Prolonged recovery and delayed side effects of sedation for diagnostic imaging studies in children

Reducing pediatric total-body PET/CT imaging scan time with multimodal artificial intelligence technology

OBJECTIVES

This study aims to decrease the scan time and enhance image quality in pediatric total-body PET imaging by utilizing multimodal artificial intelligence techniques.

METHODS

A total of 270 pediatric patients who underwent total-body PET/CT scans with a uEXPLORER at the Sun Yat-sen University Cancer Center were retrospectively enrolled. 18F-fluorodeoxyglucose (18F-FDG) was administered at a dose of 3.7 MBq/kg with an acquisition time of 600 s. Short-term scan PET images (acquired within 6, 15, 30, 60 and 150 s) were obtained by truncating the list-mode data. A three-dimensional (3D) neural network was developed with a residual network as the basic structure, fusing low-dose CT images as prior information, which were fed to the network at different scales. The short-term PET images and low-dose CT images were processed by the multimodal 3D network to generate full-length, high-dose PET images. The nonlocal means method and the same 3D network without the fused CT information were used as reference methods. The performance of the network model was evaluated by quantitative and qualitative analyses.

RESULTS

Multimodal artificial intelligence techniques can significantly improve PET image quality. When fused with prior CT information, the anatomical information of the images was enhanced, and 60 s of scan data produced images of quality comparable to that of the full-time data.

CONCLUSION

Multimodal artificial intelligence techniques can effectively improve the quality of pediatric total-body PET/CT images acquired using ultrashort scan times. This has the potential to decrease the use of sedation, enhance guardian confidence, and reduce the probability of motion artifacts.

Parental preferences for the procedural sedation of children in dentistry: a discrete choice experiment

Purpose

The aim of this study was to explore parental preferences for the procedural sedation of children in dentistry through a discrete choice experiment (DCE) to inform clinical decisions and oral health management.

Methods

Based on literature reviews, interviews with parents of pediatric dental patients, and expert consultation, six attributes, including fasting time, recovery time, sedative administration routes, adverse reactions, sedation depth and procedure cost, were incorporated into the DCE questionnaire. The DCE questionnaire collected data on parental preferences for pediatric dental sedation treatment from June to August 2022. A conditional logit model was used to analyze preference and willingness to pay (WTP) for each attribute and its level. Subgroup analyses assessing the impact of parents' dental anxiety on procedural sedation preferences were also conducted using conditional logit models.

Results

A total of 186 valid questionnaires were gathered. Parents' preferences for fewer adverse reactions, a milder sedation depth, lower out-of-pocket cost, shorter fasting and recovery times and administration by inhalation were significantly associated with their choice of sedation model. The conditional logit model showed that parents were most interested in treatments with no adverse reactions (0% vs. 15%) (Coef, 1.033; 95% CI, 0.833-1.233), followed by those providing minimal sedation (vs. deep sedation) (Coef, 0.609; 95% CI, 0.448-0.769). Moreover, the relative importance of adverse reactions and fasting time was higher among anxious than nonanxious parents. The study found a WTP threshold of ¥1,538 for reducing adverse reactions (15% to 0%). The WTP threshold for the best sedation procedure scenario (no fasting requirement, 10 min recovery time, administration by inhalation, 0% adverse reaction incidence and minimal sedation) was ¥3,830.

Conclusion

Reducing the adverse reactions and depth of sedation are predominant considerations for parents regarding procedural sedation in pediatric dentistry, followed by lower cost, shorter fasting and recovery times and inhalation sedation. Parents with dental anxiety had a stronger preference for options with a lower incidence of adverse reactions and shorter fasting time than parents without dental anxiety. This discovery is helpful for doctors and can promote collaborative decision-making among parents and doctors.

Utility of the New Faster Compressed SENSE MRCP at 3 Tesla MRI in Children with Pancreatitis

OBJECTIVE

To compare the acquisition time, diagnostic efficacy, and image quality of the newer compressed SENSE 3D MRCP (CS-3D MRCP) with conventional 3D MRCP (C-3D MRCP) in children with pancreatitis.

METHODS

A total of 24 children (2-17 y) diagnosed with pancreatitis were included in this study. The children underwent CS-3D MRCP and C-3D MRCP sequences. C-3D MRCP and CS-3D MRCP images were evaluated for the acquisition time duration, visualization of the pancreaticobiliary ducts, background suppression, image quality degradation by artifacts, and overall image quality by the two radiologists independently. Paired sample t-test was used to compare the acquisition time, the McNemar test for the image quality features, and the kappa coefficient was used for interobserver agreement.

RESULTS

A two-fold decrease in the acquisition time of CS-3D MRCP (~148 ± 61 s) was seen, compared to C-3D MRCP (~310 ± 98 s), p < 0.001. The median scores for overall image quality on CS-3D MRCP and C-3D MRCP, respectively, were 2.05 ± 0.52 and 2.21 ± 0.53 (p = 0.18) for both radiologists. No significant difference was seen for the visibility of ducts, background suppression, and artifacts between the two radiologists, with substantial to almost perfect agreement seen for the different findings.

CONCLUSION

The application of compressed SENSE 3D MRCP in children with pancreatitis results in a two-fold reduction in acquisition time with acceptable image quality. This may help in reducing the need for long sedation in children requiring anesthesia support for the MRCP and potentially help in reducing motion artifacts.

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.

Safety and efficacy of pediatric sedation protocol for diagnostic examination in a pediatric emergency room: A retrospective study

Pediatric patients undergoing diagnostic tests in the pediatric emergency room are frequently sedated. Although efforts are made to prevent adverse events, no sedation protocol has specified the optimal regimen, dosage, and interval of medication to prevent adverse events. This study analyzed the safety and efficacy of sequential pediatric sedation protocols for pediatric patients undergoing diagnostic tests in the pediatric emergency room of a single tertiary medical center. The medical records of patients aged < 18 years who visited the pediatric emergency room of Seoul Asan Medical Center between January and December 2019 for diagnostic testing were retrospectively reviewed. Sedation protocols consisted of 50 mg/kg and 25 mg/kg chloral hydrate, 0.1 mg/kg and 0.1 mg/kg midazolam, and 1 mg/kg and 0.5 to 1 mg/kg ketamine, administered sequentially at intervals of 30, 20, 10, 10, and 10 minutes, respectively. Patients were assessed prior to sedation, and adverse events were investigated. Of the 289 included patients, 20 (6.9%) experienced adverse events, none serious, and nine (3.1%) failed to reach the depth of sedation required to complete the test. The regimen (P = .622) and dosage (P = .777) of the sedatives were unrelated to the occurrence of adverse events when sedation was performed according to protocol. The sedation protocol used in these patients, consisting of sequential administration of minimum dosages, achieved a sufficient depth of sedation with relatively few adverse events, indicating that this protocol can be used safely and effectively for painless sedation in pediatric patients undergoing diagnostic testing.

Economic Evaluation Comparing Virtual Reality with Child Life Programming for Non-sedated Pediatric Medical Imaging: A Cost-Consequence Analysis

INTRODUCTION

Effective preparation of children for hospital procedures, including non-sedated medical imaging, is an important clinical issue. This study aimed to assess the costs and consequences (effects) of preparing pediatric patients using two methods of delivering preparation for a scheduled magnetic resonance image (MRI)-virtual reality (VR-MRI) and a certified Child Life Program (CLP).

METHODS

A cost-consequence analysis (CCA) was performed using a societal perspective in Canada. The CCA catalogs a wide range of costs and consequences of VR-MRI compared with a CLP. The evaluation uses data from a prior randomized clinical trial evaluating VR and a CLP in a simulated trial. The economic evaluation encompassed health-related effects, including anxiety, safety and adverse events, and non-health effects, including preparation time, displaced time from usual activities, workload capacity, patient-specific adaptation, administrative burden, and user-experience metrics. The costs have been categorized into hospital operational costs, travel costs, other patient costs, and societal costs.

RESULTS

VR-MRI has similar benefits to the CLP in managing anxiety, safety and adverse events, as well as converting patients to non-sedated medical imaging. Preparation time and patient-specific adaptation are in favor of the CLP, while displaced time from usual activities, potential workload capacity, and administrative burden are in favor of VR-MRI. Both programs rank favorably in terms of user experience. The hospital operational costs ranged in Canadian dollars (CAN$) from CAN$32.07 for the CLP to between CAN$107.37 and CAN$129.73 for VR-MRI. Travel costs ranged from CAN$50.58 to CAN$2365.18 depending on travel distance for the CLP, and CAN$0 for VR-MRI. Other patient costs involved caregiver time off, and ranged from CAN$190.69 to CAN$$1144.16 for the CLP and CAN$47.67 for VR-MRI. The total cost for the CLP ranged from CAN$315.16 (CAN$277.91-$426.64) to CAN$3843.41 (CAN$3196.59-$4849.91) per patient depending on travel distance and amount of administrative support required, while VR-MRI preparation ranged from CAN$178.30 (CAN$178.20-$188.76) to CAN$283.85 (CAN$283.71-$298.40) per patient. For every instance where patient travel to visit a Certified Child Life Specialist (CCLS) onsite was replaced with VR-MRI, between CAN$119.01 and CAN$3364.62 total costs could be saved per patient.

CONCLUSIONS

While it is neither feasible nor appropriate to replace all preparation with VR, using VR to reach children who cannot otherwise visit the CLP onsite could increase access to quality preparation, and using VR in place of the CLP where clinically indicated could reduce the overall costs for patients, the hospital, and society. Our CCA gives decision makers a cost analysis and the relevant effects of each preparation program so they can value the VR and CLP programs more broadly within the potential health and non-health outcomes of pediatric patients scheduled for MRI at their facilities.

Needle-free pharmacological sedation techniques in paediatric patients for imaging procedures: a systematic review and meta-analysis

BACKGROUND

Sedation techniques and drugs are increasingly used in children undergoing imaging procedures. In this systematic review and meta-analysis, we present an overview of literature concerning sedation of children aged 0-8 yr for magnetic resonance imaging (MRI) procedures using needle-free pharmacological techniques.

METHODS

Embase, MEDLINE, Web of Science, and Cochrane databases were systematically searched for studies on the use of needle-free pharmacological sedation techniques for MRI procedures in children aged 0-8 yr. Studies using i.v. or i.m. medication or advanced airway devices were excluded. We performed a meta-analysis on sedation success rate. Secondary outcomes were onset time, duration, recovery, and adverse events.

RESULTS

Sixty-seven studies were included, with 22 380 participants. The pooled success rate for oral chloral hydrate was 94% (95% confidence interval [CI]: 0.91-0.96); for oral chloral hydrate and intranasal dexmedetomidine 95% (95% CI: 0.92-0.97); for rectal, oral, or intranasal midazolam 36% (95% CI: 0.14-0.65); for oral pentobarbital 99% (95% CI: 0.90-1.00); for rectal thiopental 92% (95% CI: 0.85-0.96); for oral melatonin 75% (95% CI: 0.54-0.89); for intranasal dexmedetomidine 62% (95% CI: 0.38-0.82); for intranasal dexmedetomidine and midazolam 94% (95% CI: 0.78-0.99); and for inhaled sevoflurane 98% (95% CI: 0.97-0.99).

CONCLUSIONS

We found a large variation in medication, dosage, and route of administration for needle-free sedation. Success rates for sedation techniques varied between 36% and 98%.

Melatonin Versus Chloral Hydrate for Sleep Electroencephalography Recording in Children: A Comparative Study Using Bispectral Index Monitoring Scores and Electroencephalographic Sleep Stages

PURPOSE

To compare the effects of chloral hydrate and melatonin on sleep EEG recordings in children by using standard EEG sleep stages and the bispectral index scores (BIS).

METHODS

A total of 86 children were randomly assigned to two groups: (1) melatonin group (n = 43) and (2) chloral hydrate group (n = 43). BIS monitoring scores and sleep EEGs were recorded simultaneously. The effect of two drugs on sleep EEG recording was evaluated with sleep stages of EEG and BIS.

RESULTS

There was no statistically significant difference between the groups with regard to time to sleep onset and the need for a second drug ( P = 0.432; P = 1.000). Eight patients (18.6%) in chloral hydrate group reported side effects while there were no reported side effects in the melatonin group ( P = 0.006). Mean BIS values during EEG recordings were similar in both groups (59.72 ± 18.69 minutes and 66.17 ± 18.44 minutes, respectively, P = 1.000). The average time to achieve N2 sleep was 32.38 minutes in the chloral hydrate group and 43.25 minutes in the melatonin group ( P < 0.001). Both "time spent in wakefulness" and "N1 sleep" were found to be significantly higher in the melatonin group ( P < 0.001 and P = 0.005). BIS scores higher than 75 were found to be suggestive for wakefulness; 75 to 66 for N1, 65 to 46 for N2, and values lower than 46 were found to be indicative for N3 sleep with a good strength of agreement in weighted Kappa analysis (95% confidence interval; weighted Kappa = 0.67).

CONCLUSIONS

Melatonin is reliable and at least as effective as chloral hydrate for sleep EEG acquisition in children.

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.

Trends and patterns in the practice of pediatric sedation for magnetic resonance imaging in Japan: A longitudinal descriptive study from 2012 to 2019

BACKGROUND

Worldwide, pediatric sedation for magnetic resonance imaging is a standard practice; however, there are few studies on its trends and patterns.

AIMS

This study aimed to investigate the trends and patterns of pediatric sedation for magnetic resonance imaging in Japan and determine the incidence of and risk factors for adverse events/interventions.

METHODS

This longitudinal descriptive study assessed children (age < 15 years) who underwent sedation for magnetic resonance imaging between April 2012 and December 2019 in Japan using a nationwide claims database. We assessed the patients' demographic characteristics, time trends in sedatives, sedative patterns by age, and adverse events/interventions within two post-sedation days. Further, we used multivariable logistic regression models to explore factors related to the incidence of adverse events/interventions.

RESULTS

We identified 29 187 cases (median age, 2.0 years; 55.2% males). The most common sedative was triclofos sodium (n = 18 812, 51.7%). There was an increasing trend in barbiturate use (17.0% [2012] to 25.0% [2019]) and decreasing trends in the use of triclofos sodium (56.4% [2012] to 47.7% [2019]) and chloral hydrate (15.6% [2012] to 10.8% [2019]). We identified 534 adverse events/interventions in 460 cases (1.5%). Multivariable logistic regression analyses revealed that the incidence of adverse events/interventions mainly increased with the number of sedatives (≥3; adjusted odds ratio, 5.10; 95% confidence interval, 3.67-7.10) and unscheduled setting (adjusted odds ratio, 6.28; 95% confidence interval, 4.85-8.61); further, it decreased with high hospital procedure volume (adjusted odds ratio, 0.62; 95% confidence interval, 0.49-0.78).

CONCLUSIONS

Based on a Japanese real-world setting, there is an increasing trend in barbiturate use and decreasing trends in the use of triclofos sodium and chloral hydrate in pediatric sedation for magnetic resonance imaging. Low hospital procedure volumes were associated with an increased risk of adverse events/interventions.

A Descriptive Review of the Impact of Patient Motion in Early Childhood Resting-State Functional Magnetic Resonance Imaging

Resting-state functional magnetic images (rs-fMRIs) can be used to map and delineate the brain activity occurring while the patient is in a task-free state. These resting-state activity networks can be informative when diagnosing various neurodevelopmental diseases, but only if the images are high quality. The quality of an rs-fMRI rapidly degrades when the patient moves during the scan. Herein, we describe how patient motion impacts an rs-fMRI on multiple levels. We begin with how the electromagnetic field and pulses of an MR scanner interact with a patient’s physiology, how movement affects the net signal acquired by the scanner, and how motion can be quantified from rs-fMRI. We then present methods for preventing motion through educational and behavioral interventions appropriate for different age groups, techniques for prospectively monitoring and correcting motion during the acquisition process, and pipelines for mitigating the effects of motion in existing scans.

Recovery characteristics and parental satisfaction in pediatric procedural sedation

BACKGROUND

Despite being a standard of care for children undergoing stressful procedures, little data exist on parental perception of pediatric sedation.

AIMS

This study aimed to investigate recovery characteristics and parental satisfaction for pediatric sedations performed with four widely used sedative regimens.

METHODS

A prospective observational study was conducted at the Institute for Maternal and Child Health of Trieste, Italy, enrolling children undergoing procedural sedation with one of the following pharmacological regimens: propofol, propofol + midazolam, ketamine + propofol, and dexmedetomidine + midazolam. A questionnaire was used to assess the occurrence of symptoms upon recovery from sedation and the following day, and the caregivers' satisfaction for both the recovery pattern and the overall sedation experience, according to a numerical rating scale (0-10). Answers were collected through a telephone survey. The primary outcome was the difference in the quality of the recovery as perceived by caregivers; the secondary and tertiary outcomes were the perceived quality of the overall sedation experience and the frequency of sedation-related adverse events, respectively.

RESULTS

Data from 655 patients, 149 receiving propofol, 245 propofol + midazolam, 134 ketamine + propofol, and 127 dexmedetomidine + midazolam, were analyzed. The level of parents' satisfaction for both the recovery and the sedation experience was overall high and increased with the patients' age in all the pharmacological groups (Spearman's rank correlation, ρ .083, p = .033, and ρ .087, p = .026, respectively), with no statistically significant differences between groups when adjusting for age. The occurrence of irritability, prolonged sleepiness, hyperactivity, unsteadiness, hallucinations, emesis, and respiratory distress at any moment negatively affected parental satisfaction.

CONCLUSIONS

In this study, caregivers' satisfaction with pediatric sedation was high, regardless of the regimen used. Lower parental satisfaction was associated with younger age, irritability after sedation, prolonged sleepiness, hyperactivity, unsteadiness, hallucinations, emesis, and respiratory distress.

Safety of pediatric cerebral angiography

OBJECTIVE

Catheter-based cerebral angiography is commonly used for neurovascular diagnosis in children. In this work, the authors aimed to quantify the complication rate of cerebral angiography in children, characterize these complications, and identify risk factors for complications.

METHODS

Relevant clinical data were retrospectively obtained for 587 consecutive cerebral angiography procedures performed in 390 children from March 2002 to March 2020. Complications were categorized as neurological or nonneurological, and severity was graded using a standard schema. Incidences of complications were reported as point estimates. Associations between risk factors and complications were characterized in univariate analysis using the two-tailed Fisher exact test and in multivariate analysis using multiple logistic regression with bidirectional elimination based on the Akaike information criterion. In both univariate and multivariate analyses, statistical significance was corrected for multiple comparisons using the Benjamini-Hochberg method.

RESULTS

Complications occurred in 6.5% of procedures, including neurological complications in 1.9% and nonneurological complications in 4.8%. Permanent deficits occurred in only 0.2% of cases. Overall, 0.5% of procedures resulted in major complications, while 6.0% resulted in minor complications. Female sex and a history of hypertension or ischemic stroke were associated with an increased risk of complications, while femoral artery access was associated with a decreased risk of complications.

CONCLUSIONS

Pediatric cerebral angiography was shown to have a low rate of major or permanent complications. Children who were female and those with a history of hypertension or ischemic stroke were shown to be at higher risk of complications, while the use of femoral access carried a lower risk of complications.

Post-Discharge Effects and Parents' Opinions of Intranasal Fentanyl with Oral Midazolam Sedation in Pediatric Dental Patients: A Cross-Sectional Study

The aim of this study was to evaluate the post-discharge effects of oral midazolam with intranasal fentanyl sedation in pediatric patients who had dental treatment and to evaluate parents' preference regarding sedation visits.

METHODS

A total of 32 uncooperative healthy pediatric patients aged 3-6 years old who met the inclusion criteria were included. In the first visit, one group received oral midazolam (0.7 mg/kg) with intranasal fentanyl (1 μg/kg) sedation (M/F) and the other group received oral midazolam with intranasal placebo (M), and in the second visit each group received the other type of sedation in a cross-over type. In this cross-sectional study, a post-discharge phone-call questionnaire was carried out 24 h after both sedation visits with the parents to evaluate the children's behavior, function, balance, eating pattern, sleeping pattern, vomiting incidents, and any possible side effects, as well as parents' satisfaction and preference. The Wilcoxon signed-rank test was used to analyze the categorical variables, and the Chi-square test was performed to analyze the parents' preference.

RESULT

A total of 32 parents responded to the phone-call questionnaire after 64 sedation visits. All of them were mothers. There was no statistically significant difference between the two groups with respect to recovery to normal function and balance, behavior, incidents of fever, vomiting, sleep disturbance, oversleeping, and adverse behavioral changes (p > 0.05). Children required a significantly longer amount of time until the first meal after M/F sedation (p = 0.04). No significant difference was found between parents' preferences regarding the sedation visits (p > 0.05).

CONCLUSION

Intranasal fentanyl added to oral midazolam sedation could have an effect on post-discharge adverse behavioral changes, prolonged sleeping, and prolonged recovery time. Children sedated with midazolam/fentanyl required a longer amount of time until the first meal. Vomiting and fever occurred similarly in both sedation regimens with a low incidence. There was no difference in parents' preferences regarding the two sedation regimens.

Patient background related to success and adverse event in pediatric sedated MRI

BACKGROUND

The success rate of sedation with triclofos sodium and midazolam for pediatric magnetic resonance imaging (MRI) has been reported. However, there are no reports of an association of adverse events and examination success rates with patient medical backgrounds using a combination of these sedatives. We performed this study to investigate these points.

METHODS

We investigated 191 pediatric patients who were sedated for MRI with triclofos sodium and midazolam at Matsudo City Hospital between November 2013 and October 2015. We surveyed the patients' characteristics, including age, sex, body weight, allergies, medication, neuromuscular, gastrointestinal, respiratory, and cardiac disorders, airway obstruction factors, and developmental disorders. Outcomes were sedation success and adverse events, including oxygen desaturation. We reviewed the relationship between patient backgrounds and each adverse event or success rate of sedation.

RESULTS

Among all cases, the success rate was 92.7%. Older age (odds ratio [OR] = 0.984), developmental disorders (OR = 0.215), and respiratory disorders (OR = 0.353) were factors for lower success rates. Adding midazolam was associated with a higher success rate (OR = 5.971), but the higher total dose of midazolam was associated with sedation failure (OR = 0.003). The only adverse event was oxygen desaturation (11.5%). Older age affected oxygen desaturation with multiple analysis. However, by stepwise analysis, no patient medical background nor sedative dose was associated with oxygen desaturation.

CONCLUSIONS

Older age, developmental disorders, and respiratory disorders were associated with sedation failure. Increasing midazolam did not increase the success rate, and there might be an optimal dose of midazolam.

Comparing a Virtual Reality-Based Simulation App (VR-MRI) With a Standard Preparatory Manual and Child Life Program for Improving Success and Reducing Anxiety During Pediatric Medical Imaging: Randomized Clinical Trial

Background

The experience of undergoing magnetic resonance imaging (MRI) can be anxiety provoking, particularly for pediatric patients and their families. Alternative methods to improve success and experiences without the use of sedation are needed.

Objective

This study aims to compare the effectiveness of a virtual reality (VR)—based simulation app (VR-MRI) with a standard preparatory manual (SPM) and a hospital-based Child Life Program (CLP) on success and anxiety during a simulated pediatric MRI scan. Our secondary aim is to compare caregivers’ reported anxiety, procedural data, caregiver usability, child satisfaction, and fun.

Methods

This unblinded, randomized, triple-arm clinical trial involved 92 children aged 4-13 years and their caregivers. Recruitment was conducted through posters, public libraries, community centers, and social media. At a 2-hour session, participants were instructed to prepare for a simulated MRI head scan using one of three randomly assigned preparation materials: the VR-MRI app, SPM, or the CLP. Data were collected before preparation, during a simulated MRI head scan, and after the simulated scan. The primary outcomes were the success of the simulated MRI scan (MoTrak head motion tracking system), and child-reported anxiety (Venham picture test). We secondarily measured caregivers’ reported anxiety (short State-Trait Anxiety Inventory), procedural data (minutes), usability (Usefulness, Satisfaction, and Ease of Use Questionnaire), and child-reported satisfaction and fun (visual analog scales).

Results

A total of 84 participants were included in the final analysis (VR-MRI: 30/84, 36%; SPM: 24/84, 29%; and CLP: 30/84, 36%). There were no clinically significant differences between the groups in terms of success during the MRI simulation (P=.27) or the children’s reported anxiety at any timepoint (timepoint 1, P=.99; timepoint 2, P=.008; timepoint 3, P=.10). Caregivers reported being significantly more anxious after preparing with the manual than caregivers in the other 2 groups (P<.001). Child and caregiver anxiety had a significant relationship, increasing together with moderate effect (r₈₄=0.421; P<.001). Participants using VR-MRI took the most time to prepare (P<.001) and participants using the manual took the least time (P<.001). No statistically significant relationships were found between time preparing and time completing the simulated assessment (P=.13). There were no differences found in ease of use (P=.99), ease of learning (P=.48), and usefulness (P=.11) between the groups; however, caregivers reported being significantly more satisfied with the VR-MRI app and CLP than SPM (P<.001). Children reported the most satisfaction with the CLP (P<.001). There were no differences in how much fun the preparation materials were perceived to be (P=.37).

Conclusions

Digital preparation experiences using VR-based media could be a viable solution to improve the success of nonsedated MRI scans, with outcomes comparable with hospital-based in-person preparatory programs. Future research should focus on validating the results in a real MRI setting.

Trial Registration

Clinicaltrials.gov NCT03931382; https://clinicaltrials.gov/ct2/show/NCT03931382

European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB): An Update on the Pediatric CEUS Registry on Behalf of the "EFSUMB Pediatric CEUS Registry Working Group"

The European Federation of Ultrasound in Medicine and Biology (EFSUMB) created the "EFSUMB Pediatric Registry" (EFSUMB EPR) with the purpose of collecting data regarding the intravenous application of pediatric contrast-enhanced ultrasound (CEUS). The primary aim was to document the current clinical practice and usefulness of the technique and secondarily to assess CEUS safety in children. We issue the preliminary results of this database and examine the overall practice of CEUS in children in Europe.

Three-dimensional motion-corrected T1 relaxometry with MPnRAGE

PURPOSE

To test the performance of the MPnRAGE motion-correction algorithm on quantitative relaxometry estimates.

METHODS

Twelve children (9.4 ± 2.6 years, min = 6.5 years, max = 13.8 years) were imaged 3 times in a session without sedation. Stabilization padding was not used for the second and third scans. Quantitative T1 values were estimated in each voxel on images reconstructed with and without motion correction. Mean T1 values were assessed in various regions determined from automated segmentation algorithms. Statistical tests were performed on mean values and the coefficient of variation across the measurements. Accuracy of T1 estimates were determined by scanning the High Precision Devices (Boulder, CO) MRI system phantom with the same protocol.

RESULTS

The T1 values obtained with MPnRAGE agreed within 4% of the reference values of the High Precision Devices phantom. The best fit line was T1 (MPnRAGE) = 1.02 T1 (reference)-0.9 ms, R2  = 0.9999. For in vivo studies, motion correction reduced the coefficients of variation of mean T1 values in whole-brain tissue regions determined by FSL FAST by 74% ± 7%, and subcortical regions determined by FIRST and FreeSurfer by 32% ± 21% and 33% ± 26%, respectively. Across all participants, the mean coefficients of variation ranged from 0.8% to 2.0% for subcortical regions and 0.6% ± 0.5% for cortical regions when motion correction was applied.

CONCLUSION

The MPnRAGE technique demonstrated highly accurate values in phantom measurements. When combined with retrospective motion correction, MPnRAGE demonstrated highly reproducible T1 values, even in participants who moved during the acquisition.

Enhancing cooperation during pediatric ultrasound: Oral midazolam versus conventional techniques

Background and Aims:

Ultrasound is a safe and non-invasive method for detecting numerous pathologies. Pediatric patients are often uncooperative which leads to decreased quality and increased time of scan. We compared the conventional means alone and combination of oral midazolam for the above cited purpose.

Material and Methods:

This double blind prospective study (CTRI/2016/06/007030) was conducted after obtaining due approval from institutional ethical committee. One hundred Children aged 2-6 years belonging to ASA class 1 or 2, posted for high resolution ultrasonography of abdomen were included in the study. They were randomised to receive midazolam 0.3 mg/kg mixed in 20 mL of apple juice (Group I) or 20 mL of apple juice alone (Group II) 20 minutes prior to the procedure. The parameters assessed were level of cooperation, sonologist's satisfaction, total scan time, heart rate and SpO₂.

Results:

Out of 100 patients, 44 patients of group I and 42 of group II were analysed. The cooperation score was significantly higher in Group I (35%) than Group II (19%). Likert scale revealed very satisfied and satisfied rating in 61.3% (Group I) and 21.4% (Group II). The time taken by sonologist and number of attempts were significantly less in Group I than Group II. There was no difference in discharge time between the groups. There was no reportable adverse event in either group.

Conclusion:

Oral midazolam is a safe and effective agent to aid routine abdominal ultrasonography in pediatric patients.

Engaging patients and families in pediatric radiology

While patient and family-centered care (PFCC) is currently a hot topic in medicine, it has long been a specific focus of pediatrics. The concept of PFCC includes a change in culture where physicians and patients move away from paternalism and instead view patients and families as partners in care. Although there are many ways in which adult-focused radiologists can learn from pediatric radiologists as leaders in PFCC, there remain many opportunities for improvement for all radiologists.

Melatonin is useful alternative for sedation in children undergoing auditory brainstem responses testing

Auditory brainstem responses testing (ABRs) is frequently required to assess auditory function in children. It is done usually in outpatient fashion and requires deep sleep to avoid artefacts. Sedation method used for the test should allow a deep sleep while avoiding general anaesthesia that requires special monitoring, dedicated staff and operating room availability. For this purpose, several sedation methods have been used, with the risk of respiratory depression and sides effects. We aim to assess the efficacy and the usefulness of melatonin in sedation for children undergoing auditory brainstem responses testing. We calculated success rate of complete bilateral ABR, sleep delay and quality of sleep of 247 children referred for ABR testing. Two hundred six children (83.4%) successfully underwent both ears testing. The delay to sleep was variable with a mean of 32 min. The quality of sleep was described as continuous in 156 infants (75.7%) and discontinuous in 50 infants (24.27%) requiring either simple nursing or a second dose of melatonin 30 min later.Conclusion: Melatonin has the advantages of inducing natural sleep and reducing sleep delay without adverse effects or respiratory depression risk. It is efficient and useful sedation method for ABRs in an outpatient setting. What Is Known? • Auditory brainstem responses test is the most used objective test to assess auditory function in children and requires deep sleep to avoid artefacts. • Melatonin is an endogenous pineal hormone used for sedation in electrophysiological testing and magnetic resonance imaging. What Is New? • 83.4% of children in our study successfully performed a bilateral ABR under melatonin-induced sleep with continuous sleep in 75.7%. • The use of melatonin to induce sleep for ABR tests is useful in an outpatient setting and it is a good alternative to general anaesthesia in Morocco.

Variable Refocusing Flip Angle Single-Shot Imaging for Sedation-Free Fast Brain MRI

BACKGROUND AND PURPOSE

Conventional single-shot FSE commonly used for fast MRI may be suboptimal for brain evaluation due to poor image contrast, SNR, or image blurring. We investigated the clinical performance of variable refocusing flip angle single-shot FSE, a variation of single-shot FSE with lower radiofrequency energy deposition and potentially faster acquisition time, as an alternative approach to fast brain MR imaging.

MATERIALS AND METHODS

We retrospectively compared half-Fourier single-shot FSE with half- and full-Fourier variable refocusing flip angle single-shot FSE in 30 children. Three readers reviewed images for motion artifacts, image sharpness at the brain-fluid interface, and image sharpness/tissue contrast at gray-white differentiation on a modified 5-point Likert scale. Two readers also evaluated full-Fourier variable refocusing flip angle single-shot FSE against T2-FSE for brain lesion detectability in 38 children.

RESULTS

Variable refocusing flip angle single-shot FSE sequences showed more motion artifacts (P < .001). Variable refocusing flip angle single-shot FSE sequences scored higher regarding image sharpness at brain-fluid interfaces (P < .001) and gray-white differentiation (P < .001). Acquisition times for half- and full-Fourier variable refocusing flip angle single-shot FSE were faster than for single-shot FSE (P < .001) with a 53% and 47% reduction, respectively. Intermodality agreement between full-Fourier variable refocusing flip angle single-shot FSE and T2-FSE findings was near-perfect (κ = 0.90, κ = 0.95), with an 8% discordance rate for ground truth lesion detection.

CONCLUSIONS

Variable refocusing flip angle single-shot FSE achieved 2× faster scan times than single-shot FSE with improved image sharpness at brain-fluid interfaces and gray-white differentiation. Such improvements are likely attributed to a combination of improved contrast, spatial resolution, SNR, and reduced T2-decay associated with blurring. While variable refocusing flip angle single-shot FSE may be a useful alternative to single-shot FSE and, potentially, T2-FSE when faster scan times are desired, motion artifacts were more common in variable refocusing flip angle single-shot FSE, and, thus, they remain an important consideration before clinical implementation.

Intranasal dexmedetomidine versus oral chloral hydrate for diagnostic procedures sedation in infants and toddlers: A systematic review and meta-analysis

BACKGROUND

Intranasal dexmedetomidine is a relatively new way to sedate young children undergoing nonpainful diagnostic procedures. We performed a meta-analysis to compare the efficacy and safety of intranasal dexmedetomidine in young children with those of oral chloral hydrate, which has been a commonly used method for decades.

METHODS

We searched PubMed, Embase, and the Cochrane Library for all randomized controlled trials that compared intranasal dexmedetomidine with oral chloral hydrate in children undergoing diagnostic procedures. Data on success rate of sedation, onset time, recovery time, and adverse effects were extracted and respectively analyzed.

RESULTS

Five studies with a total of 720 patients met the inclusion criteria. Intranasal dexmedetomidine provided significant higher success rate of sedation (relative risk [RR], 1.12; 95% confidence interval [CI], 1.02 to 1.24; P = .02; I = 74%) than oral chloral hydrate. Furthermore, it experienced significantly shorter onset time (weight mean difference [WMD], -1.79; 95% CI, -3.23 to -0.34; P = .02; I = 69%). Nevertheless, there were no statistically differences in recovery time (WMD, -10.53; 95% CI, -24.17 to 3.11; P = .13; I = 92%) and the proportion of patients back to normal activities (RR, 1.11; 95% CI, 0.77-1.60; P = .57; I = 0%). Intranasal dexmedetomidine was associated with a significantly lower incidence of nausea and vomiting (RR, 0.05; 95% CI, 0.01-0.22; P < .0001; I = 0%) than oral chloral hydrate. Although adverse events such as bradycardia, hypotension and hypoxia were not synthetized due to lack of data, no clinical interventions except oxygen supplementation were required in any patients.

CONCLUSION

Our meta-analysis revealed that intranasal dexmedetomidine is possibly a more effective and acceptable sedation method for infants and toddlers undergoing diagnostic procedures than oral chloral hydrate. Additionally, it shows similar safety profile and could be a potential alternative to oral chloral hydrate.

Exploring Non-Pharmacological Management among Anesthesia Providers to Reduce Preoperative Distress in Children

Preparation for surgery with the induction of general anesthesia is one of the most stressful events that a child can experience. It produces several threats to the child, including physical harm, parent separation, and fear of the unknown. Anesthesia providers utilize non-pharmacological and pharmacological interventions to decrease this preoperatively. However, little is known about the non-pharmacological interventions utilized by anesthesia providers in practice. The purpose of this study was to explore non-pharmacological interventions utilized by anesthesia providers before and during the induction of general anesthesia to reduce preoperative distress in children ages one to six years old. A qualitative descriptive approach was used in this study. Twenty anesthesia providers, fourteen registered nurse anesthetists and six anesthesiologists, participated in face to face, in-depth interviews in South Florida. Content analysis was used to identify and define the major themes that emerged from the interviews. A total of seven main themes were identified. Only the three themes directly related to parent-provider-child relationship are discussed in this paper: (I) Communication, (II) Observational Skills, and (III) Parental Presence. The anesthesia providers who participated in this study offered an opportunity to better understand the non-pharmacological interventions used to impact the management of preoperative distress among children. Study findings provide evidence about non-pharmacological anesthesia providers' clinical work not found elsewhere in the literature. Non-pharmacological interventions are effective in reducing preoperative distress in 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.

Kitten Scanner reduces the use of sedation in pediatric MRI

The use of sedation before a magnetic resonance imaging (MRI) scan is a common practice to overcome motion artifacts and anxiety in children. However, this technique has its drawbacks. We retrospectively compared the number of children undergoing a brain MRI scan with or without sedation before and after the introduction of an educational training protocol using a toy scanner (the Philips Kitten Scanner) and we investigated the effectiveness of this training in relation to children's age and gender. We considered 1461 children between 4 years and 14 years. Of them, 158 had a diagnosis of autism spectrum disorder or attention-deficit hyperactivity disorder and were excluded from further analysis. After the introduction of the Kitten Scanner training protocol, the sedation need decreased by 30% in the total sample group and in children younger than 10 years in particular. Before the training, females were more likely to undergo the MRI examination without sedation as compared to males, while after its introduction this gender difference was no more visible.

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.

Added Value From Abbreviated Brain MRI in Children With Headache

OBJECTIVE. The purposes of this article are to describe implementation of an abbreviated brain MRI protocol for use in children with primary headache and to present an experience with the adaptation of the protocol in practice, work flow integration, and effects on sedation use. CONCLUSION. The abbreviated brain MRI protocol reduced the need for sedation for 74% of the study sample. Use of this protocol in this particular patient population continues, but further validation is required before its use is expanded to other pediatric populations.

Using a checklist to assess if a child undergoing MRI needs general anaesthesia

AIM

To assess if a child-assessment checklist covering tasks children are expected to perform during magnetic resonance imaging (MRI) can determine whether the child requires general anaesthesia (GA) during MRI.

MATERIALS AND METHODS

In this institute review board approved study, children who underwent MRI from September 2016 to June 2017 at KK Women's and Children's Hospital were assessed using a checklist by a research assistant before their examination. During this project, the checklist had no influence on whether the MRI was performed under GA or not. The checklist consisted of five items rated on a binary scale assessing the child's behaviour. Binary logistic regression was performed separately on the overall sample and for a subset of younger children to identify variables associated with the requirement for GA.

RESULTS

The mean age of the overall sample (798 children) and the subset of children <8 years (124 children) were 11.7±3.7 and 5.5±1.3 years, respectively. In both groups, children who required GA were significantly younger than those who did not (p<0.001). No gender differences were observed. Children who required GA scored higher on the checklist compared to those who did not in both groups (p<0.001). The diagnostic accuracy of the checklist was found to be good (area under the curve [AUC]=0.97 for both groups), with a suggested cut-off score of 4. Intraclass correlation coefficient of the ratings by two independent individuals was 0.78.

CONCLUSION

The child assessment checklist was useful in identifying GA requirement in children undergoing MRI and can be administered by non-medical staff with good inter-rater reliability.

Usefulness of Cranial Ultrasound for Detecting Neonatal Middle Cerebral Artery Stroke

Magnetic resonance imaging is the gold standard technique in establishing the diagnosis of neonatal arterial ischemic stroke (NAIS). The diagnostic value of cranial ultrasound scanning in this clinical context is controversial. We aimed to assess the current sensitivity of the cranial ultrasound scan (CUS) in detecting NAIS, as this issue has not been well described in the literature. Newborns with NAIS diagnosed by magnetic resonance imaging between 2010 and 2016 were included. All CUSs were blindly analyzed retrospectively by a neonatologist expert in neuroimaging and compared with the findings of non-expert evaluators recorded on medical charts immediately after performing the evaluation. The overall sensitivity of CUS in detecting an imaging finding suggestive of NAIS was 87% (95% confidence interval (CI): 79%-95%) for an expert evaluator, but declined to 72% (61%-83%) when performed by a non-expert evaluator (p 0.002). Sensitivity was 83% and 61% in the first 24 h and 86% and 66% at 24-48 h for expert and non-expert evaluators, respectively (p < 0.05). CUS has higher sensitivity than previously reported in the detection of a NAIS, for both expert and non-expert evaluators. These findings may be explained by the advanced technology of new ultrasound equipment. Expertise in performing CUS is useful, particularly in the first 48 h after clinical debut.

Premedication and Induction of Anaesthesia in paediatric patients

Perioperative anxiety has been associated with adverse clinical outcomes such as emergence delirium, increased analgesic requirements and negative postoperative behavioural changes such as sleep disturbance, separation anxiety, eating problems and new-onset enuresis. Predictors of preoperative anxiety have been identified, and these include, among other factors, the age and temperament of the child. Any plan for anaesthetic induction in a child must take into account these factors. The anaesthetic plan must be individualised for special situations, for example, the child with behavioural disorder or at risk of aspiration. This article details the pharmacological and nonpharmacological methods to minimise preoperative anxiety and the techniques of anaesthetic induction in infants and children undergoing surgery. The benefits and limitations of inhalational and intravenous induction and the current status of rapid sequence induction in children are discussed. MEDLINE database was searched for this narrative review using the keywords including preoperative anxiety, child, premedication, paediatric and anaesthetic induction. Search was restricted to articles in English, but without any publication date restrictions.

Ultrafast Brain MRI Can Be Used for Indications beyond Shunted Hydrocephalus in Pediatric Patients

BACKGROUND AND PURPOSE

Evaluation of shunted hydrocephalus is the most common indication for ultrafast brain MRI. Radiation-/sedation-free imaging capabilities make this protocol more desirable over CT and standard brain MRI. We hypothesized that ultrafast brain MRI can be used for selected indications beyond shunted hydrocephalus without adverse outcomes.

MATERIALS AND METHODS

Ultrafast brain MRI was performed with axial, sagittal, and coronal HASTE. The radiology information system was used to identify pediatric patients (0-18 years of age) who underwent ultrafast brain MRI between March 2014 and May 2016. A retrospective chart review was completed to identify indications other than shunted hydrocephalus, such as ventriculomegaly, macrocephaly, or intracranial cyst. All ultrafast brain MRIs were evaluated by a certified neuroradiologist and a neurosurgeon. Ultrafast brain MRI was deemed of sufficient diagnostic value for these indications if no further standard brain MRI was required for the study indication or if additional imaging was performed for an alternate indication.

RESULTS

The radiology information system identified 800 patients who had undergone an ultrafast brain MRI during the study period. One hundred twenty-two of these patients had ventriculomegaly, macrocephaly, or intracranial cyst as the study indication. Twenty-one of the 122 patients were excluded due to insufficient follow-up. Of the remaining 101 patients, only 5 had a standard brain MRI for the same indication, with no additional clinically significant information identified on those studies.

CONCLUSIONS

These results suggest that ultrafast brain MRI is sufficient to evaluate ventriculomegaly, macrocephaly, or intracranial cyst. Ultrafast brain MRI is radiation- and sedation-free; therefore, we recommend its use as the primary screening neuroimaging study for these indications.

Rapid-sequence brain magnetic resonance imaging for Chiari I abnormality

OBJECTIVE Fast magnetic resonance imaging (fsMRI) sequences are single-shot spin echo images with fast acquisition times that have replaced CT scans for many conditions. Introduced as a means of evaluating children with hydrocephalus and macrocephaly, these sequences reduce the need for anesthesia and can be more cost-effective, especially for children who require multiple surveillance scans. However, the role of fsMRI has yet to be investigated in evaluating the posterior fossa in patients with Chiari I abnormality (CM-I). The goal of this study was to examine the diagnostic performance of fsMRI in evaluating the cerebellar tonsils in comparison to conventional MRI. METHODS The authors performed a retrospective analysis of 18 pediatric patients with a confirmed diagnosis of CM-I based on gold-standard conventional brain MRI and 30 controls without CM-I who had presented with various neurosurgical conditions. The CM-I patients were included if fsMRI studies had been obtained within 1 year of conventional MRI with no surgical intervention between the studies. Two neuroradiologists reviewed the studies in a blinded fashion to determine the diagnostic performance of fsMRI in detecting CM-I. For the CM-I cohort, the fsMRI and T2-weighted MRI exams were randomized, and the blinded reviewers performed tonsillar measurements on both scans. RESULTS The mean age of the CM-I cohort was 7.39 years, and 50% of these subjects were male. The mean time interval between fsMRI and conventional T2-weighted MRI was 97.8 days. Forty-four percent of the subjects had undergone imaging after posterior fossa decompression. The sensitivity and specificity of fsMRI in detecting CM-I was 100% (95% CI 71.51%-100%) and 92.11% (95% CI 78.62%-98.34%), respectively. If only preoperative patients are considered, both sensitivity and specificity increase to 100%. The authors also performed a cost analysis and determined that fsMRI was significantly cost-effective compared to T2-weighted MRI or CT. CONCLUSIONS Despite known limitations, fsMRI may serve as a useful diagnostic and surveillance tool for CM-I. It is more cost-effective than full conventional brain MRI and decreases the need for sedation in young children.

Cost-effectiveness of Treating Severe Childhood Caries under General Anesthesia versus Conscious Sedation

BACKGROUND

Two common methods of treating pediatric dental patients with severe early childhood caries (S-ECC) are general anesthesia (GA) and conscious sedation (CS). We sought to first evaluate the cost-effectiveness of treating S-ECC with GA versus CS and then compare the cost-effectiveness at 2 time points: 2011 and 2015.

METHODS

We used a decision tree model to produce 2-y estimates of costs and outcomes from the Medicaid perspective. The model cohort consisted of healthy 3-y-olds with S-ECC in need of a theoretical set of dental treatments to be performed under either a single GA visit or 3 CS visits. Outcomes were measured in caries-free months. Costs were evaluated in 2015 US dollars. Costs, probabilities, and outcomes were estimated from published data, expert opinion, and Medicaid billing at an academic health center. One-way and probabilistic sensitivity analyses were performed.

RESULTS

As compared with CS, GA resulted in 4 additional caries-free months per child. The cost of a caries-free month for GA versus CS rose from $596 in 2011 to $881 in 2015. These findings were sensitive to loss to follow-up for subsequent CS visits and total cost of GA.

CONCLUSIONS

Comprehensive S-ECC treatment had better outcomes when performed under GA versus CS. However, GA was not cost saving when compared with CS. While the cost of dental treatment increased for both GA and CS from 2011 to 2015, the cost rose faster for GA. These results have important implications due to the increasing cost to Medicaid insurance and the rising number of young children being treated for S-ECC under GA.

KNOWLEDGE TRANSFER STATEMENT

Medicaid policy makers can use the results of this study to evaluate the cost-effectiveness of dental treatment for young children with S-ECC at 2 time points: 2011 and 2015. Compared with CS, GA resulted in a longer amount of time during which children were free from dental caries but at a higher cost. The cost difference rose from 2011 to 2015.

Sedation: A Primer for Pediatricians

There has been an increasing use of pediatric procedural sedation and analgesia over the past 20 years, along with numerous medical and technological developments. Sedation can facilitate the smooth completion of otherwise stressful procedures, but it also can be associated with life-threatening complications. Pediatric practitioners need to be familiar with the basic tenets of providing safe and optimal sedation outside the operating room. This review focuses on the current understanding of sedation-related classification, guidelines, and medications, and discusses some special considerations for procedural sedation in common clinical settings. [Pediatr Ann. 2018;47(6):e254-e258.].

Comprehensive Multi-Dimensional MRI for the Simultaneous Assessment of Cardiopulmonary Anatomy and Physiology

Diagnostic testing often assesses the cardiovascular or respiratory systems in isolation, ignoring the major pathophysiologic interactions between the systems in many diseases. When both systems are assessed currently, multiple modalities are utilized in costly fashion with burdensome logistics and decreased accessibility. Thus, we have developed a new acquisition and reconstruction paradigm using the flexibility of MRI to enable a comprehensive exam from a single 5-15 min scan. We constructed a compressive-sensing approach to pseudo-randomly acquire highly subsampled, multi-dimensionally-encoded and time-stamped data from which we reconstruct volumetric cardiac and respiratory motion phases, contrast-agent dynamics, and blood flow velocity fields. The proposed method, named XD flow, is demonstrated for (a) evaluating congenital heart disease, where the impact of bulk motion is reduced in a non-sedated neonatal patient and (b) where the observation of the impact of respiration on flow is necessary for diagnostics; (c) cardiopulmonary imaging, where cardiovascular flow, function, and anatomy information is needed along with pulmonary perfusion quantification; and in (d) renal function imaging, where blood velocities and glomerular filtration rates are simultaneously measured, which highlights the generality of the technique. XD flow has the ability to improve quantification and to provide additional data for patient diagnosis for comprehensive evaluations.

Intranasal Dexmedetomidine for Procedural Sedation in Children, a Suitable Alternative to Chloral Hydrate

Sedation is often required for children undergoing diagnostic procedures. Chloral hydrate has been one of the sedative drugs most used in children over the last 3 decades, with supporting evidence for its efficacy and safety. Recently, chloral hydrate was banned in Italy and France, in consideration of evidence of its carcinogenicity and genotoxicity. Dexmedetomidine is a sedative with unique properties that has been increasingly used for procedural sedation in children. Several studies demonstrated its efficacy and safety for sedation in non-painful diagnostic procedures. Dexmedetomidine's impact on respiratory drive and airway patency and tone is much less when compared to the majority of other sedative agents. Administration via the intranasal route allows satisfactory procedural success rates. Studies that specifically compared intranasal dexmedetomidine and chloral hydrate for children undergoing non-painful procedures showed that dexmedetomidine was as effective as and safer than chloral hydrate. For these reasons, we suggest that intranasal dexmedetomidine could be a suitable alternative to chloral hydrate.

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.

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.

Safety and efficacy of chloral hydrate for conscious sedation of infants in the pediatric cardiovascular intensive care unit

This study evaluates the safety and efficacy of chloral hydrate administration for the conscious sedation of infants in the pediatric cardiovascular intensive care unit (PCICU).We conducted a retrospective review of the charts of 165 infants with congenital heart disease who received chloral hydrate in our PCICU between January 2014 and December 2014. Chloral hydrate was administered orally or rectally to infants using doses of 50 mg/kg. We collected and analyzed relevant clinical parameters.The overall length of time to achieve sedation was ranged from 5 to 35 min (10.8 ± 6.2 min); the overall mean duration of sedation was ranged from 15 to 60 min (33.5 ± 11.3 min); and the overall mean length of time to return to normal activity was 10 min to 6 h (34.3 ± 16.2 min). The length of the PCICU stay was ranged from 3 to 30 days (8.2 ± 7.1 days). Physiologically, there were no clinically significant changes in heart rate, mean arterial pressure, respiratory rate, or peripheral oxygen saturation before, during, or after use of the chloral hydrate. There were no significant differences regarding sedative effects in the subgroups (cyanotic vs acyanotic group, with pulmonary infection vs without pulmonary infection group, and with pulmonary hypertension vs without pulmonary hypertension group).Our experience suggests that chloral hydrate is a safe and efficacious agent for conscious sedation of infants in the PCICU.

Charges associated with imaging techniques in evaluation of pediatric hearing loss

OBJECTIVE

The best imaging study for evaluation of pediatric hearing loss is debated and it is well known magnetic resonance imaging is more costly than computed tomography. The objective of this study is to evaluate charges of computed tomography temporal bone (CTTB) versus magnetic resonance imaging brain, internal auditory canal/cerebellopontine angle (MRI IAC/CPA), with and without sedation in the pediatric population in order to assess to what extent the charges for the procedure are increased. In addition, differences in need for sedation and duration of sedation will be evaluated.

METHODS

All patients, 0-18 years that underwent CTTB or MRI IAC/CPA, between January 2013 through December 2014 within department of otolaryngology.

RESULTS

120 CTTBs (118 non-sedated and 2 sedated) and 51 MRI IAC/CPAs (32 non-sedated and 19 sedated) were performed. Average charge for non-sedated CTTB was $1856. CTTB scan under sedation incurred total additional charges of $2385. Average charges for non-sedated MRI IAC/CPA was $3770. Technical charges for sedated MRI IAC/CPA was $151 lower ($2858) but had additional sedation charges of $2256, a recovery room charge of $250, and additional professional fees of $1496 for total charges of $7621. 37% of MRI IAC/CPAs needed sedation to be completed in comparison to 1.6% of CTTB.

CONCLUSION

MRI IAC/CPAs are, on average, twice as costly as CTTBs. Almost 40% of patients need sedation to complete MRI IAC/CPA. These considerations may factor into decision making when choosing imaging modality in evaluation of pediatric hearing loss.