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Beaulieu FP, Zuckerberg G, Coletti K, Mapelli E, Flibotte J, Sampath S, Hwang M, Drum ET. Sedation and anesthesia for imaging of the infant and neonate-a brief review. Pediatr Radiol 2024; 54:1579-1588. [PMID: 39060413 DOI: 10.1007/s00247-024-05995-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 06/26/2024] [Accepted: 06/29/2024] [Indexed: 07/28/2024]
Abstract
Sedation and anesthesia are often required in order to facilitate collection of high-quality imaging studies free of significant motion artifact for infants and neonates. Provision of safe sedation and anesthesia requires good communication between the ordering provider, radiologist, and anesthesiologist, careful pre-procedural evaluation of the patient, and availability of appropriate and sufficient equipment, drugs, personnel, and facilities. There are many additional factors to be considered for provision of safe sedation or anesthesia for infants and neonates-it is ideal to involve a fellowship-trained pediatric anesthesiologist in the planning and carry-out of these plans. In this review, we discuss some of the basic definitions of sedation and anesthesia, requirements for safe sedation and anesthesia, and many of the germane risks and additional considerations that factor into the delivery of a safe sedation or anesthesia plan for the imaging of an infant or neonate.
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Affiliation(s)
- Forrest P Beaulieu
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
| | - Gabriel Zuckerberg
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Kristen Coletti
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | - Emily Mapelli
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - John Flibotte
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | - Spoorthi Sampath
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | - Misun Hwang
- Department of Radiology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Elizabeth T Drum
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
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Sarvas E, Webb J, Landrigan-Ossar M, Yin L. Oral Health Care for Children and Youth With Developmental Disabilities: Clinical Report. Pediatrics 2024; 154:e2024067603. [PMID: 39034828 DOI: 10.1542/peds.2024-067603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 05/23/2024] [Accepted: 05/24/2024] [Indexed: 07/23/2024] Open
Abstract
Oral health is an essential component of overall health for all individuals. The oral health of children and youth with developmental disabilities (CYDD) involves unique characteristics and needs of which pediatricians and pediatric clinicians can be aware. Risk for oral disease in CYDD is multifactorial and includes underlying medical conditions, medications, and ability to participate in preventive oral health care and treatment, and lack of access to providers is common for this population despite being eligible for Medicaid. Pediatric clinicians are uniquely positioned to support the oral health needs of CYDD and their families through the medical home. This clinical report aims to inform pediatric clinicians about the unique oral health needs of CYDD. It provides guidance on assessing caries risk and periodontal status using structured screening instruments; understanding dental trauma, the role of diet and caries risk, trauma prevention, and malocclusion; and providing anticipatory guidance on oral hygiene that includes tooth brushing, use of fluoridated toothpaste, assessing community water fluoridation, advocating for a dental home by 1 year of age, and transition to adult dental care as part of adolescent health care. It also highlights special considerations for dental treatment rendered under sedation or general anesthesia that CYDD may need. Pediatric clinicians can help reduce risk of CYDD developing dental disease by understanding the unique needs of their patients and their barriers to accessing oral health care in their community, communicating with the child's dental home, and advocating for safe and accessible dental procedures.
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Affiliation(s)
| | | | | | - Larry Yin
- Associate Professor of Clinical Pediatrics, Keck School of Medicine of USC and Children's Hospital Los Angeles, Los Angeles, California
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Cui Y, Tang M, Mu Q, Wu Q, Kang L, Chen Q, He Y. Four-year review of safe and effective procedural sedation in neonates and young infants. Front Pharmacol 2024; 15:1381413. [PMID: 39130634 PMCID: PMC11310124 DOI: 10.3389/fphar.2024.1381413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Accepted: 07/11/2024] [Indexed: 08/13/2024] Open
Abstract
Objectives Newborns and small infants are unable to cooperate actively during diagnostic procedures; therefore, sedation is often employee to maintain immobilization and obtain high-quality images. However, these procedures are often indicated in sick, vulnerable, or hemodynamically unstable neonates and young infants, which raises the associated risks of sedation. This study summarizes our 4-year of experience with safe and effective procedural sedation in this vulnerable population. Study design This retrospective study analyzed data on neonates and young infants who underwent non-painful diagnostic procedures from December 2019 to November 2023. Patients were categorized into the neonate (aged≦ 28 days) and the young infant (29 days ≦ aged ≦ 90 days) groups. Results Non-pharmacological strategies, including sleeping naturally, swaddling/facilitated tucking, non-nutritive sucking, and skin-to-skin care, can achieve a success rate for sedation about 98.4%. In terms of pharmacological methods, our institution primarily utilizes chloral hydrate for procedural sedation in neonates and young infants undergoing non-painful diagnostic procedures. Midazolam serves as an alternative sedative. Chloral hydrate alone demonstrated a 92.5% success rate on the first attempt, compared to midazolam alone, with an 85.11% success rate. Neonates experienced a higher incidence of adverse events during sedation compared to young infants. Conclusion This study reviews our 4-year experience with procedural sedation in neonates and young infants. Chloral hydrate demonstrated a high degree of safety and efficacy in this population. However, supervision by skilled medical personnel and extended observation is required. In our institution, the experience with midazolam is limited in this population, and further research is warranted to establish its safety and efficacy. Non-pharmacological strategies can achieve an acceptable rate of sedation success, which can be used based on patient's tolerance.
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Escobar N, Levy-Lambert D, Fisher J, DiMaggio C, Kazmi S, Tomita S. Early Findings of a Preterm Twin Cohort Study Examining the Effect of General Anesthesia on Developmental Outcomes. J Dev Behav Pediatr 2024:00004703-990000000-00186. [PMID: 38990148 DOI: 10.1097/dbp.0000000000001300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 05/13/2024] [Indexed: 07/12/2024]
Abstract
PURPOSE The premature infant brain may be particularly vulnerable to anesthesia effects, but there is conflicting evidence on the association between anesthesia exposure and developmental outcomes. Twin studies can control for confounding factors. A twin cohort of premature twins provides internal control of difficulty to measure confounders and delivers added power to a study examining the effects of anesthesia on neurodevelopmental outcomes. METHODS We conducted a retrospective cohort study of sets of premature twins and multiples born at an academic medical center, in which 1 member of the set was exposed to general anesthesia. The primary outcome was the composite scores using Bayley Scale of Infant and Toddler Development III performed at age 6 months to 18 months. Unpaired and paired analyses were performed with linear regression models, Wilcoxon signed rank test, and Mann-Whitney U test. RESULTS We identified 81 children born at less than 32 weeks gestation within 39 sets of twins and 1 set of triplets for a total of 18 paired observations. All of the exposed infants had a single exposure to general anesthesia. There was no significant association between anesthesia exposure and a diagnosis of developmental delay (OR = 0.8; 95% confidence interval, 0.2-3.2; p = 0.99). Regression models demonstrated no association between anesthesia exposure and cognitive (96.67 vs 97.50; p = 0.74), language (98.33 vs 98.61; p = 0.94), or motor (96.25 vs. 96.44; p = 0.91) composite Bayley scores. There was no association between duration of anesthesia and the 3 composite Bayley scores (p = 0.33; p = 0.40; p = 0.74). CONCLUSION Using a premature twin cohort with discordant exposure to anesthesia, our data did not demonstrate any association between anesthesia exposure and developmental delay in this vulnerable population of premature infants.
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Affiliation(s)
- Natalie Escobar
- Division of Pediatric Surgery, Department of Surgery, Hassenfeld Children's Hospital at NYU Langone, NYU Langone Grossman School of Medicine, New York, NY
| | - Dina Levy-Lambert
- Division of Pediatric Surgery, Department of Surgery, Hassenfeld Children's Hospital at NYU Langone, NYU Langone Grossman School of Medicine, New York, NY
| | - Jason Fisher
- Division of Pediatric Surgery, Department of Surgery, Hassenfeld Children's Hospital at NYU Langone, NYU Langone Grossman School of Medicine, New York, NY
| | - Charles DiMaggio
- Department of Surgery, NYU Langone Grossman School of Medicine, New York, NY; and
| | - Sadaf Kazmi
- Division of Neonatology, Department of Pediatrics, NYU Langone Grossman School of Medicine, New York, NY
| | - Sandra Tomita
- Division of Pediatric Surgery, Department of Surgery, Hassenfeld Children's Hospital at NYU Langone, NYU Langone Grossman School of Medicine, New York, NY
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Wan S, Wu W, Bu W. Application of intranasal dexmedetomidine in magnetic resonance imaging of preterm infants: The ED50, efficacy and safety analysis. Medicine (Baltimore) 2024; 103:e38040. [PMID: 38701317 PMCID: PMC11062713 DOI: 10.1097/md.0000000000038040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 04/05/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND Infants undergoing magnetic resonance imaging (MRI) often require pharmacological sedation. Dexmedetomidine serves as a novel sedative agent that induces a unique unconsciousness similar to natural sleep, and therefore has currently been used as the first choice for sedation in infants and young children. OBJECTIVE To determine the 50% effective dose (ED50) and 95% confidence interval (95%CI) of intranasal dexmedetomidine for MRI in preterm and term infants, and to observe the incidence of adverse events. To explore whether there were differences in ED50 and 95%CI, heart rate (HR) and blood oxygen saturation (SpO2), the induction time and wake-up time and the incidence of adverse events between the 2 groups, so as to provide guidance for clinical safe medication for the meanwhile. METHODS A total of 68 infants were prospectively recruited for MRI examination under drug sedation (1 week ≤ age ≤ 23 weeks or weight ≤ 5kg). The children were divided into 2 groups according to whether they had preterm birth experience (Preterm group, Atterm group). The Dixon up-and-down method was used to explore ED50. The basic vital signs of the 2 groups were recorded, and the heart rate and SpO2 were recorded every 5 minutes until the infants were discharged from the hospital. The induction time, wake-up time and adverse events were recorded. RESULTS The ED50 (95%CI) of intranasal dexmedetomidine in the Preterm group and the Atterm group were 2.23 (2.03-2.66) μg/kg and 2.64 (2.49-2.83) μg/kg, respectively (P < .05). the wake-up time was longer in Preterm group (98.00min) than in Atterm group (81.00 min) (P < .05), the incidence of bradycardia in Preterm group was 3/33, which was higher than that in Atterm group (1/35). There was no difference in the induction time between the 2 groups (P > .05), and there was no significant difference in other adverse events. CONCLUSIONS Intranasal dexmedetomidine can be safely used for sedation in preterm infants undergoing MRI. Compared with term infants, preterm infants have a lower dose of dexmedetomidine, a higher incidence of bradycardia, and a longer weak-up time.
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Affiliation(s)
- Shengjun Wan
- Department of Anesthesiology, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Wu
- Department of Anesthesiology, CR & WISCO General Hospital, Affiliated to Wuhan University of Science and Technology, Wuhan, China
| | - Wenhao Bu
- Department of Anesthesiology, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Wallace TE, Piccini D, Kober T, Warfield SK, Afacan O. Rapid motion estimation and correction using self-encoded FID navigators in 3D radial MRI. Magn Reson Med 2024; 91:1057-1066. [PMID: 37929608 PMCID: PMC10843402 DOI: 10.1002/mrm.29899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/15/2023] [Accepted: 10/06/2023] [Indexed: 11/07/2023]
Abstract
PURPOSE To develop a self-navigated motion compensation strategy for 3D radial MRI that can compensate for continuous head motion by measuring rigid body motion parameters with high temporal resolution from the central k-space acquisition point (self-encoded FID navigator) in each radial spoke. METHODS A forward model was created from low-resolution calibration data to simulate the effect of relative motion between the coil sensitivity profiles and the underlying object on the self-encoded FID navigator signal. Trajectory deviations were included in the model as low spatial-order field variations. Three volunteers were imaged at 3 T using a modified 3D gradient-echo sequence acquired with a Kooshball trajectory while performing abrupt and continuous head motion. Rigid body-motion parameters were estimated from the central k-space signal of each spoke using a least-squares fitting algorithm. The accuracy of self-navigated motion parameters was assessed relative to an established external tracking system. Quantitative image quality metrics were computed for images with and without retrospective correction using external and self-navigated motion measurements. RESULTS Self-encoded FID navigators achieved mean absolute errors of 0.69 ± 0.82 mm and 0.73 ± 0.87° relative to external tracking for maximum motion amplitudes of 12 mm and 10°. Retrospective correction of the 3D radial data resulted in substantially improved image quality for both abrupt and continuous motion paradigms, comparable to external tracking results. CONCLUSIONS Accurate rigid body motion parameters can be rapidly obtained from self-encoded FID navigator signals in 3D radial MRI to continuously correct for head movements. This approach is suitable for robust neuroanatomical imaging in subjects that exhibit patterns of large and frequent motion.
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Affiliation(s)
| | - Davide Piccini
- Advanced Clinical Imaging Technology, Siemens Healthineers International AG, Lausanne, Switzerland
- Department of Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- LTS5, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Tobias Kober
- Advanced Clinical Imaging Technology, Siemens Healthineers International AG, Lausanne, Switzerland
- Department of Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- LTS5, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Simon K. Warfield
- Department of Radiology, Boston Children’s Hospital, Boston, MA, USA
- Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - Onur Afacan
- Department of Radiology, Boston Children’s Hospital, Boston, MA, USA
- Department of Radiology, Harvard Medical School, Boston, MA, USA
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Al-Damri A, Alotaibi HM. Congenital Cataracts in Preterm Infants: A Review. Cureus 2023; 15:e40378. [PMID: 37456485 PMCID: PMC10344420 DOI: 10.7759/cureus.40378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2023] [Indexed: 07/18/2023] Open
Abstract
A congenital cataract is one of the most treatable causes of visual impairment during infancy. Preterm infants who are born alive before 37 weeks of pregnancy need special care, including proper age documentation, preoperative assessment, and monitoring postoperatively for at least 24 hours. Management of cataracts in preterm infants is critical as regards the timing of cataract surgery and the challenges associated with cataract surgery and posterior segment management for retinopathy of prematurity (ROP). This narrative review aims to provide comprehensive insight and up-to-date clinical research findings regarding the pathophysiology and management of congenital cataracts in preterm infants.
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Sbaraglia F, Spinazzola G, Adduci A, Continolo N, De Riso M, Ferrone G, Festa R, Garra R, Tosi F, Rossi M. Children and neonates anesthesia in magnetic resonance environment in Italy: an active call survey. BMC Anesthesiol 2022; 22:279. [PMID: 36056321 PMCID: PMC9438255 DOI: 10.1186/s12871-022-01821-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 08/19/2022] [Indexed: 11/25/2022] Open
Abstract
Background Pediatric anesthesia care in the Magnetic Resonance Imaging is a challenge for clinicians. The recent debate about the role of anesthetic agent on neural development, encouraged an evaluation of their actual activity in this environment. In this active call survey, the authors sought to delineate the Italian situation regarding national centers, staff involved, monitoring tools available and sedation techniques. Methods A complete sample of all national centers performing almost a pediatric discharge in the 2014 was obtained from Health Ministry registers. All Institutions were contacted for a prospective phone investigation and a three-section survey was fill out with the Physician in charge. A descriptive and exploratory analyzes about the organization setting of the Centers were performed. Results Among 876 Institution screened, only 106 (37%) met minimal criteria for inclusion. Children are managed by anesthesiologists in the 95% of cases, while neonates in the 54%. A dedicated nurse is present in 74% of centers. While a pulse oximetry is present in 100% of centers, the rate of prevalence of other monitoring is lower. A specific MRI-compatible ventilator is available in the 95% of Centers, but many tools are not equally homogenously distributed. Pharmacological approach is preferred in pediatric age (98%), but its use for newborns is reduced to 43%. Conclusions We found significant heterogeneity in the daily clinical practice of sedation in MRI. Our results could be a starting point to evaluate the further evolution of approach to children and neonates in magnetic resonance setting. Trial registration ClinicalTrials.gov identifier: NCT04775641. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01821-3.
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Affiliation(s)
- Fabio Sbaraglia
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168, Rome, Italy.
| | - Giorgia Spinazzola
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168, Rome, Italy
| | - Alessia Adduci
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168, Rome, Italy
| | - Nicola Continolo
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168, Rome, Italy
| | - Mariella De Riso
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168, Rome, Italy
| | - Giuliano Ferrone
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168, Rome, Italy
| | - Rossano Festa
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168, Rome, Italy
| | - Rossella Garra
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168, Rome, Italy
| | - Federica Tosi
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168, Rome, Italy
| | - Marco Rossi
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168, Rome, Italy
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Imaging of Macrocephaly. Clin Perinatol 2022; 49:715-734. [PMID: 36113931 DOI: 10.1016/j.clp.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Macrocephaly is a common diagnosis in the pediatric population, particularly in the infantile time period. There is a wide range of causes of macrocephaly, from benign to malignant, for which imaging plays a key role in the diagnosis and clinical guidance. Our aim is to review the distinct and prevalent neuroimaging findings in the evaluation of the macrocephalic infant.
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Boriosi JP, Lasarev MR, Peters ME, Ferrazzano P, Hollman GA. Anticholinergics and serious adverse events in pediatric procedural sedation: A report of the pediatric sedation research consortiums. Paediatr Anaesth 2022; 32:665-672. [PMID: 35072305 DOI: 10.1111/pan.14403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 12/17/2021] [Accepted: 01/14/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pediatric sedation is a clinical activity with potential for serious but rare airway adverse events, particularly laryngospasm. Anticholinergic drugs, atropine and glycopyrrolate, are frequently used with the intention to improve sedation safety by virtue of their antisialagogue effects. AIMS The objective of this study is to describe the current practice of anticholinergic use in pediatric sedation and to compare the frequency of serious sedation-related adverse events in patients who received anticholinergics to those who did not. METHODS We examined prospectively collected data from the Pediatric Sedation Research Consortium database. Patient characteristics, procedure type, sedation provider, sedatives, location of sedation, anticholinergic administered, adverse events, and airway interventions were reported. Propensity score matching and multivariable logistic regression were used to test whether any association exists between anticholinergic use and serious sedation-related adverse events. RESULTS Anticholinergics were administered in 7.1% (n = 18 707) of all cases (n = 263 883) reported between November 2011 and October 2017. When anticholinergics were used, atropine was used in 22% (n = 4111) and glycopyrrolate in 78.1% (n = 14 601) of sedations. Use of anticholinergics was more common in patients with well-described risk factors for airway adverse events: active/history of upper respiratory infection, history of reactive airway disease/asthma, and exposure to smoke. However, infants and ASA 3 patients were not associated with higher rate of anticholinergic use. Anticholinergic use was independently associated with an increase in the odds of serious adverse events, OR 1.8 (95% CI 1.6-2.1), especially airway adverse events. CONCLUSIONS In this large Pediatric Sedation Research Consortium study, we found the use of anticholinergic adjuvants independently associated with greater odds of serious adverse events, especially airway adverse events, after adjusting for well-known sedation risk factors using propensity score matching and multivariate analysis.
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Affiliation(s)
- Juan P Boriosi
- Department of Pediatrics, University of Wisconsin, Madison, Wisconsin, USA
| | - Michael R Lasarev
- Department of Biostatistics, University of Wisconsin, Madison, Wisconsin, USA
| | - Megan E Peters
- Department of Pediatrics, University of Wisconsin, Madison, Wisconsin, USA
| | - Peter Ferrazzano
- Department of Pediatrics, University of Wisconsin, Madison, Wisconsin, USA
| | - Gregory A Hollman
- Department of Pediatrics, University of Wisconsin, Madison, Wisconsin, USA
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Schooler GR, Cravero JP, Callahan MJ. Assessing and conveying risks and benefits of imaging in neonates using ionizing radiation and sedation/anesthesia. Pediatr Radiol 2022; 52:616-621. [PMID: 34283256 DOI: 10.1007/s00247-021-05138-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/24/2021] [Accepted: 06/14/2021] [Indexed: 12/15/2022]
Abstract
Neonates represent a unique subset of the pediatric population that requires special attention and careful thought when implementing advanced cross-sectional imaging with CT or MRI. The ionizing radiation associated with CT and the sedation/anesthesia occasionally required for MRI present risks that must be balanced against the perceived benefit of the imaging examination in the unique and particularly susceptible neonatal population. We review the perceived risks of ionizing radiation and the more concrete risks of sedation/anesthesia in term and preterm neonates in the context of an imaging paradigm. When the expected diagnostic yield from CT and MRI is similar, and sedation is required for MRI but not for CT, CT likely has the higher benefit-to-risk ratio in the neonate. However, despite the risks, the most appropriate imaging modality should always be chosen after thoughtful consideration is given to each unique patient and informed discussions including radiology, anesthesia, neonatology and the parents/caregivers are pursued.
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Affiliation(s)
- Gary R Schooler
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA.
| | - Joseph P Cravero
- Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, USA
| | - Michael J Callahan
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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12
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Gloff MS, Robinson R, Correll LR, Lander H, Pyne S, Webber A. Preoperative optimization in the pediatric patient. Int Anesthesiol Clin 2022; 60:56-63. [PMID: 34711789 DOI: 10.1097/aia.0000000000000342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Marjorie S Gloff
- Department of Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York
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Eichhorn H, Vascan AV, Nørgaard M, Ellegaard AH, Slipsager JM, Keller SH, Marner L, Ganz M. Characterisation of Children's Head Motion for Magnetic Resonance Imaging With and Without General Anaesthesia. FRONTIERS IN RADIOLOGY 2021; 1:789632. [PMID: 37492164 PMCID: PMC10365093 DOI: 10.3389/fradi.2021.789632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 11/08/2021] [Indexed: 07/27/2023]
Abstract
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.
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Affiliation(s)
- Hannah Eichhorn
- Neurobiology Research Unit, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Niels Bohr Institute, University of Copenhagen, Copenhagen, Denmark
| | - Andreea-Veronica Vascan
- Neurobiology Research Unit, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Computer Science, University of Copenhagen, Copenhagen, Denmark
| | - Martin Nørgaard
- Neurobiology Research Unit, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Center for Reproducible Neuroscience, Department of Psychology, Stanford University, Stanford, CA, United States
| | | | - Jakob M. Slipsager
- TracInnovations, Ballerup, Denmark
- Department of Applied Mathematics and Computer Science, Technical University of Denmark, Lyngby, Denmark
- Department of Clinical Physiology, Nuclear Medicine & PET, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Sune Høgild Keller
- Department of Clinical Physiology, Nuclear Medicine & PET, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Lisbeth Marner
- Department of Clinical Physiology, Nuclear Medicine & PET, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Melanie Ganz
- Neurobiology Research Unit, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Computer Science, University of Copenhagen, Copenhagen, Denmark
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14
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Morton SU, Labrecque M, Moline M, Hansen A, Leeman K. Reducing Benzodiazepine Exposure by Instituting a Guideline for Dexmedetomidine Usage in the NICU. Pediatrics 2021; 148:e2020041566. [PMID: 34610948 DOI: 10.1542/peds.2020-041566] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/22/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Midazolam is a benzodiazepine sedative used in NICUs. Because benzodiazepine's effects include respiratory depression and potential detrimental developmental effects, minimizing exposure could benefit neonates. Dexmedetomidine is routinely used for sedation in older pediatric populations. We implemented a quality improvement initiative with the aim of decreasing midazolam infusions by 20% through use of dexmedetomidine. METHODS A multidisciplinary committee created a sedation guideline that included standardized dexmedetomidine dosing escalation and weaning. Baseline data collection occurred from January 2015 to February 2018, with intervention from March 2018 to December 2019. Percentage of sedation episodes with dexmedetomidine initiated was followed as a process measure. Outcomes measures were percentage of eligible infants receiving midazolam infusions and midazolam-free days per sedation episode. Bradycardia with dexmedetomidine, unplanned extubation rates, and morphine dosage were monitored as balancing measures. RESULTS Our study included 434 episodes of sedation in 386 patients. Dexmedetomidine initiation increased from 18% to 49%. The intervention was associated with a significant reduction in midazolam initiation by 30%, from 95% to 65%, with special cause variation on statistical process control chart analysis. Midazolam-free days per sedation episode increased from 0.3 to 2.2 days, and patients receiving dexmedetomidine had lower midazolam doses (1.3 mg/kg per day versus 2.2 mg/kg per day, P = 5.97 × 10-04). Bradycardia requiring discontinuation of dexmedetomidine, unplanned extubation rates, and morphine doses were unchanged. CONCLUSIONS Implementation of a quality improvement initiative was successful in reducing the percentage of patients receiving midazolam infusions and increased midazolam-free days per sedation episode, revealing an overall reduction in benzodiazepine exposure while maintaining adequate sedation.
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Affiliation(s)
- Sarah U Morton
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Michelle Labrecque
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Mark Moline
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Anne Hansen
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Kristen Leeman
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School, Harvard University, Boston, Massachusetts
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15
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Yoo YM, Park JE, Park MS, Lee JH. Implementation of the Feed and Swaddle Technique as a Non-Pharmacological Strategy to Conduct Brain Magnetic Resonance Imaging in Very Low Birth Weight Infants. NEONATAL MEDICINE 2021. [DOI: 10.5385/nm.2021.28.3.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Purpose: Magnetic resonance imaging (MRI) is a useful tool for evaluating brain injury and maturation in preterm infants and often requires sedation to acquire images of sufficient quality. Infant sedation is often associated with adverse events, despite extreme precautions. In this study, the swaddling technique was investigated as an alternative non-pharmacological strategy to obtain brain MRIs of sufficient quality.Methods: We applied the feed and swaddle technique during routine brain MRI as a quality improvement project and compared its morbidity with that of sedation in a historic age-matched group. Seventy-nine very low birth weight infants in the neonatal intensive care unit of Ajou University Hospital (Suwon, Korea) were enrolled. Thirty-two (40.5%) infants were in the feed and swaddling group, and 47 (59.5%) were in the sedation group.Results: The morbidity associated with the cardiopulmonary system (swaddling group vs. sedation group: 53.13% [n=17] vs. 63.83% [n=30], P=0.723) and central nervous system (40.63% [n=13] vs. 29.79% [n=14], P=0.217) were not significantly different between groups. The MRI failure rate was not significantly different (swaddling group vs. sedation group: 12.5% [n=4] vs. 4.3% [n=2], P=0.174). The MRI scanning time was longer in the swaddling group than in the sedation group (76.5±20.3 minutes vs. 61.5±13.6 minutes, P=0.001). Cardiopulmonary adverse events were significantly less common in the swaddling group than in the sedation group (3.13% [n=1] vs. 34.04% [n=16], P=0.002).Conclusion: The success rate of MRI was comparable between the swaddling technique and sedation. Furthermore, despite the drawback of prolonged scan time, cardiopulmonary adverse events are fewer with swaddling than with sedative agents. Therefore, swaddling can be an alternative to sedation or anesthesia when performing neonatal MRI scans.
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16
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Webber AM, Willer BL. Obesity, Race, and Perioperative Complications. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00458-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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17
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Schlegelmilch M, Roback MG, Bhatt M. Impact of young age on outcomes of emergency department procedural sedation. Am J Emerg Med 2021; 46:116-120. [PMID: 33744747 DOI: 10.1016/j.ajem.2021.03.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 03/04/2021] [Accepted: 03/05/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Relatively little is known about outcomes of procedural sedation in very young children. Our objective was to examine the association between procedural sedation in young children (≤ 2 years) and the incidence of sedation-related adverse events. METHODS This is a secondary analysis of a prospective cohort study of children 0 to 18 years undergoing parenteral procedural sedation in six Canadian pediatric emergency departments (ED). The primary risk factor was age ≤ 2 years. Secondary risk factors were sex, procedure type, pre-procedure and sedation medications. The outcomes examined were: serious adverse events (SAE), significant interventions, oxygen desaturation and vomiting. RESULTS Of the 6295 patients included, 946 (15%) were ≤2 years. Children 13-24 months comprised 90% of the young age group. Children ≤ 2 years were sedated most commonly for laceration repair (n = 450; 47.6%), while orthopedic reduction was most common in children > 2 (n = 3983; 74.5%). Ketamine was the most common medication in both groups, but was used more frequently in children ≤ 2 years (80.9% vs 58.9%; p < 0.001). There was no difference in the odds of SAE (OR 0.83, 95% Confidence Interval (CI) 0.4 to 1.9), significant intervention (OR 0.82, 95% CI 0.4 to 1.7) or oxygen desaturation (OR 0.95, 95% CI 0.7 to 1.3) between age groups, however children ≤ 2 years vomited less frequently (OR 0.24, 95% CI 0.1 to 0.6). CONCLUSIONS Young age, specifically between 13 and 24 months, was not associated with a significant difference in the incidence of adverse events.
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Affiliation(s)
- Michael Schlegelmilch
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario K1H 8L1, Canada.
| | - Mark G Roback
- Department of Pediatrics, University of Colorado School of Medicine, 13001 E 17th Pl, Aurora, CO 80045, USA.
| | - Maala Bhatt
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario K1H 8L1, Canada.
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18
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Wallace TE, Afacan O, Jaimes C, Rispoli J, Pelkola K, Dugan M, Kober T, Warfield SK. Free induction decay navigator motion metrics for prediction of diagnostic image quality in pediatric MRI. Magn Reson Med 2021; 85:3169-3181. [PMID: 33404086 PMCID: PMC7904595 DOI: 10.1002/mrm.28649] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 11/05/2020] [Accepted: 11/25/2020] [Indexed: 12/23/2022]
Abstract
Purpose To investigate the ability of free induction decay navigator (FIDnav)‐based motion monitoring to predict diagnostic utility and reduce the time and cost associated with acquiring diagnostically useful images in a pediatric patient cohort. Methods A study was carried out in 102 pediatric patients (aged 0‐18 years) at 3T using a 32‐channel head coil array. Subjects were scanned with an FID‐navigated MPRAGE sequence and images were graded by two radiologists using a five‐point scale to evaluate the impact of motion artifacts on diagnostic image quality. The correlation between image quality and four integrated FIDnav motion metrics was investigated, as well as the sensitivity and specificity of each FIDnav‐based metric to detect different levels of motion corruption in the images. Potential time and cost savings were also assessed by retrospectively applying an optimal detection threshold to FIDnav motion scores. Results A total of 12% of images were rated as non‐diagnostic, while a further 12% had compromised diagnostic value due to motion artifacts. FID‐navigated metrics exhibited a moderately strong correlation with image grade (Spearman's rho ≥ 0.56). Integrating the cross‐correlation between FIDnav signal vectors achieved the highest sensitivity and specificity for detecting non‐diagnostic images, yielding total time savings of 7% across all scans. This corresponded to a financial benefit of $2080 in this study. Conclusions Our results indicate that integrated motion metrics from FIDnavs embedded in structural MRI are a useful predictor of diagnostic image quality, which translates to substantial time and cost savings when applied to pediatric MRI examinations.
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Affiliation(s)
- Tess E Wallace
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, Boston, MA, USA.,Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - Onur Afacan
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, Boston, MA, USA.,Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - Camilo Jaimes
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, Boston, MA, USA.,Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - Joanne Rispoli
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, Boston, MA, USA.,Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - Kristina Pelkola
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, Boston, MA, USA
| | - Monet Dugan
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, Boston, MA, USA
| | - Tobias Kober
- Advanced Clinical Imaging Technology, Siemens Healthcare AG, Lausanne, Switzerland.,Department of Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,LTS5, École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Simon K Warfield
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, Boston, MA, USA.,Department of Radiology, Harvard Medical School, Boston, MA, USA
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Kuga S, Maeda T, Ihara K. Pediatric procedural sedation in Japan: A single-facility study of 1,436 cases. Pediatr Int 2020; 62:1346-1350. [PMID: 32501599 DOI: 10.1111/ped.14331] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 05/20/2020] [Accepted: 05/29/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pediatric procedural sedation (PPS) has been established worldwide as standard practice for several decades. However, there are no comprehensive guidelines or multi-facility databases of PPS in Japan, and the current status of PPS and PPS-related adverse events is unclear. The objectives of this study were to investigate the status of PPS in Japan and clarify the adverse events and risk factors. METHODS This study was a single-facility, database survey performed at Oita University Hospital from September 2016 to March 2019. Children under 18 years of age who had been kept sedated for medical procedures with intravenous sedatives were enrolled in this study. Adverse events were recorded and defined according to the Quebec Guideline. RESULTS During the study period, PPS was performed for 1,436 consecutive cases. The majority (94%) of the sedatives used were thiamylal alone or thiamylal combined with ketamine. There were a total of 253 adverse events in 233 cases (16.2%), including oxygen desaturation, airway hypersensitivity, and vomiting. Patients recovered from respiratory-related adverse events immediately with simple intervention. No patient required endotracheal intubation and no severe adverse event occurred. Four risk factors (a higher American Society of Anesthesiologists classification, longer procedure time, non-compliance of nil per os status, and no Pediatric Advanced Life Support certification for sedation personnel) were associated with the occurrence of adverse events. CONCLUSIONS Adverse events occurred in 16.2% of all PPS cases. Further studies are needed to analyze the serious adverse events and risk factors for PPS in Japan.
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Affiliation(s)
- Shuji Kuga
- Department of Pediatrics, Faculty of Medicine, Oita University, Yufu, Japan
| | - Tomoki Maeda
- Department of Pediatrics, Faculty of Medicine, Oita University, Yufu, Japan
| | - Kenji Ihara
- Department of Pediatrics, Faculty of Medicine, Oita University, Yufu, Japan
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20
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Han YS, Kim HH, Kim HS, Yang MS, Ahn SY, Sung SI, Chang YS, Park WS. Sedation for Brain Magnetic Resonance Imaging in Preterm Infants: Using Propofol under Anesthesiologist Supervision. NEONATAL MEDICINE 2020. [DOI: 10.5385/nm.2020.27.3.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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21
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Kamat PP, McCracken CE, Simon HK, Stormorken A, Mallory M, Chumpitazi CE, Cravero JP. Trends in Outpatient Procedural Sedation: 2007-2018. Pediatrics 2020; 145:peds.2019-3559. [PMID: 32332053 DOI: 10.1542/peds.2019-3559] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Pediatric subspecialists routinely provide procedural sedation outside the operating room. No large study has reported trends in outpatient pediatric procedural sedation. Our purpose in this study was to identify significant trends in outpatient procedural sedation using the Pediatric Sedation Research Consortium. METHODS Prospectively collected data from 2007 to 2018 were used for trending procedural sedation. Patient characteristics, medications, type of providers, serious adverse events, and interventions were reported. The Cochran-Armitage test for trend was used to explore the association between the year and a given characteristic. RESULTS A total of 432 842 sedation encounters were identified and divided into 3 4-year epochs (2007-2011, 2011-2014, and 2014-2018). There was a significant decrease in infants <3 months of age receiving procedural sedation (odds ratio = 0.97; 95% confidence interval, 0.96-0.98). A large increase was noticed in pediatric hospitalists providing procedural sedation (0.6%-9.5%; P < .001); there was a decreasing trend in sedation by other providers who were not in emergency medicine, critical care, or anesthesiology (13.9%-3.9%; P < .001). There was an increasing trend in the use of dexmedetomidine (6.3%-9.3%; P < .001) and a decreasing trend in the use of chloral hydrate (6.3%-0.01%; P < .001) and pentobarbital (7.3%-0.5%; P < .001). Serious adverse events showed a nonsignificant increase overall (1.35%-1.75%). CONCLUSIONS We report an increase in pediatric hospitalists providing sedation and a significant decrease in the use of chloral hydrate and pentobarbital by providers. Further studies are required to see if sedation services decrease costs and optimize resource use.
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Affiliation(s)
| | | | - Harold K Simon
- Departments of Pediatrics and.,Emergency Medicine, School of Medicine, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Anne Stormorken
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio
| | - Michael Mallory
- Pediatric Emergency Medicine Associates, Scottish Rite Hospital, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Corrie E Chumpitazi
- Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas; and
| | - Joseph P Cravero
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Harvard University and Boston Children's Hospital, Boston, Massachusetts
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22
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Kopanoglu E, Deniz CM, Erturk MA, Wise RG. Specific absorption rate implications of within-scan patient head motion for ultra-high field MRI. Magn Reson Med 2020; 84:2724-2738. [PMID: 32301177 DOI: 10.1002/mrm.28276] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 03/10/2020] [Accepted: 03/16/2020] [Indexed: 12/31/2022]
Abstract
PURPOSE This study investigates the implications of all degrees of freedom of within-scan patient head motion on patient safety. METHODS Electromagnetic simulations were performed by displacing and/or rotating a virtual body model inside an 8-channel transmit array to simulate 6 degrees of freedom of motion. Rotations of up to 20° and displacements of up to 20 mm including off-axis axial/coronal translations were investigated, yielding 104 head positions. Quadrature excitation, RF shimming, and multi-spoke parallel-transmit excitation pulses were designed for axial slice-selection at 7T, for seven slices across the head. Variation of whole-head specific absorption rate (SAR) and 10-g averaged local SAR of the designed pulses, as well as the change in the maximum eigenvalue (worst-case pulse) were investigated by comparing off-center positions to the central position. RESULTS In their respective worst-cases, patient motion increased the eigenvalue-based local SAR by 42%, whole-head SAR by 60%, and the 10-g averaged local SAR by 210%. Local SAR was observed to be more sensitive to displacements along right-left and anterior-posterior directions than displacement in the superior-inferior direction and rotation. CONCLUSION This is the first study to investigate the effect of all 6 degrees of freedom of motion on safety of practical pulses. Although the results agree with the literature for overlapping cases, the results demonstrate higher increases (up to 3.1-fold) in local SAR for off-axis displacement in the axial plane, which had received less attention in the literature. This increase in local SAR could potentially affect the local SAR compliance of subjects, unless realistic within-scan patient motion is taken into account during pulse design.
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Affiliation(s)
- Emre Kopanoglu
- Cardiff University Brain Research Imaging Centre (CUBRIC), School of Psychology, Cardiff University, Cardiff, UK
| | - Cem M Deniz
- Department of Radiology, New York University Langone Health, New York, New York
| | - M Arcan Erturk
- Restorative Therapies Group, Medtronic, Minneapolis, Minnesota
| | - Richard G Wise
- Cardiff University Brain Research Imaging Centre (CUBRIC), School of Psychology, Cardiff University, Cardiff, UK.,Institute for Advanced Biomedical Technologies, Department of Neuroscience, Imaging and Clinical Sciences, G. D'Annunzio University of Chieti-Pescara, Chieti, Italy
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23
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Bhatt M, Cheng W, Roback MG, Johnson DW, Taljaard M. Impact of Timing of Preprocedural Opioids on Adverse Events in Procedural Sedation. Acad Emerg Med 2020; 27:217-227. [PMID: 31894606 DOI: 10.1111/acem.13913] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 11/29/2019] [Accepted: 12/15/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND The risk of respiratory depression is increased when opioids are added to sedative agents. In our recent multicenter emergency department (ED) procedural sedation cohort, we reported a strong association between preprocedural opioids and sedation-related adverse events. We sought to examine the association between timing of opioids and the incidence of adverse sedation outcomes. METHODS We conducted a secondary analysis of a prospective cohort of children aged 0 to 18 years who received sedation for a painful procedure in six Canadian pediatric EDs from July 2010 to February 2015. The primary risk factor was timing of opioid administration, adjusted for age, opioid type, preprocedural and sedation medications, and procedure type. Outcomes were 1) oxygen desaturation, 2) vomiting, and 3) positive pressure ventilation (PPV). RESULTS Of the 6,295 children in the original cohort, 1,806 (29%) received a preprocedural opioid. Patients receiving preprocedural opioids had a higher incidence of oxygen desaturation (risk difference = 4.3%, 95% confidence interval [CI] = 2.9% to 5.8%), vomiting (risk difference 2.0%, 95% CI = 0.7% to 3.3%), and PPV (risk difference = 1.5%, 95% CI = 0.7% to 2.3%). Multivariable regression with timing of opioids modeled as a restricted cubic spline revealed the risk for each outcome was highest when opioids were administered in the 30 minutes prior to sedation. Timing of opioid administration was statistically significantly associated with oxygen desaturation and vomiting (p < 0.0001) but not with PPV (p = 0.113). CONCLUSIONS Timing of opioids was significantly associated with the risk of oxygen desaturation and vomiting. Being aware of this increased risk will help clinicians prepare for sedation and the potential need for patient rescue.
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Affiliation(s)
- Maala Bhatt
- Department of Pediatrics Children’s Hospital of Eastern Ontario Ottawa Ontario Canada
| | - Wei Cheng
- Clinical Epidemiology Program Ottawa Hospital Research Institute Ottawa Ontario Canada
| | - Mark G. Roback
- Department of Pediatrics University of Colorado School of Medicine Aurora CO
| | - David W. Johnson
- Department of Pediatrics Cumming School of Medicine University of Calgary Calgary Alberta Canada
- Department of Emergency Medicine Cumming School of Medicine University of Calgary Calgary Alberta Canada
- Department of Physiology and Pharmacology Cumming School of Medicine University of Calgary Calgary Alberta Canada
- Alberta Children’s Hospital Research Institute University of Calgary Calgary Alberta Canada
| | - Monica Taljaard
- Clinical Epidemiology Program Ottawa Hospital Research Institute Ottawa Ontario Canada
- School of Epidemiology, Public Health and Preventive Medicine University of Ottawa Ottawa Ontario Canada
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Donato J, Rao K, Lewis T. Pharmacology of Common Analgesic and Sedative Drugs Used in the Neonatal Intensive Care Unit. Clin Perinatol 2019; 46:673-692. [PMID: 31653302 DOI: 10.1016/j.clp.2019.08.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In this review of analgesic and sedation medication in neonates, important classes of old and newer medications commonly used in the neonatal intensive care unit setting are discussed. In addition to drug metabolism, efficacy, and safety for individual drugs, new insights into multimodal analgesic approaches suggest ways in which multiple analgesic drug classes can be combined to maximize efficacy and minimize toxicity. Opiate pharmacogenetics and the potential for a precision therapeutics approach is explored, with a final description of gaps in knowledge and a call for future research of pain and sedation control in the neonatal population.
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Affiliation(s)
- Jamesia Donato
- Department of Pediatrics, Division of Neonatology, UMKC School of Medicine, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Karishma Rao
- Department of Pediatrics, Division of Neonatology, UMKC School of Medicine, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Tamorah Lewis
- Department of Pediatrics, Division of Neonatology, UMKC School of Medicine, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA; Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Department of Pediatrics, Division of Pediatric Clinical Pharmacology, UMKC School of Medicine, Children's Mercy Hospital, Kansas City, MO, USA.
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25
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Evolution of the Pediatric Intensivist Sedation Service. CURRENT PEDIATRICS REPORTS 2019. [DOI: 10.1007/s40124-019-00200-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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26
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Rovner MS, Wolf BJ, Rubin M, Ritter A, Heine CL, Wester TE, Furse CM. Instillation of 5% Povidone-Iodine Ophthalmic Drops Decreases the Respiratory Rate in Children Undergoing Strabismus Surgery: A Randomized Controlled Trial. J Pediatr Ophthalmol Strabismus 2019; 56:378-382. [PMID: 31743406 PMCID: PMC7340011 DOI: 10.3928/01913913-20190923-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 08/30/2019] [Indexed: 11/20/2022]
Abstract
PURPOSE To investigate the effects of topical application of ophthalmic 5% povidone-iodine eye drops, which has been reported to cause apnea in spontaneously breathing children during general anesthesia. METHODS The authors conducted a randomized, controlled, single-blinded study comparing the effect of balanced salt solution eye drops and povidone-iodine eye drops on respiration in spontaneously breathing children during general anesthesia with sevoflurane via a laryngeal mask airway. Fifty patients received balanced salt solution eye drops and 50 patients received 5% povidone-iodine eye drops. RESULTS None of the control patients had a significant change in respiration. Thirty of the 50 (60%) povidone-iodine patients had a slowing of respiration within the first 6 breaths after eye drop instillation (P < .001). The median time of respiratory pause in those 30 patients was 18.5 seconds (range: 4.36 to 96.2 seconds). Among the povidone-iodine patients, children with a history of a prior tonsillectomy and adenoidectomy and/or bilateral myringotomy had a 7.2 times greater chance of experiencing a change in respiration after instillation of the povidone-iodine eye drops. CONCLUSIONS Topical application of 5% povidone-iodine eye drops causes a slowing and pause in spontaneous ventilation in a majority of children prior to strabismus surgery. This may represent activation of the diving reflex. [J Pediatr Ophthalmol Strabismus. 2019;56(6):378-382.].
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Coté CJ, Wilson S. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures. Pediatrics 2019; 143:peds.2019-1000. [PMID: 31138666 DOI: 10.1542/peds.2019-1000] [Citation(s) in RCA: 130] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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Miller KA, Andolfatto G, Miner JR, Burton JH, Krauss BS. Clinical Practice Guideline for Emergency Department Procedural Sedation With Propofol: 2018 Update. Ann Emerg Med 2019; 73:470-480. [DOI: 10.1016/j.annemergmed.2018.12.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 12/06/2018] [Accepted: 12/10/2018] [Indexed: 12/11/2022]
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Slipsager JM, Ellegaard AH, Glimberg SL, Paulsen RR, Tisdall MD, Wighton P, van der Kouwe A, Marner L, Henriksen OM, Law I, Olesen OV. Markerless motion tracking and correction for PET, MRI, and simultaneous PET/MRI. PLoS One 2019; 14:e0215524. [PMID: 31002725 PMCID: PMC6474595 DOI: 10.1371/journal.pone.0215524] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 04/03/2019] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE We demonstrate and evaluate the first markerless motion tracker compatible with PET, MRI, and simultaneous PET/MRI systems for motion correction (MC) of brain imaging. METHODS PET and MRI compatibility is achieved by careful positioning of in-bore vision extenders and by placing all electronic components out-of-bore. The motion tracker is demonstrated in a clinical setup during a pediatric PET/MRI study including 94 pediatric patient scans. PET MC is presented for two of these scans using a customized version of the Multiple Acquisition Frame method. Prospective MC of MRI acquisition of two healthy subjects is demonstrated using a motion-aware MRI sequence. Real-time motion estimates are accompanied with a tracking validity parameter to improve tracking reliability. RESULTS For both modalities, MC shows that motion induced artifacts are noticeably reduced and that motion estimates are sufficiently accurate to capture motion ranging from small respiratory motion to large intentional motion. In the PET/MRI study, a time-activity curve analysis shows image improvements for a patient performing head movements corresponding to a tumor motion of ±5-10 mm with a 19% maximal difference in standardized uptake value before and after MC. CONCLUSION The first markerless motion tracker is successfully demonstrated for prospective MC in MRI and MC in PET with good tracking validity. SIGNIFICANCE As simultaneous PET/MRI systems have become available for clinical use, an increasing demand for accurate motion tracking and MC in PET/MRI scans has emerged. The presented markerless motion tracker facilitate this demand.
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Affiliation(s)
- Jakob M. Slipsager
- Department of Applied Mathematics and Computer Science, Technical University of Denmark, Lyngby, Denmark
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- TracInnovations, Ballerup, Denmark
| | - Andreas H. Ellegaard
- Department of Applied Mathematics and Computer Science, Technical University of Denmark, Lyngby, Denmark
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Rasmus R. Paulsen
- Department of Applied Mathematics and Computer Science, Technical University of Denmark, Lyngby, Denmark
| | - M. Dylan Tisdall
- Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Paul Wighton
- Athinoula. A. Matinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - André van der Kouwe
- Athinoula. A. Matinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Lisbeth Marner
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Otto M. Henriksen
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Ian Law
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Oline V. Olesen
- Department of Applied Mathematics and Computer Science, Technical University of Denmark, Lyngby, Denmark
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- TracInnovations, Ballerup, Denmark
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Sampson MA, Berg AD, Huber JN, Olgun G. Necessity of Intracranial Imaging in Infants and Children With Macrocephaly. Pediatr Neurol 2019; 93:21-26. [PMID: 30704866 DOI: 10.1016/j.pediatrneurol.2018.10.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 10/18/2018] [Accepted: 10/27/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND Macrocephaly is frequently encountered in pediatrics and often leads to imaging. There are no recommendations from the American Academy of Pediatrics or the American College of Radiology providing imaging guidelines for macrocephaly. The goal of this study is to identify risk factors for pathologic macrocephaly and to aid the clinician in identifying patients that would benefit from imaging. METHODS We conducted a medical record review throughout a multistate health care system, Sanford Health, from January 1, 2012 to December 31, 2016. Patients with macrocephaly were identified by problem list in children aged less than 36 months. Data collection included basic demographics, imaging modality, developmental delay, prematurity, seizures, focal neurological symptoms, family history of macrocephaly, sedation used, and sedation complications. RESULTS A total of 169 patients were included in the analysis. Imaging modalities included 39 magnetic resonance imagings (23.1%), 47 cranial computed tomographies (27.8%), and 83 head ultrasounds (49.1%). Imaging results demonstrated 13 abnormal studies with five of those studies being abnormal with high clinical yield. Patients with abnormal studies were more likely to have developmental delay (P = 0.04) or neurological symptoms (P = 0.015). Positive family history of macrocephaly was predictive of normal imaging (P = 0.004). There were no sedation complications. CONCLUSIONS Intracranial imaging does not appear to be necessary in children with no risk factors and or a positive family history of macrocephaly. Risk factors such as developmental delay or neurological symptoms could identify children at risk for imaging abnormalities that require further management.
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Affiliation(s)
- Megan A Sampson
- Department of Pediatrics, Sanford USD Medical Center, Sanford Children's Hospital, Sioux Falls, South Dakota; University of South Dakota Sanford School of Medicine, Vermillion, South Dakota
| | - Aaron D Berg
- University of South Dakota Sanford School of Medicine, Vermillion, South Dakota; Sanford USD Medical Center, Sioux Falls, South Dakota
| | - Jody N Huber
- Department of Pediatrics, Sanford USD Medical Center, Sanford Children's Hospital, Sioux Falls, South Dakota; University of South Dakota Sanford School of Medicine, Vermillion, South Dakota
| | - Gokhan Olgun
- Department of Pediatrics, Sanford USD Medical Center, Sanford Children's Hospital, Sioux Falls, South Dakota; University of South Dakota Sanford School of Medicine, Vermillion, South Dakota.
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Kim D, Lee EK, Jeong JS, Gil NS, Hahm TS, Shin YH. Incidence and risk factors of unplanned intubation during pediatric sedation for MRI. J Magn Reson Imaging 2019; 49:1053-1061. [PMID: 30350443 DOI: 10.1002/jmri.26314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 08/08/2018] [Accepted: 08/09/2018] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND It is often difficult for the pediatric patient to cooperate or to remain immobile during MR scans. Therefore, sedation is usually needed for children. PURPOSE To evaluate the incidence and contributing factors of unanticipated intubation during sedation for MRI scan in children. STUDY TYPE Retrospective observational study. POPULATION/SUBJECTS In all, 1165 charts were reviewed retrospectively of patients who had been sedated by anesthesiologists at a single institution from May 2015 to June 2016. ASSESSMENT Patient's demographics, the region of the MRI scan, total amount of medication, duration of sedation, and any adverse event during MRI were assessed. The adverse events during sedation including airway obstruction, apnea, desaturation, bradycardia, and hypotension were also assessed. STATISTICAL TESTS Risk factors of unplanned intubation during MRI sedation were identified by univariate and multivariate analysis. Firth's exact logistic regression was used for univariate and multivariate analysis. According to the results from multiple logistic regression, a nomogram was developed to predict the risk. RESULTS A total of 1165 children aged 7 days to 18 years with sedation used during an MRI scan during the study period showed an incidence of unexpected intubation as ~2% (n = 23, 95% confidence interval [CI]; 0.0123, 0.0295). Multivariate logistic regression revealed the following risk factors of unplanned intubation: American Society of Anesthesiologists (ASA) class III patients (odds ratio [OR] 1.212, P < 0.001), premature birth (OR 2.317, P < 0.001), and the presence of gastroesophageal reflux disease (GERD) (OR 1.474, P < 0.001) or congenital heart disease (OR 1.118, P < 0.001). DATA CONCLUSION This study identified risk factors of unplanned intubation as follows: ASA class III patients, premature birth, and the presence of GERD or congenital heart disease. The physician should screen risk factors of unexpected intubation and maintain adequate sedation during MRI scans in pediatric patients. Level of Evidence 3. Technical Efficacy Stage 5. J. Magn. Reson. Imaging 2019;49:1053-1061.
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Affiliation(s)
- Doyeon Kim
- Department of Anesthesiology and Pain medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Eun Kyung Lee
- Department of Anesthesiology and Pain medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ji Seon Jeong
- Department of Anesthesiology and Pain medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Nam-Su Gil
- Department of Anesthesiology and Pain medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Tae Soo Hahm
- Department of Anesthesiology and Pain medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young Hee Shin
- Department of Anesthesiology and Pain medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Kamat PP, Kudchadkar SR, Simon HK. Sedative and Anesthetic Neurotoxicity in Infants and Young Children: Not Just an Operating Room Concern. J Pediatr 2019; 204:285-290. [PMID: 30270160 DOI: 10.1016/j.jpeds.2018.08.039] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 07/15/2018] [Accepted: 08/17/2018] [Indexed: 02/07/2023]
Affiliation(s)
- Pradip P Kamat
- Department of Pediatrics, Division of Critical Care Medicine, Emory University School of Medicine, Atlanta, GA; Children's Sedation Services at Egleston, Children's Healthcare of Atlanta at Egleston, Atlanta, GA.
| | - Sapna R Kudchadkar
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Charlotte R. Bloomberg Children's Center, Baltimore, MD; Department of Pediatrics, Johns Hopkins University School of Medicine, Charlotte R. Bloomberg Children's Center, Baltimore, MD; Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Charlotte R. Bloomberg Children's Center, Baltimore, MD
| | - Harold K Simon
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, GA; Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA
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Abstract
There are several benefits to clinical registries as an information repository tool, ultimately lending itself to the acquisition of new knowledge. Registries have the unique advantage of garnering much data quickly and are, therefore, especially helpful for niche populations or low-prevalence diseases. They can be used to inform on the ideal structure, process, or outcome involving an identified population. The data can be used in many ways, for example, as an observational tool to reveal associations or as a basis for framing future research studies or quality improvement projects.
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Wallace TE, Afacan O, Waszak M, Kober T, Warfield SK. Head motion measurement and correction using FID navigators. Magn Reson Med 2018; 81:258-274. [PMID: 30058216 DOI: 10.1002/mrm.27381] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 04/18/2018] [Accepted: 05/08/2018] [Indexed: 11/09/2022]
Abstract
PURPOSE To develop a novel framework for rapid, intrinsic head motion measurement in MRI using FID navigators (FIDnavs) from a multichannel head coil array. METHODS FIDnavs encode substantial rigid-body motion information; however, current implementations require patient-specific training with external tracking data to extract quantitative positional changes. In this work, a forward model of FIDnav signals was calibrated using simulated movement of a reference image within a model of the spatial coil sensitivities. A FIDnav module was inserted into a nonselective 3D FLASH sequence, and rigid-body motion parameters were retrospectively estimated every readout time using nonlinear optimization to solve the inverse problem posed by the measured FIDnavs. This approach was tested in simulated data and in 7 volunteers, scanned at 3T with a 32-channel head coil array, performing a series of directed motion paradigms. RESULTS FIDnav motion estimates achieved mean absolute errors of 0.34 ± 0.49 mm and 0.52 ± 0.61° across all subjects and scans, relative to ground-truth motion measurements provided by an electromagnetic tracking system. Retrospective correction with FIDnav motion estimates resulted in substantial improvements in quantitative image quality metrics across all scans with intentional head motion. CONCLUSIONS Quantitative rigid-body motion information can be effectively estimated using the proposed FIDnav-based approach, which represents a practical method for retrospective motion compensation in less cooperative patient populations.
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Affiliation(s)
- Tess E Wallace
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Onur Afacan
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Maryna Waszak
- Advanced Clinical Imaging Technology, Siemens Healthcare AG, Lausanne, Switzerland.,Department of Radiology, University Hospital (CHUV), Lausanne, Switzerland.,LTS5, École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Tobias Kober
- Advanced Clinical Imaging Technology, Siemens Healthcare AG, Lausanne, Switzerland.,Department of Radiology, University Hospital (CHUV), Lausanne, Switzerland.,LTS5, École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Simon K Warfield
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Vlassakova BG, Sinnott SM, Askins N, Callahan MX, Leahy IC, Zurakowski D, Hickey PR, Cravero JP. The Anesthesia Perioperative “Call for Help”—Experience at a Quaternary Pediatric Medical Center. Anesth Analg 2018; 127:126-133. [DOI: 10.1213/ane.0000000000003353] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Scherrer PD, Rogers AP, Kamat PP. Shifting the Paradigm: The Quiet Revolution of Pediatric Procedural Sedation Practice. Hosp Pediatr 2018; 8:372-374. [PMID: 29844023 DOI: 10.1542/hpeds.2018-0063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Patricia D Scherrer
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia; and
| | - Amber P Rogers
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Pradip P Kamat
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia; and
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Pavlek LR, Slaughter JL, Berman DP, Backes CH. Catheter-based closure of the patent ductus arteriosus in lower weight infants. Semin Perinatol 2018; 42:262-268. [PMID: 29909074 DOI: 10.1053/j.semperi.2018.05.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Risks associated with drug therapy and surgical ligation have led health care providers to consider alternative strategies for patent ductus arteriosus (PDA) closure. Catheter-based PDA closure is the procedure of choice for ductal closure in adults, children, and infants ≥6kg. Given evidence among older counterparts, interest in catheter-based closure of the PDA in lower weight (<6kg) infants is growing. Among these smaller infants, the goals of this review are to: (1) provide an overview of the procedure; (2) review the types of PDA closure devices; (3) review the technical success (feasibility); (4) review the risks (safety profile); (5) discuss the quality of evidence on procedural efficacy; (6) consider areas for future research. The review provided herein suggests that catheter-based PDA closure is technically feasible, but the lack of comparative trials precludes determination of the optimal strategy for ductal closure in this subgroup of infants.
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Affiliation(s)
- Leeann R Pavlek
- Center for Perinatal Research, Nationwide Children's Hospital, Columbus, OH
| | - Jonathan L Slaughter
- Center for Perinatal Research, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics at The Ohio State University Wexner Medical Center, Columbus, OH
| | - Darren P Berman
- Department of Pediatrics at The Ohio State University Wexner Medical Center, Columbus, OH; Center for Cardiovascular and Pulmonary Research, Nationwide Children's Hospital, Columbus, OH; The Heart Center, Nationwide Children's Hospital, Columbus, OH
| | - Carl H Backes
- Center for Perinatal Research, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics at The Ohio State University Wexner Medical Center, Columbus, OH; The Heart Center, Nationwide Children's Hospital, Columbus, OH.
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Levit Y, Mandel D, Matot I. Frequency-specific auditory brainstem response testing with age-appropriate sedation. Int J Pediatr Otorhinolaryngol 2018; 108:73-79. [PMID: 29605369 DOI: 10.1016/j.ijporl.2018.02.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 02/13/2018] [Accepted: 02/14/2018] [Indexed: 01/27/2023]
Abstract
OBJECTIVE Auditory brainstem response (ABR) testing is the gold-standard procedure for hearing evaluation in pediatric patients who cannot complete a behavioral hearing test. The amount of audiological information obtained depends on the quality of the patient's sleep during the test. In this retrospective database review, we aimed to assess the amount and the characteristics of the audiological information obtained in ABR testing in pediatric patients with age-appropriate sedation. METHODS A retrospective chart review was conducted on 501 consecutive ABR sedation sessions performed between January 2014 and June 2016 at the Tel Aviv Medical Center. Oral triclofos was used for the sedation of younger patients (3-24 months) and intravenous propofol for older patients (>24 months). The dataset included 370 triclofos sessions (in 337 patients) and 131 propofol sessions (in 126 patients). RESULTS None of the children developed complications, and all were discharged on the same day of the evaluation. Among the hearing-impaired children, a mean of 10 (1.8 SD) ABR threshold measurements was obtained from propofol-sedated patients and 9.4 (2.8 SD) measurements from those sedated with triclofos (P = 0.039). The major characteristics of the hearing loss, including its degree, type, and configuration, were obtained from all propofol-sedated patients and from 95% of those sedated with triclofos. CONCLUSIONS A comprehensive evaluation of hearing status can be obtained in ABR testing with age-appropriate sedation. An average number of ∼10 threshold measurements were obtained during ABR testing with age-appropriate sedation, thus allowing for the evaluation of the degree, type and configuration of the hearing loss.
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Affiliation(s)
- Yael Levit
- Hearing Clinic, Ear, Nose and Throat Department, Tel Aviv Medical Center, Tel Aviv, Israel.
| | - Dror Mandel
- Neonatology, Dana-Dwek Children's Hospital, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Idit Matot
- Anesthesia, Pain and Intensive Care Division, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Parad RB. Non-sedation of the neonate for radiologic procedures. Pediatr Radiol 2018; 48:524-530. [PMID: 29550867 DOI: 10.1007/s00247-017-4002-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 09/01/2017] [Accepted: 09/26/2017] [Indexed: 12/13/2022]
Abstract
On Dec. 16, 2016, the U.S. Food and Drug Administration (FDA) released a warning regarding the potential neurotoxicity of anesthesia and sedation agents on the developing brain in children younger than 3 years and in women during their 3rd trimester of pregnancy. These concerns have relevance to the pediatric radiologist who must take into consideration how the child's state might impact image quality. In this review the author provides background on the special concerns in the potentially highest-risk group, pre-term and term neonates, and provides guidance and rationale for the avoidance of sedation in procedural imaging of the newborn.
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Affiliation(s)
- Richard B Parad
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, 75 Francis St., Rm. CWN418, Boston, MA, 02115, USA. .,Department of Pediatrics, Harvard Medical School, Boston, MA, 02115, USA.
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Ionizing radiation from computed tomography versus anesthesia for magnetic resonance imaging in infants and children: patient safety considerations. Pediatr Radiol 2018; 48:21-30. [PMID: 29181580 DOI: 10.1007/s00247-017-4023-6] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 09/19/2017] [Accepted: 10/30/2017] [Indexed: 12/20/2022]
Abstract
In the context of health care, risk assessment is the identification, evaluation and estimation of risk related to a particular clinical situation or intervention compared to accepted medical practice standards. The goal of risk assessment is to determine an acceptable level of risk for a given clinical treatment or intervention in association with the provided clinical circumstances for a patient or group of patients. In spite of the inherent challenges related to risk assessment in pediatric cross-sectional imaging, the potential risks of ionizing radiation and sedation/anesthesia in the pediatric population are thought to be quite small. Nevertheless both issues continue to be topics of discussion concerning risk and generate significant anxiety and concern for patients, parents and practicing pediatricians. Recent advances in CT technology allow for more rapid imaging with substantially lower radiation exposures, obviating the need for anesthesia for many indications and potentially mitigating concerns related to radiation exposure. In this review, we compare and contrast the potential risks of CT without anesthesia against the potential risks of MRI with anesthesia, and discuss the implications of this analysis on exam selection, providing specific examples related to neuroblastoma surveillance imaging.
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Zhang Q, Peng Y, Wang Y. Long-duration general anesthesia influences the intelligence of school age children. BMC Anesthesiol 2017; 17:170. [PMID: 29258430 PMCID: PMC5735791 DOI: 10.1186/s12871-017-0462-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Accepted: 12/10/2017] [Indexed: 11/15/2022] Open
Abstract
Background General anesthesia has been linked to impaired brain development in immature animals and young children. In this study the influence of orthopedic surgery under general anesthesia on the intelligence of school age children has been evaluated. Methods A total of 209 subjects aged 6–12 years were recruited and allocated into 4 groups according to the duration of general anesthesia, including a control group (n = 30), short (< 1 h, n = 49), moderate- (1–3 h, n = 51) and long-duration groups (> 3 h, n = 79), respectively. The intelligence quotient (IQ) of the subjects was measured by the Raven’s Standard Progressive Matrices (RSPM) before and after orthopedic surgery under general anesthesia of various durations (vide supra). Results The IQ score decreased significantly in the long-duration group at 1 month post-operation compared with the pre-operation score (P < 0.001), and IQ did not recover completely at 3 months postoperatively (P < 0.05), but had recovered when measured at the 1-year follow-up. Moreover, this study showed that the development of children’s intelligence was affected by the exposure time to anesthetics at a younger age (OR = 5.26, 95% CI:2.70–8.41, P < 0.001), having a mother with a low education level (OR = 2.71, 95% CI:1.24–6.14, P = 0.014) and premature birth (OR = 2.76, 95% CI:1.34–5.46, P = 0.005). Conclusions More than 3 h general anesthesia influenced the IQ of school age children for up to 3 months after orthopedic surgery. Beside extended exposure time to anesthetics additional factors for post-operative IQ reduction were younger children age, mothers with low educational levels and premature birth. Trial registration Chinese Clinical Trial Registry with registration number ChiCTR-OOC-17013497 retrospectively registered on 11/23/2017.
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Affiliation(s)
- Qingqing Zhang
- Department of Anesthesiology and Critical Care Medicine, Xinhua Hospital Affiliated to Shanghai Jiaotong University, 1665 Kongjiang Road, Shanghai, China
| | - Yuanzhi Peng
- Department of Anesthesiology and Critical Care Medicine, Xinhua Hospital Affiliated to Shanghai Jiaotong University, 1665 Kongjiang Road, Shanghai, China
| | - Yingwei Wang
- Department of Anesthesiology, Huashan Hospital Affiliated to Fudan University, 12 Wulumuqi Middle Road, Shanghai, 200040, China.
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Experience with the use of propofol for radiologic imaging in infants younger than 6 months of age. Pediatr Radiol 2017; 47:974-983. [PMID: 28488002 DOI: 10.1007/s00247-017-3844-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 02/24/2017] [Accepted: 03/21/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND There is an increased risk associated with procedural sedation of infants younger than 6 months of age. The use of propofol for radiologic imaging of this age group is not well studied. OBJECTIVE We hypothesize that adverse events are higher in the infant population receiving propofol for radiologic imaging. MATERIALS AND METHODS A retrospective chart review was undertaken of 304 infants younger than 6 months old who received propofol for procedural sedation from October 2012 to February 2015. Patient demographics, propofol dosing, sedation-related adverse events and interventions were collected. Serious adverse events were defined as laryngospasm, aspiration, the need for admission, cardiac arrest or death. RESULTS Procedural sedation for radiologic imaging was successful in 301/304 (99%) of infants using propofol. Of these 304 patients, 130 (42.8%) patients were female, and 240 of the 304 (79%) were between 3 and 6 months of age. The majority of patients (172/304 [56.6%]) were American Society of Anesthesiologists-Physical Status Class II. There were 57 sedation-related, minor adverse events in 39 out of 304 (12.8%) patients. Thirteen of the 304 (4.3%) patients had 14 serious adverse events, with airway obstruction the most common. Eighty interventions were required in 56/304 (18.4%) patients. The most common interventions were continuous positive airway pressure (CPAP) in 25/304 patients (8.2%) and jaw thrust in 15/304 (4.9%). The median induction propofol dose was 4.7 mg/kg. A need for an increase in the propofol infusion rate during the procedure was noted in 162/304 (53.3%) infants. No significant predictors of sedation-related adverse events were detected. CONCLUSION Propofol can be used for radiologic imaging of infants younger than 6 months of age with a high success rate. Practitioners should be mindful of significantly higher dosing requirements and a higher incidence of airway events, which can be easily identified and managed by a team of experienced sedation providers.
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Afacan O, Erem B, Roby DP, Roth N, Roth A, Prabhu SP, Warfield SK. Evaluation of motion and its effect on brain magnetic resonance image quality in children. Pediatr Radiol 2016; 46:1728-1735. [PMID: 27488508 PMCID: PMC5083190 DOI: 10.1007/s00247-016-3677-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 06/02/2016] [Accepted: 07/20/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Motion artifacts pose significant problems for the acquisition of MR images in pediatric populations. OBJECTIVE To evaluate temporal motion metrics in MRI scanners and their effect on image quality in pediatric populations in neuroimaging studies. MATERIALS AND METHODS We report results from a large pediatric brain imaging study that shows the effect of motion on MRI quality. We measured motion metrics in 82 pediatric patients, mean age 13.4 years, in a T1-weighted brain MRI scan. As a result of technical difficulties, 5 scans were not included in the subsequent analyses. A radiologist graded the images using a 4-point scale ranging from clinically non-diagnostic because of motion artifacts to no motion artifacts. We used these grades to correlate motion parameters such as maximum motion, mean displacement from a reference point, and motion-free time with image quality. RESULTS Our results show that both motion-free time (as a ratio of total scan time) and average displacement from a position at a fixed time (when the center of k-space was acquired) were highly correlated with image quality, whereas maximum displacement was not as good a predictor. Among the 77 patients whose motion was measured successfully, 17 had average displacements of greater than 0.5 mm, and 11 of those (14.3%) resulted in non-diagnostic images. Similarly, 14 patients (18.2%) had less than 90% motion-free time, which also resulted in non-diagnostic images. CONCLUSION We report results from a large pediatric study to show how children and young adults move in the MRI scanner and the effect that this motion has on image quality. The results will help the motion-correction community in better understanding motion patterns in pediatric populations and how these patterns affect MR image quality.
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Affiliation(s)
- Onur Afacan
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Ave., WB215, Boston, MA, 02115, USA.
| | - Burak Erem
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Ave., WB215, Boston, MA, 02115, USA
| | - Diona P Roby
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Ave., WB215, Boston, MA, 02115, USA
| | - Noam Roth
- Robin Medical Inc., Baltimore, MD, USA
| | - Amir Roth
- Robin Medical Inc., Baltimore, MD, USA
| | - Sanjay P Prabhu
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Ave., WB215, Boston, MA, 02115, USA
| | - Simon K Warfield
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Ave., WB215, Boston, MA, 02115, USA
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Coté CJ, Wilson S. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. Pediatrics 2016; 138:peds.2016-1212. [PMID: 27354454 DOI: 10.1542/peds.2016-1212] [Citation(s) in RCA: 139] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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 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.
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