safety reports were service coordination (34%), drug reactions (19%), and diagnostic test and ordering errors (11%).

CONCLUSION

The overall rate of safety reports in pediatric MRI is 0.52%. Interventions should focus on vulnerable populations, such as younger patients, those requiring sedation, and those in need of acute medical attention.

A Simulation Study of Propofol Effect-Site Concentration for Appropriate Sedation in Pediatric Patients Undergoing Brain MRI: Pharmacodynamic Analysis

PURPOSE

We aimed to establish the propofol effect-site concentration (Ce) for appropriate sedation by pharmacodynamic analysis and to determine the propofol Ce during occurrence of sedation-related side effects in pediatric patients undergoing brain magnetic resonance imaging (MRI).

MATERIALS AND METHODS

In 50 pediatric patients scheduled for brain MRI, sedation was induced with 2.0 mg/kg propofol; additional propofol doses were 0.5-1 mg/kg. Propofol Ce was simulated by inputting the propofol administration profiles of patients into a pediatric compartmental model (Choi model). The relationship between propofol Ce and probabilities of sedation and recovery were analyzed using a sigmoidal Emax model. The simulated propofol Ce for sedation-related side effects was investigated. Population model parameters were estimated using the Nonlinear Mixed-Effects Modelling software.

RESULTS

The mean values of propofol Ce₅₀ for sedation during the preparation, scanning, and recovery phases were 1.23, 0.43, and 0.39 μg/mL. The simulated propofol Ce values during oxygen desaturation (SpO₂ <90%) (3 patients; 6%), hypotension (16 patients; 32%), and bradycardia (12 patients; 24%) were 3.01±0.04, 2.05±0.63, and 2.41±0.89 μg/mL, respectively.

CONCLUSION

The required propofol Ce₅₀ for applying monitors during the preparation phase before the start of MRI was higher than the propofol Ce₅₀ required during the scanning phase. During low-intensity stimulation phases, such as scanning, propofol bolus dose should be strictly titrated not to exceed the propofol Ce that can lead to oxygen desaturation because of the relatively low propofol Ce (Ce₉₅, 1.43 μg/mL) required for sedation in most patients.

Performance characteristics of magnetic resonance imaging without contrast agents or sedation in pediatric appendicitis

BACKGROUND

Magnetic resonance imaging (MRI) has emerged as a promising modality for evaluating pediatric appendicitis. However optimal imaging protocols, including roles of contrast agents and sedation, have not been established and diagnostic criteria have not been fully evaluated.

OBJECTIVE

To investigate performance characteristics of rapid MRI without contrast agents or sedation in the diagnosis of pediatric appendicitis.

MATERIALS AND METHODS

We included patients ages 4-18 years with suspicion of appendicitis who underwent rapid MRI between October 2013 and March 2015 without contrast agent or sedation. After two-radiologist review, we determined performance characteristics of individual diagnostic criteria and aggregate diagnostic criteria by comparing MRI results to clinical outcomes. We used receiver operating characteristic (ROC) curves to determine cut-points for appendiceal diameter and wall thickness for optimization of predictive power, and we calculated area under the curve (AUC) as a measure of test accuracy.

RESULTS

Ninety-eight MRI examinations were performed in 97 subjects. Overall, MRI had a 94% sensitivity, 95% specificity, 91% positive predictive value and 97% negative predictive value. Optimal cut-points for appendiceal diameter and wall thickness were ≥7 mm and ≥2 mm, respectively. Independently, those cut-points produced sensitivities of 91% and 84% and specificities of 84% and 43%. Presence of intraluminal fluid (30/33) or localized periappendiceal fluid (32/33) showed a significant association with acute appendicitis (P<0.01), with sensitivities of 91% and 97% and specificities of 60% and 50%. For examinations in which the appendix was not identified by one or both reviewers (23/98), the clinical outcome was negative.

CONCLUSION

Rapid MRI without contrast agents or sedation is accurate for diagnosis of pediatric appendicitis when multiple diagnostic criteria are considered in aggregate. Individual diagnostic criteria including optimized cut-points of ≥7 mm for diameter and ≥2 mm for wall thickness demonstrate high sensitivities but relatively low specificities. Nonvisualization of the appendix favors a negative diagnosis.

Pilot Study of Renal Diffusion Tensor Imaging as a Correlate to Histopathology in Pediatric Renal Allografts

OBJECTIVE

Fractional anisotropy (FA) is a measure of molecular motion obtained from diffusion tensor imaging (DTI). The objective of this study was to assess the use of FA as a noninvasive correlate of renal allograft histopathology.

SUBJECTS AND METHODS

Sixteen pediatric renal allograft recipients were imaged using DTI in a prospective study, between October 2014 and January 2016, before a same-day renal allograft biopsy. The Kendall tau correlation coefficient was used to assess the relationship between cortical and medullary FA values and several clinically important Banff renal allograft histopathology scores. The Mann-Whitney U test was also used to compare cortical and medullary FA values in the region of biopsy in patients whose biopsy results did and in those whose biopsy results did not change clinical management.

RESULTS

Medullary FA values had direct inverse correlation with several histopathology scores: tubulitis (designated "t" score in Banff pathologic classification, p < 0.04), interstitial inflammation (i score, p < 0.005), tubular atrophy (ct score, p < 0.002), and interstitial fibrosis (ci score, p < 0.007). Cortical FA values inversely correlated with peritubular capillaritis (ptc score, p < 0.02). Neither medullary nor cortical FA values correlated with glomerulitis (g score). At a b value of 800 s/mm², medullary FA values of pediatric renal allograft recipients whose renal biopsies prompted a change in clinical management (mean ± SD at a b value of 800 s/mm² = 0.262 ± 0.07; n = 9) were statistically different compared with the group whose biopsy results did not change clinical management (mean ± SD at a b value of 800 s/mm² = 0.333 ± 0.06; n = 7) (p < 0.006).

CONCLUSION

FA is a noninvasive correlate of several important renal allograft histopathology scores and a potential noninvasive method of assessing renal allograft health in pediatric allograft recipients.

Free-breathing high-pitch 80kVp dual-source computed tomography of the pediatric chest: Image quality, presence of motion artifacts and radiation dose

OBJECTIVES

To investigate image quality, presence of motion artifacts and effects on radiation dose of 80kVp high-pitch dual-source CT (DSCT) in combination with an advanced modeled iterative reconstruction algorithm (ADMIRE) of the pediatric chest compared to single-source CT (SSCT).

MATERIALS AND METHODS

The study was approved by the institutional review board. Eighty-seven consecutive pediatric patients (mean age 9.1±4.9years) received either free-breathing high-pitch (pitch 3.2) chest 192-slice DSCT (group 1, n=31) or standard-pitch (pitch 1.2) 128-slice SSCT (group 2, n=56) with breathing-instructions by random assignment. Tube settings were similar in both groups with 80 kVp and 74 ref. mAs. Images were reconstructed using FBP for both groups. Additionally, ADMIRE was used in group 1. Effective thorax diameter, image noise, and signal-to-noise ratio (SNR) of the pectoralis major muscle and the thoracic aorta were calculated. Motion artifacts were measured as doubling boarders of the diaphragm and the heart. Images were rated by two blinded readers for overall image quality and presence of motion artifacts on 5-point-scales. Size specific dose estimates (SSDE, mGy) and effective dose (ED, mSv) were calculated.

RESULTS

Age and effective thorax diameter showed no statistically significant differences in both groups. Image noise and SNR were comparable (p>0.64) for SSCT and DSCT with ADMIRE, while DSCT with FBP showed inferior results (p<0.01). Motion artifacts were reduced significantly (p=0.001) with DSCT. DSCT with ADMIRE showed the highest overall IQ (p<0.0001). Radiation dose was lower for DSCT compared to SSCT (median SSDE: 0.82mGy vs. 0.92mGy, p<0.02; median ED: 0.4 mSv vs. 0.48mSv, p=0.02).

CONCLUSIONS

High-pitch 80kVp chest DSCT in combination with ADMIRE reduces motion artifacts and increases image quality while lowering radiation exposure in free-breathing pediatric patients without sedation.

Incidence and risk factors for adverse events during anesthesiologist-led sedation or anesthesia for diagnostic imaging in children: a prospective, observational cohort study

Background

Pediatric sedation for diagnostic radiological procedures remains the mainstay for adequate imaging quality.

Objectives

To clarify the risk of adverse events during anesthesiologist-led sedation or anesthesia for diagnostic radiological procedures in children in order to improve quality of care.

Methods

We enrolled children aged <15 years given sedation or anesthesia by an anesthesiologist and scheduled for computed tomography, magnetic resonance imaging, or nuclear medicine imaging November 2010-September 2014. We recorded adverse events occurring in the first 24 h.

Results

Of 1,042 patients enrolled, adverse events were recorded in 254 (24.4%, 95% confidence interval [CI] 21.9 to 27.1). Adverse respiratory events occurred in 31 (3.0%), cardiovascular events in 7 (0.7%), sedation was prolonged in 165 (15.8%), there was one case of contrast allergy (0.01%), and there were 50 other minor complications (4.9%). Of the respiratory complications, there were 14 of airway obstruction (1.3%), 2 of apnea (0.2%), 14 of oxygen desaturation (1.3%), and one of laryngospasm (0.01%). There were no life threatening complications or consequences. Age <1 year (adjusted odds ratio [adjusted OR] 2.5, 95% CI 1.2 to 5.3) and American Society of Anesthesiologists (ASA) physical status classification 2 and 3 (adjusted OR 4.6, 95% CI 1.1 to 19.8, and adjusted OR 6.3, 95% CI 1.3 to 30.9, respectively) were risk factors for respiratory complications.

Conclusions

Adverse events were common during sedation or anesthesia, but no life threatening or sentinel events occurred under experienced supervision. Caution should be exercised in children <1 year or with an ASA classification >1.

Efficacy of the Sequential Administration of Melatonin, Hydroxyzine, and Chloral Hydrate for Recording Sleep EEGs in Children

Sedation of children for electroencephalography (EEG) recordings is often required. Chloral hydrate (CH) requires medical clearance and continuous monitoring. To try to reduce personnel and time resources associated with CH administration, a new sedation policy was formulated. This study included all children who underwent an EEG during a consecutive 3-month period following the implementation of the new sedation policy, which consists of the sequential administration of melatonin, hydroxyzine (if needed), and CH (if needed). The comparator group included all children with a recorded EEG during a consecutive 3-month period when the sedation policy consisted of the sole administration of CH. A total of 803 children with a mean age of 7.9 years (SD = 5.1, range = 0.5-17.7 years) were included. Sleep EEG recordings were obtained in 364 of 385 children (94.6%) using the old sedation policy and in 409 of 418 children (97.9%) using the new one. With the new sedation policy, the percentage of children requiring CH dropped from 37.1% to 6.7% (P < .001). Time to sleep onset and duration of sleep were not significantly different between the 2 policies. The new sedation policy was very well tolerated. The new sedation policy is very safe, is highly efficacious in obtaining sleep EEG recordings, and will result in substantial saving of time and personnel resources.