Sedation and Alternative Techniques in Helping Pediatric Patients During MR Imaging - Paper Sample

Introduction

The purpose of this literature review is to demonstrate how using sedation and other alternative techniques aids in obtaining diagnostic MR Imaging examinations on children. Since magnetic resonance imaging requires a patient to be still for a long while, sedation, well known as general anesthesia, is mostly used to help relax patients, especially children. Although it has become common practice, sedation has its adverse effects. These effects include respiratory depression due to too much anesthesia, which could later cause difficulty in airway maintenance, and long-term neurodevelopmental effects due to anesthesia exposure. Thus, other alternatives have been used, such as mock MRI scanners, which are replicas of the MRI system, which reduce anxiety in children, thus aiding in quality diagnostic images. The use of such alternative methods has helped in avoiding some of the hazardous effects of general anesthesia.

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Methods

A literature review was done using Academic First Search, EbcoHost, and ERIC, obtained through the university library. The top search terms used were Pediatric MRI, radiology sedation, and alternatives to general anesthesia, among others. All those articles discussing the use of sedation and alternative methods for children's preparation during an MRI were included. Those articles that only addressed anesthesia usage and its alternative methods in general without specifying their use on children were excluded. Searching for literature cited by specifically essential works resulted in other additional articles. When examining the articles, several techniques emerged as alternatives to sedation: mock scanners, feed and sleep methods, infant incubators, and melatonin administration.

Discussion

During MRI, patients must stay still for a long while in a tightly enclosed area with some loud noises being produced by the equipment. This unfamiliar environment can be disturbing, especially to children, and as a result, they may react in ways that might affect the quality of the MR images. Due to this reason, pre-procedural sedation is mostly used to calm down children who are under the age of 18 years (McGuirt.,2016). This can vary from little to deep sedation, depending on the responsiveness of the patient. The sedation method is highly effective as it keeps the patients calm during the entire process, thus eliminating any movement that might alter the quality of the images. However, sedation has some adverse effects, including a greater risk of respiratory depression in case of excessive administration of anesthesia and a cause of protective reflexes loss (Ahmad et al., 2018). General anesthesia usage also increases procedural time, thus adding costs to the hospital and the family. Anesthetics, inpatient resources, and expensive drugs are required, and longer hours are taken to administer the anesthesia. In some cases, like with pediatric patients suffering from Attention-deficit hyperactivity disorder (ADHD), the patients have been said to require more sedation than patients without this diagnosis (Kitt., 2015). Despite the little research done in this area, this assumption has been proven wrong, which means that an alternative method could be used on these patients.

Therefore, alternative techniques for preparing children for MRI scans are necessary to reduce patient risk and make it cheaper for hospitals and families (Edwards, & Arthurs, 2011). Some of these techniques are implemented, while others are just alternatives. They include mock MRI scanners, magnetic resonance-compatible audiovisual Systems, feed-sleep manipulation techniques, play therapy, infant incubators, and melatonin administration. The mock MRI scanner involves exposing children to a replica of the MRI system before the procedure. It has been implemented in Australia in the Royal Children's hospital with a success rate of 98% of all performed examinations (McGuirt.,2016). The use of audiovisual systems compatible with the MR is another method that allows the patients to watch or listen to movies or music during the scan. This technique was observed to occupy children and relax them, thus avoiding sedation. Altering a child's usual feeding and sleeping routine was another successful alternative to anesthesia.

Dean et al. did a study that involved imaging three months to 4-year-old children during a natural sleep, which was not sedated. The success rate was 96%, which meant that a child did not have to be sedated for quality images to be obtained during MRI (McGuirt.,2016). Since infants are at a higher risk of over-sedation and cardiovascular complications, other alternatives involving MR-compatible incubators have been used. Marthur et al. developed precise steps for conducting MR scanning on infants without sedation, which involved 30 to 45 minutes of sleep deprivation before the scan. This method's success rate was 94%, which demonstrated that quality diagnostic images could still be obtained without the use of anesthesia (Ahmad et al., 2018). The use of melatonin, a sleep cycle regulator that is orally administered to children to induce sleep, has also been used as an alternative to conventional anesthesia. In a prospective study, melatonin administration was found to be cost-effective and to be safer than standard anesthesia (Pasini et al.,2018).

Play therapy is a technique that involves the use of a child life specialist. A certified Child Life Specialist offers help to pediatric patients by teaching them how to cope positively in their medical undertakings. CCLSs in radiology use various methods to reduce anxiety in patients (Fraser et al., 2019). These professionals meet with the patient and the family before the radiology procedure and take them through the required preparation. They provide psychological preparation, which significantly reduces anxiety in children before they undergo the actual process. This preparation may include going through the procedure, displaying pictures of the scanner, and playing noises produced by the scanner. Some hospitals even allow the children to get into the actual scanner (Jaimes, & Gee, 2016). This exposure helps familiarize the patients with the equipment, making the actual process less scary to the children. The CCLSs may also use diverting the patients' attention from the procedure, thus reducing anxiety. These methods may include listening to audiobooks, guided imagery, and color projectors.

In light of the high levels of anxiety and stress in pediatric patients experienced during MRI, various strategies have been developed to ease this anxiety without deep sedation. These include simulator MRI, feed-sleep techniques, MR -compatible goggles, optimizing the MRI environment, and audiovisual systems (Perez et al., 2019). The use of mock MRI has been implemented in several hospitals and has shown excellent results. In Australia, the Royal Children's Hospital registered tremendous success in this program, with 98% of the examinations being deemed successful (Perez et al., 2019). The method was most effective in children between 3 to 8 years old (Delaney, 2016). Audiovisual devices were also observed to cause a significant reduction in pediatrics patient anxiety during MRI. According to Kitt et al, (2015) study, this method was most effective in children between 3 to 10 years of age. The feed-sleep technique has been most influential in patients aged six months and below. Children above ten years old have been observed to be relaxed when using goggles to watch movies or listen to music since the goggles are joined with MRI headphones (McGuirt, 2016).

To further alleviate anxiety in pediatric patients, an animal-assisted therapy program could be used. The program involves the patient spending time with a dog before the scan for about 20 to 60 minutes with a professional trainer's supervision (Perez et al., 2019). The trainer uses the dog to assure the child of the scan's safety, for example, by placing a pair of headphones made to protect a dog's hearing on the dog and explaining to the child that they will be wearing such earplugs. This non-pharmacological method aids in reducing anxiety in children during preparation for MRI, at the same time achieving quality scans (Manuela et al.,2019).

Suggestions for Future Research

Little research has been done to explore alternatives to sedation in MRI. For instance, most of the studies have discussed using an audiovisual system with a specialist, and little has been shared on the use of this method without a specialist. Sparse literature is also available concerning sedatives' dosage requirements on children with Attention-deficit hyperactivity disorder (ADHD). A larger sample of participants should also be used to ensure a proper representation of the general population. A fair distribution should also be considered such that children suffering from various diseases are tested, not just those suffering from neurological conditions.

Conclusion

MR Imaging is increasingly becoming a necessary medical procedure for children. The use of sedation as a way to ensure quality images in pediatric patients has, therefore, become a common practice. It has been proved to be one of the most effective ways of reducing anxiety in patients and thus minimizing any chances of movement that might alter the MR images. However, general anesthesia has been found to have some hazardous long-term effects on pediatric patients. These limitations have, therefore, resulted in various alternative techniques being explored in an attempt to make the MRI procedure safe and cost-effective. Despite this innovation, some challenges have still been encountered. Therefore for safe and effective MRI scans to be performed on pediatric patients, radiologists, anesthetics, and CCLSs are needed to ensure that quality images are obtained at the lowest scan time practicable.

References

Ahmad, R., Hu, H. H., Krishnamurthy, R., & Krishnamurthy, R. (2018). Reducing sedation for pediatric body MRI using accelerated and abbreviated imaging protocols. Pediatric Radiology, 48(1), 37-49.

Edwards, A. D., & Arthurs, O. J. (2011). Pediatric MRI under sedation: is it necessary? What is the evidence for the alternatives? Pediatric radiology, 41(11), 1353.

Fraser, C., Gray, S. B., & Boles, J. (2019). Patient Awake While Scanned: Program To Reduce the Need for Anesthesia In Pediatric MRI. Pediatric Nursing, 45(6).

Jaimes, C., & Gee, M. S. (2016). Strategies to minimize sedation in pediatric body magnetic resonance imaging. Pediatric radiology, 46(6), 916-927.

Kitt, E., Friderici, J., Kleppel, R., & Canarie, M. (2015). Procedural sedation for MRI in children with ADHD. Pediatric Anesthesia, 25(10), 1026-1032.

McGuirt, D. (2016). Alternatives to sedation and general anesthesia in pediatric magnetic resonance imaging: a literature review. Radiologic technology, 88(1), 18-26.

Pasini, A. M., Marjanovic, J., Roic, G., Dukaric, N., Batoš, A. T., Bahtijarevic, Z., & Gagro, A. (2018). Melatonin as an alternative sedation method during magnetic resonance imaging in preschool children with musculoskeletal problems. European journal of pediatrics, 177(9), 1359-1362.

Perez, M., Cuscaden, C., Somers, J. F., Simms, N., Shaheed, S., Kehoe, L. A., ... & Greer, M. L. C. (2019). Easing anxiety in preparation for pediatric magnetic resonance imaging: a pilot study using animal-assisted therapy. Pediatric radiology, 49(8), 1000-1009.