Changing the paradigm for diagnostic MRI in pediatrics: Don't hold your breath

Abstract

Increasingly complex pediatric patients and improvements in technology warrant reevaluation of the risk associated with anesthesia for diagnostic imaging. Although magnetic resonance imaging is the imaging modality of choice for children given the potentially harmful effects of computerized tomography-associated ionizing radiation, we dare to suggest that certain patients would benefit from the liberalization of our current standard. Incorporating the use of newer computerized tomography technology may improve safety for those that are already at higher risk for adverse events. Furthermore, magnetic resonance imaging is not risk-free-what is often overlooked is the need for controlled ventilation and breath-holding to minimize motion artifact. As physicians at the forefront of the development and sustainability of the perioperative surgical home, anesthesiologists must work to not only optimize patients preoperatively but should also act as gatekeepers for procedural safety.

Is MRI imaging in pediatric age totally safe? A critical reprisal

“…Diagnostic images are produced without breathholds and patient cooperation and, thus, without general anaesthesia. A typical example is Cardiac CT [33].…”

“…Furthermore, adverse events, especially pulmonary complications, also include patients with obesity, history of snoring, and developmental disabilities. In children with congenital cardiac diseases, the frequency of adverse events was estimated to be between 0 and 10.4% [33] and direct patient observation is prevented by physical separation. Besides, little is known about the long-term effects after exposure to analgesics or sedatives [34].…”

Should I irradiate with computed tomography or sedate for magnetic resonance imaging?

“…Largescale perioperative data broadly suggest that the immediate risks of anesthesia are approximately 1 in 10,000 for death, cardiac arrest or similar severe adverse events [9,26,27]. Specific risks of MRI with sedation/anesthesia have been described in the pediatric anesthesia literature, citing that the extent of risk for general anesthesia varies with patient age and underlying pathology [17]. In particular, populations at a higher risk of adverse events and pulmonary complications include children younger than 1 year and people with an American Society of Anesthesiologists (ASA) status score of ≥3 [28].…”

“…We believe that the development of ultrafast CT imaging (and a resultant decreased requirement for sedation/anesthesia for pediatric CT) [16] allows one to reconsider the risks of CT radiation against the risks of sedation/anesthesia for MRI. As such, a comparison of these risks has been highlighted in the pediatric literature [17][18][19]. However, before these risks can be estimated and compared, one must always assess the sensitivity and specificity of each imaging modality for a given diagnosis.…”

Noteworthy Literature published in 2017 for Congenital Cardiac Anesthesiologists

“…Faster scanning is possible with the use of dual source X-ray tube scanners resulting in a 1-second thoracic image and 5-second whole body image acquisition being possible with far less sedation needed for children. 32 These powerful imaging modalities are being transformed with the emerging technology of 3D printed models to accurately replicate complex cardiac anatomy. In a recent prospective study of 40 CHD patients ranging from 1 month to 34 years of age, at 10 international centers, consideration of a 3D printed model reconstruction acquired from MRI and CT imaging helped redefine the surgical approach in 19 of 40 cases.…”