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

The effect of video-based education program applied before children's pediatric Magnetic Resonance Imaging (MRI) on anxiety in Turkey: A randomized controlled study

OBJECTIVE

This study is a randomized controlled trial conducted to examine the effects of a Turkish video-based education program on scanned image quality and child and parent anxiety during Magnetic Resonance Imaging (MRI).

DESIGN AND METHODS

The study was conducted with 66 children aged between 4 and 15 years at Zonguldak Bulent Ecevit University Health Practice and Research Hospital, between January 2019 and December 2019. A video-based educational program was applied to an intervention group before MRI.

RESULTS

The video-based education program reduced children's anxiety and fear (p < 0.001). The study also showed a significant reduction in parental stress (p < 0.001). The image quality in the intervention group was better than that in the control group (control group: 3.24 ± 1.20; intervention group: 4.18 ± 0.81) (p = 0.001). Significantly fewer children refused to enter the MRI room in the intervention group than in the control group (p < 0.05).

CONCLUSION

Child-friendly and video-based educational programs can be organized for children and parents in diagnostic and treatment procedures for children in hospitals.

PRACTICE IMPLICATIONS

MRI scans can be uncomfortable for children and require transport to a better-equipped hospital for sedation. They can also cause financial loss for children and their parents and disrupt facility workflow. An educational program to adjust the children and their families will improve the scanning process and its success rate.

Planetary Health and Radiology: Why We Should Care and What We Can Do

Climate change adversely affects the well-being of humans and the entire planet. A planetary health framework recognizes that sustaining a healthy planet is essential to achieving individual, community, and global health. Radiology contributes to the climate crisis by generating greenhouse gas (GHG) emissions during the production and use of medical imaging equipment and supplies. To promote planetary health, strategies that mitigate and adapt to climate change in radiology are needed. Mitigation strategies to reduce GHG emissions include switching to renewable energy sources, refurbishing rather than replacing imaging scanners, and powering down unused scanners. Radiology departments must also build resiliency to the now unavoidable impacts of the climate crisis. Adaptation strategies include education, upgrading building infrastructure, and developing departmental sustainability dashboards to track progress in achieving sustainability goals. Shifting practices to catalyze these necessary changes in radiology requires a coordinated approach. This includes partnering with key stakeholders, providing effective communication, and prioritizing high-impact interventions. This article reviews the intersection of planetary health and radiology. Its goals are to emphasize why we should care about sustainability, showcase actions we can take to mitigate our impact, and prepare us to adapt to the effects of climate change. © RSNA, 2024 Supplemental material is available for this article. See also the article by Ibrahim et al in this issue. See also the article by Lenkinski and Rofsky in this issue.

A survey of non-sedate practices when acquiring pediatric magnetic resonance imaging examinations

BACKGROUND

Improving access to magnetic resonance imaging (MRI) in childhood can be facilitated by making it faster and cheaper and reducing need for sedation or general anesthesia (GA) to mitigate motion. Some children achieve diagnostic quality MRI without GA through the use of non- practices fostering their cooperation and/or alleviating anxiety. Employed before and during MRI, these variably educate, distract, and/or desensitize patients to this environment.

OBJECTIVE

To assess current utilization of non-sedate practices in pediatric MRI, including variations in practice and outcomes.

MATERIALS AND METHODS

A survey-based study was conducted with 1372 surveys emailed to the Society for Pediatric Radiology members in February 2021, inviting one response per institution.

RESULTS

Responses from 50 unique institutions in nine countries revealed 49/50 (98%) sites used ≥ 1 non-sedate practice, 48/50 (96%) sites in infants < 6 months, and 11/50 (22%) for children aged 6 months to 3 years. Non-sedate practices per site averaged 4.5 (range 0-10), feed and swaddle used at 47/49 (96%) sites, and child life specialists at 35/49 (71%). Average success rates were moderate (> 50-75%) across all sites and high (> 75-100%) for 20% of sites, varying with specific techniques. Commonest barriers to use were scheduling conflicts and limited knowledge.

CONCLUSION

Non-sedate practice utilization in pediatric MRI was near-universal but widely variable across sites, ages, and locales, with room for broader adoption. Although on average non-sedate practice success rates were similar, the range in use and outcomes suggest a need for standardized implementation guidelines, including patient selection and outcome metrics, to optimize utilization and inform educational initiatives.

Leveraging an efficient preparation method into magnetic resonance examinations of young children aged 3-6

PURPOSE

To evaluate the benefits of a multifaceted concept, ANMTE (Appropriate Number of children, appropriate learning Methods, appropriate adaptive Training, and appropriate Encouragement), proposed by our group, in improving the success rate, efficiency and image quality of Magnetic Resonance (MR) examinations for children from 3 to 6 years old.

METHOD

In this study, 150 participants were included from July 2019 to January 2023, including 50 non-sedated children in ANMTE group, 50 in the group with sedative, and 50 in the group with routine preparations. ANMTE refers to appropriate number of children, appropriate learning methods, appropriate adaptive training, and appropriate encouragement, developed by our group for MR examinations of children from 3 to 6 years old. Group differences in success rate, efficiency, and image quality were evaluated across the three groups using Kaplan-Meier, Log-rank and Chi-square test, respectively.

RESULTS

The rates of successful MR examinations were 44/50 (88 %), 45/50 (90 %), and 36/50 (72 %) for ANMTE group, the group with sedatives and the group with routine preparations, respectively (P = 0.03). Image quality of the 3 groups showed no significant group difference (P = 0.067). In terms of the median duration of MR examinations, ANMTE group was comparable to the group with sedative (both were about 10.0 min), but better than the group with routine preparations (16.5 min) (P = 0.024).

CONCLUSION

We demonstrated the feasibility of our comprehensive nursing method ANMTE in MR examinations of young children, similar to the group with sedative at the success rate and image quality as well as the durations of MR examinations. ANMTE has not only better efficiency but also higher safety as it does not require sedative, which could be promising in clinical routine MR examinations for young children aged 3-6 years old.

Application of intelligent pacifying strategy information system in reducing short-duration MRI sedation rate in children

Exploring and analyzing the effectiveness of an intelligent pacifying strategy information system based on assisted decision-making in reducing the sedation rate of children in short-duration magnetic resonance scans. A total of 125 children aged 3-5 years who underwent MRI scans at a children's hospital from July to December 2021 participated in this study, during which 62 children were assigned to a control group from July to September, and 63 children were assigned to an intervention group from October to December. In the intervention group, the pacifier used the intelligent pacifying strategy information system based on assisted decision-making to assess children's temperament, and utilization of a system-generated pacification plan according to assessment results. In the control group, the pacification plan was formulated by the pacifier based on their own experience and discussion with families of the participating children. The success rate of pacification, duration of pacification, and image quality of the two groups were compare. Compared with the control group, the intervention group had a higher success rate of pacification and lower duration of pacification, with statistically significant differences (P < 0.05). There was no difference in image quality between the two groups (P > 0.05). The intelligent pacifying strategy information system can help reduce the use of the sedative drugs in children aged 3-5 years who underwent a short-duration MRI scan.

Nonpharmacological Interventions to Reduce Sedation and General Anesthesia in Pediatric MRI: A Meta-analysis

CONTEXT

Nonpharmacological strategies are increasingly used in pediatric procedures, but in pediatric MRI, sedation and general anesthesia are still commonly required.

OBJECTIVES

To evaluate the effectiveness of nonpharmacological interventions in reducing use of sedation and general anesthesia in pediatric patients undergoing MRI, and to investigate effects on scan time, image quality, and anxiety.

DATA SOURCES

We searched Ovid Medline, CINAHL, Embase, and CENTRAL from inception through October 10, 2022.

STUDY SELECTION

We included randomized controlled trials and quasi-experimental designs comparing the effect of a nonpharmacological intervention with standard care on use of sedation or general anesthesia, scan time, image quality, or child and parental anxiety among infants (<2 years), children, and adolescents (2-18 years) undergoing MRI.

DATA EXTRACTION

Standardized instruments were used to extract data and assess study quality.

RESULTS

Forty-six studies were eligible for the systematic review. Limited to studies on children and adolescents, the meta-analysis included 20 studies with 33 873 patients. Intervention versus comparator analysis showed that nonpharmacological interventions were associated with reduced need for sedation and general anesthesia in the randomized control trials (risk ratio, 0.68; 95% confidence interval, 0.48-0.95; l2 = 35%) and nonrandomized studies (risk ratio, 0.58; 95% confidence interval, 0.51-0.66; l2 = 91%). The effect was largest among children aged 3 to 10 years when compared with older children and adolescents aged 11 to 18 years.

LIMITATIONS

There was substantial heterogeneity among nonrandomized studies.

CONCLUSIONS

Nonpharmacological interventions must be considered as standard procedure in infants, children, and adolescents undergoing MRI.

Emergency MRI in Spine Trauma of Children and Adolescents-A Pictorial Review

Severe spinal trauma is uncommon in the pediatric population, but due to the potentially devastating consequences of missed injury, it poses a diagnostic challenge in emergency departments. Diagnostic imaging is often needed to exclude or confirm the injury and to assess its extent. Magnetic resonance imaging (MRI) offers an excellent view of both bony and soft tissue structures and their traumatic findings without exposing children to ionizing radiation. Our pictorial review aims to demonstrate the typical traumatic findings, physiological phenomena, and potential pitfalls of emergency MRI in the trauma of the growing spine.

Pictorial Review of MRI Findings in Acute Neck Infections in Children

Pediatric neck infections and their complications, such as abscesses extending to deep neck compartments, are potentially life-threatening acute conditions. Medical imaging aims to verify abscesses and their extensions and exclude other complications. Magnetic resonance imaging (MRI) has proven to be a useful and highly accurate imaging method in acute neck infections in children. Children and adults differ in terms of the types of acute infections and the anatomy and function of the neck. This pictorial review summarizes typical findings in pediatric patients with neck infections and discusses some difficulties related to image interpretation.

The Influence of Patient-Centered Communication on Children's Anxiety and Use of Anesthesia for MR

Background: The aim of this study was to inspect the influence of patient-centered communication (PCC) with 4- to 10-year-old children on the use of anesthesia for magnetic resonance imaging exams (MRs). Methods: A total of thirty children received the PCC and pre-simulated the exam with an MR toy. Another 30 children received routine information about the MR and pre-simulated the exam with the toy. Anesthesia use in these two groups was additionally compared with a previously existing group of children (n = 30) who had received only routine information about the exam (CG). Children’s anxiety was assessed with a self-report question plus heartbeat frequency. Children’s satisfaction was assessed through several questions. The analyses were based on group comparisons and regression. Results: A total of two children (7%) in the PCC + simulation group used sedation compared with 14 (47%) in the simulation group and 21 (70%) in the CG. Differences between the PCC + simulation and the other two groups were significant (p < 0.001), although not between the simulation and the CG. The decrease in anxiety was significantly greater (self-reported p < 0.001; heart rate p < 0.05) and satisfaction was higher (p = 0.001) in the PCC + simulation, when compared with the simulation group. Reduced anxiety was associated with less anesthesia use (OR 1.39; CI 1.07−1.79; p = 0.013). Conclusions: PCC + simulation was more effective than simulation and routine practice in decreasing children’s anxiety, increasing satisfaction, and reducing the use of anesthesia for MRs.

Characterisation of Children's Head Motion for Magnetic Resonance Imaging With and Without General Anaesthesia

Head motion is one of the major reasons for artefacts in Magnetic Resonance Imaging (MRI), which is especially challenging for children who are often intimidated by the dimensions of the MR scanner. In order to optimise the MRI acquisition for children in the clinical setting, insights into children's motion patterns are essential. In this work, we analyse motion data from 61 paediatric patients. We compare structural MRI data of children imaged with and without general anaesthesia (GA), all scanned using the same hybrid PET/MR scanner. We analyse several metrics of motion based on the displacement relative to a reference, decompose the transformation matrix into translation and rotation, as well as investigate whether different regions in the brain are affected differently by the children's motion. Head motion for children without GA was significantly higher, with a median of the mean displacements of 2.19 ± 0.93 mm (median ± standard deviation) during 41.7±7.5 min scans; however, even anaesthetised children showed residual head motion (mean displacement of 1.12±0.35 mm). For both patient groups translation along the z-axis (along the scanner bore) was significantly larger in absolute terms (GA / no GA: 0.87±0.29/0.92 ± 0.49 mm) compared to the other directions. Considering directionality, both patient groups were moving in negative z-direction and thus, out of the scanner. The awake children additionally showed significantly more nodding rotation (0.33±0.20°). In future studies as well as in the clinical setting, these predominant types of motion need to be taken into consideration to limit artefacts and reduce re-scans due to poor image quality.

Play simulation for children in magnetic resonance imaging-a clinical perspective

INTRODUCTION

Magnetic Resonance Imaging (MRI) can be a challenging examination, particularly for children. The aim of this Clinical Perspective is to outline early experiences, based upon a service evaluation (defined as an assessment of how well the intended aims are achieved), of the Playful Magnetic Resonance Imaging Simulator (PMRIS) (Domed, Lyon, France) in reducing the number of children requiring general anaesthetic (GA) in order to undergo Magnetic Resonance Imaging (MRI).

METHODS

Baseline data from an audit of children undergoing MRI under GA in 2017 had previously been captured as part of the funding bid for the PMRIS. Estimation of costs associated with anaesthesia were made, then combined with the overall numbers of MRI under GA to estimate projected anaesthetic related cost-savings based on the reported effectiveness of the PMRIS. Once the PMRIS was in place, data were collected for children attending a Play Specialist supervised session. The number and age of children proceeding directly to MRI without requiring a GA was determined. The associated cost benefit was calculated and compared with the projections made in the initial funding bid.

RESULTS

Over a 7 month period 36 children, average age 6 years, age range 4 to 11 years, who had initially been triaged for MRI under GA, attended a Play Specialist led session on the PMRIS. Of these, 30, average age 6 years, age range 4 to 11 years proceeded directly to MRI without a GA. Based on the costings used for the initial funding bid, this equates to a gross cost-saving of £9,000 over 7 months.

DISCUSSION

This service evaluation shows a positive impact of Play Specialist sessions using the PMRIS with 30 out of 36 children having a successful awake MRI as a result. There are limitations to this evaluation, particularly that whilst all these children had been triaged for MRI under GA it cannot be known how many might have had an awake MRI with different preparation. Nevertheless, according to the local referral pathways these children would otherwise have had MRI under GA.

CONCLUSION

This service evaluation has shown that the number of GAs required for children having MRI has reduced for this particular service through the use of the PMRIS, with Play Specialist support, with associated reduction in risk and cost savings.

An update on pediatric sedation techniques in nonoperating room locations

PURPOSE OF REVIEW

To review advancements in care for pediatric patients in nonoperating room settings.

RECENT FINDINGS

Advances in patient monitoring technology, utilization of Child Life specialists, and alternative staffing models are helping anesthesia providers meet the rising demand for coverage of pediatric nonoperating room anesthesia (NORA) cases. The Wake Up Safe and Pediatric Sedation Research Consortium registries are exploring outcome measures regarding the safety of pediatric anesthesia in off-site locations and have reported an increased risk for severe respiratory and cardiac adverse events when compared to OR anesthesia sites. Additionally, malpractice claims for NORA have a higher proportion of claims for death than claims in operating rooms.

SUMMARY

Pediatric NORA requires thorough preparation, flexibility, and vigilance to provide safe anesthesia care to children in remote locations. Emerging techniques to reduce anesthetic exposure, improve monitoring, and alternative staffing models are expanding the boundaries of pediatric NORA to provide a safer, more satisfying experience for diagnostic and interventional procedures.

Infant and Child MRI: A Review of Scanning Procedures

Magnetic resonance imaging (MRI) is a safe method to examine human brain. However, a typical MR scan is very sensitive to motion, and it requires the subject to lie still during the acquisition, which is a major challenge for pediatric scans. Consequently, in a clinical setting, sedation or general anesthesia is often used. In the research setting including healthy subjects anesthetics are not recommended for ethical reasons and potential longer-term harm. Here we review the methods used to prepare a child for an MRI scan, but also on the techniques and tools used during the scanning to enable a successful scan. Additionally, we critically evaluate how studies have reported the scanning procedure and success of scanning. We searched articles based on special subject headings from PubMed and identified 86 studies using brain MRI in healthy subjects between 0 and 6 years of age. Scan preparations expectedly depended on subject's age; infants and young children were scanned asleep after feeding and swaddling and older children were scanned awake. Comparing the efficiency of different procedures was difficult because of the heterogeneous reporting of the used methods and the success rates. Based on this review, we recommend more detailed reporting of scanning procedure to help find out which are the factors affecting the success of scanning. In the long term, this could help the research field to get high quality data, but also the clinical field to reduce the use of anesthetics. Finally, we introduce the protocol used in scanning 2 to 5-week-old infants in the FinnBrain Birth Cohort Study, and tips for calming neonates during the scans.

Success of Nonsedated Neuroradiologic MRI in Children 1-7 Years Old

BACKGROUND. MRI use and the need for monitored anesthesia care (MAC) in children have increased. However, MAC is associated with examination delays, increased cost, and safety concerns. OBJECTIVE. The purpose of this study was to evaluate the success rate of nonsedated neuroradiologic MRI studies in children 1-7 years old and to investigate factors associated with success. METHODS. We retrospectively reviewed data from our institutional nonsedated MRI program. Inclusion criteria were outpatient nonsedated MRI referral, age 1-7 years old, and neuroradiologic indication. Exclusion criteria were MRI examinations for ventricular checks and contrast material use. Success was determined by reviewing the clinical MRI report. We recorded patient age and sex, type of MRI examination (brain, spine, craniospinal, head and neck, and brain with MRA), protocol length, presence of child life specialist, video goggle use, and MRI appointment time (routine daytime appointment or evening appointment). We used descriptive statistics to summarize patient demographics and clinical data and logistic regression models to evaluate predictors of success in the entire sample. Subset analyses were performed for children from 1 to < 3 years old and 3 to 7 years old. RESULTS. We analyzed 217 patients who underwent nonsedated MRI examinations (median age, 5.1 years). Overall success rate was 82.0% (n = 178). The success rates were 81.4% (n = 127) for brain, 90.3% (n = 28) for spine, 71.4% (n = 10) for craniospinal, 66.7% (n = 6) for head and neck, and 100% (n = 7) for brain with MRA. Age was significantly associated with success (odds ratio [OR], 1.33; p = .009). In children 1 to < 3 years old, none of the factors analyzed were significant predictors of success (all, p > .48). In children 3-7 years old, protocol duration (OR, 0.96; 95% CI, 0.93-0.99; p = .02) and video goggle use (OR, 6.38; 95% CI, 2.16-18.84; p = .001) were significantly associated with success. CONCLUSION. A multidisciplinary approach with age-appropriate resources enables a high success rate for nonsedated neuroradiologic MRI in children 1-7 years old. CLINICAL IMPACT. Using age as the primary criterion to determine the need for MAC may lead to overuse of these services. Dissemination of information regarding nonsedated MRI practice could reduce the rate of sedated MRI in young children.

Evaluation of distraction techniques for patients aged 4-10 years undergoing magnetic resonance imaging examinations

OBJECTIVES

The main aim of the review is to identify potentially effective distraction techniques for the 4 to 10 age range whilst reducing the need for sedation. Objectives also included assessment of the applicability of distraction for the 4-10 age range and, where appropriate, to identify potential cost implications and assess the interventions' impact on image quality.

KEY FINDINGS

A priori search terms, inclusion and exclusion criteria were developed and two independent reviewers were employed to assess study quality. Five studies fitted the criteria of the systematic search strategy. The studies implemented a range of distraction and preparatory techniques resulting in paediatric patients being able to complete an MRI scan to a diagnostic level in the 4 to 10-year-old age category with a sedation rate of 5-20%. All interventions included in the review required time with the patient prior to the scan.

CONCLUSION

There are a range of efficacious techniques that can be employed to reduce the sedation rates in children aged 4-10 years, whilst allowing diagnostic images to be acquired. The introduction of play and the engagement with the patient prior to the scan appear to be indicators of intervention effectiveness. The efficacy of these interventions does not appear to be linked with proprietary equipment.

IMPLICATIONS FOR PRACTICE

Age appropriate interventions are necessary for children of different ages and these distraction interventions may be implemented within departments, for little cost, with notable benefits in terms of sedation.

Effects of an MRI Try Without program on patient access

BACKGROUND

Pediatric patients are often sedated for magnetic resonance imaging (MRI) scans to ensure images are of diagnostic quality. However, access time for MRIs requiring sedation is often long due to high patient volumes and limited sedation resources.

OBJECTIVE

This study examined the effectiveness of an MRI Try Without sedation program to decrease the wait time for obtaining an MRI while simultaneously ensuring diagnostic-quality images.

MATERIALS AND METHODS

A retrospective chart review was performed on subjects who utilized the MRI Try Without program from April 2014 through June 2015 at a dedicated pediatric institution. Child life specialist preparations and access time (i.e. time from exam ordered to exam completed) were recorded in each patient's electronic medical record. MRI images were evaluated for image quality by a pediatric neuroradiologist.

RESULTS

A total of 134 patients participated in the MRI Try Without program (mean age: 6.9±1.7 years), all of whom received interventions from a child life specialist. The average number of days between when the order was placed and when the MRI was completed using the MRI Try Without program was 15.4±18.5 days, while the third-available appointment for sedation/anesthesia was 46.2 days (standard deviation [SD]±15.7 days). Nearly all patients received a "good" or "very good" image quality determination (87.3%) and only 5 (3.8%) patients were recommended for repeat examination for diagnostic-quality images.

CONCLUSION

Utilization of an MRI Try Without sedation program, with child life specialist interventions, decreased the wait time for obtaining an MRI while still providing diagnostic-quality images.

Techniques for minimizing sedation in pediatric MRI

MRI is used widely in infants and young children. However, in these young cases deep sedation or general anesthesia is often required to minimize motion artifacts during MRI examinations. Although the benefits of MR typically outweigh the potential risks of sedation when delivered by an experienced team, there are increasing concerns regarding the affect of sedation on young children. There continues to be a push to develop various strategies that can minimize the need for sedation. The present review summarizes several technical and clinical approaches that can help decrease the need for sedation in the pediatric patient. Optimization of the MRI environment, the role of child life specialists, feed-and-bundle and distraction techniques, noise-reduction methods, artificial intelligence, and MRI advances to decrease both scan times and motion artifacts will be discussed. Level of Evidence: 5 Technical Efficacy Stage: 1 J. Magn. Reson. Imaging 2019.