Sedation In Young Children Research Articles

Rapid brain MRI for image-guided ventricular catheter placement in pediatric patients: protocol and preliminary clinical outcomes.

Neuronavigation is a useful adjunct for catheter placement during neurosurgical procedures for hydrocephalus or ventricular access. MRI protocols for navigation are lengthy and require sedation for young children. CT involves ionizing radiation. In this study, the authors introduce the clinical application of a 1-minute rapid MRI sequence that does not require sedation in young children and report their preliminary clinical experience using this technique in their pediatric population. All patients who underwent ventricular catheter placement at a children's hospital using a rapid noncontrast MRI protocol, standard MRI, or head CT from July 2021 to August 2023 were included. Type of procedure, etiology of hydrocephalus, ventricle configuration and size, morphology of ventricles, need for adjunctive intraoperative ultrasound, duration of procedure, accuracy of catheter placement, and need for proximal revision within 90 days were retrospectively recorded and compared across imaging modalities. Sixty-eight patients underwent 83 procedures: 21 underwent CT navigation, 29 standard MRI, and 33 rapid MRI. Patients who received standard MRI more often had tumor etiology, while those who underwent CT and rapid MRI had posthemorrhagic etiology (χ2 = 13.04, p = 0.042). Intraoperative ultrasound was required for 1 patient in the standard MRI group and 1 patient in the CT group. There was no difference in procedure time across groups (p = 0.831). On multivariable analysis, procedure time differed by procedure type, where external ventricular drain placement and proximal revision were faster (p < 0.001 and p < 0.028, respectively). Proximal revision due to obstruction within 90 days occurred in 3 cases (in the same patient with complex loculated hydrocephalus) in the rapid MRI group and 2 cases in the CT group. Although this study was not powered for statistical inference, the authors report on the clinical use of a 1-minute rapid MRI sequence for neuronavigation in hydrocephalus or ventricular access surgery. There were no instances in which intraoperative ultrasound was required as an adjunct for procedures navigated with rapid MRI, and intraoperative time did not differ from that of standard navigation protocols.

Stromal Cell-Derived Factor 1 Alpha (SDF-1α), Cartilage Oligomeric Matrix Protein (COMP) and Circulating microRNAs 208a-3p and 221-3p: Potential Signature Biomarkers of Hemophilic Arthropathy

Introduction. Hemophilia A is a rare constitutional bleeding disorder due to a deficiency in Factor VIII. Recurrent hemarthroses, one of the major complications of the disease, lead to hemophilic arthropathy, a disabling condition difficult to diagnose with current strategies (ultrasound and magnetic resonance imaging [MRI]), with possible delayed diagnosis. MRI, the gold standard, is not of easy access nor cheap and requires sedation in young children. Ultrasound is liable to inter-operator variability and difficult to apply to such joints as ankles, especially in children for whom this is the most frequently involved location of hemophilic arthropathy. Circulating MicroRNAs are a group of endogenous, small, non-coding RNA molecules that regulate gene expression ; and knowledge on the potential roles of miRNAs in haemophilia is very limited. Aim. The aim of this project was to assess plasmatic biomolecules indicative of osteo-cartilaginous damage in patients with hemophilia with or without known arthropathy, in order to improve the diagnosis of this major complication of the disease. We also investigated microRNA expression in patients with haemophilia A with and without inhibitors, compared to healthy controls. Methods In this monocentric retrospective study, 40 patients with hemophilia A or B, for whom a plasma sample was available, provided informed consent for further analyses (multiplex immunoassays and ELISA) and collection of relevant clinical information in their medical files. Correlations were sought for between biomarkers of interest and the severity of joint lesions assessed according to Pettersson radiologic score. For miRNAs analysis, all RNAs were extracted from plasma samples. We synthesised complementary DNA from the RNA samples, and used to quantitative PCR and microarray analysis to allow us to look at changes in expression levels. Results Two biomarkers were identified, respectively SDF-1α and COMP. Their plasmatic levels were significantly increased in patients with arthropathy compared to controls and patients without arthropathy. These values correlated significantly with the Pettersson score in patients under regular prophylaxis. We also identified two microRNAs of interest, the microRNA 208a-3p was significantly downregulated in hemophilia patients with arthropathy but not in patients without arthropathy and the microRNA 221-3p had a clear tendency for statistically significant down regulation in hemophiliacs with arthropathy. Interestingly, miRNA 221-3p has been shown to be involved in rheumatoid arthritis. Dysregulation of this microRNA leads to a reduced anti-inflammatory response and drives macrophages into a pro-inflammatory state. Conclusion Two plasma proteins SDF-1 alfa and COMP and two circulating micro-RNAs have been identified as potential biomarkers that could help physicians to assess the presence and severity of hemophilic arthropathy.

An Abbreviated Non-Contrast MRI Protocol for Osteomyelitis May Reduce the Need for Sedation in Young Children.

Lengthy MRI examinations in young children often requires sedation. When sedation is unavailable, critical imaging may be delayed. Abbreviating the imaging protocol to a few essential sequences may reduce the need for sedation and prevent delays in patient care. We retrospectively evaluated an abbreviated noncontrast MRI protocol to diagnose lower extremity osteomyelitis in the pediatric population. The IRB approved this study. The radiology information system was searched for lower extremity MRI examinations for osteomyelitis in patients <20 years old from August 2020 to August 2021. Three noncontrast sequences (long axis T1 without fat saturation (FS), long axis STIR, and axial T2 with FS) were independently reviewed by 2 pediatric radiologists. The accuracy of the reviewers was compared to the clinical radiology report based on the unabridged contrast-enhanced standard department protocol. The search yielded 80 exams, mean age was 7 years old, 59% (47/80) were male, and 41% (33/80) were female. The accuracies of reviewer A and reviewer B were 95% and 89%, respectively. The reviewer inter-observer agreement for the diagnosis of osteomyelitis was strong (k=0.79). The accuracy of an abbreviated noncontrast MRI protocol to evaluate lower extremity osteomyelitis in children approaches that of the unabridged protocol and has the potential to decrease the need for sedation in young children.

Non-sedated fast spine magnetic resonance imaging in pediatric patients.

Traditional spine magnetic resonance imaging (MRI) protocols require sedation in young children and uncooperative patients. There is an increased interest in non-sedated pediatric MRI protocols to reduce risks associated with anesthetic agents and improve MRI access. To evaluate the image quality of pediatric non-sedated fast spine MRI. We retrospectively reviewed 69 pediatric non-sedated fast spine MRI exams performed in 57 patients. Two blinded readers provided image quality ratings for the evaluation of bones, cranio-cervical junction, cerebrospinal fluid (CSF) spaces, spinal cord, soft tissues, ligaments, and overall diagnostic quality on a 1-5 scale, and determined whether there was evidence of syringomyelia, abnormal conus medullaris position, or filum terminale abnormality. Mean patient age was 7.2years (age range ≤ 1-17). Indications included syringomyelia (n=25), spinal dysraphism (n=4), combination of both syringomyelia and spinal dysraphism (n=8), and other miscellaneous indications (n=32). The inter-observer agreement ranged between moderate and very good for each variable (Cohen's weighted kappa] range=0.45-0.69). The highest image quality ratings were given to CSF spaces (mean image quality=3.5/5 ± 0.8) and cranio-cervical junction evaluations (3.5/5 ± 0.9). Overall diagnostic quality was worst in the <5years group (P=0.006). Readers independently identified a cervical spinal cord syrinx in 6 cases, and 1mm spinal cord central canal dilation in one case. Readers agreed on the position of the conus medullaris in 92% of cases (23/25 cases). Non-sedated pediatric spine MRI can be an effective diagnostic test to evaluate for spine pathology, especially syringomyelia, Chiari malformation, and conus medullaris anatomy.

Silver diamine fluoride–associated delays in procedural sedation in young children: A retrospective cohort study

BackgroundThis analysis evaluated the time to first sedation or general anesthesia (GA) encounter for children treated with and without silver diamine fluoride (SDF). MethodsThis retrospective cohort study used dental claims of privately insured children from birth through age 71 months with a sedation or GA claim from 2016 through 2020. The exposure was SDF use (yes, no). The outcome was time to first sedation or GA. Descriptive and multivariable negative binomial analysis was performed. The analysis tested the hypothesis that among children who received sedation or GA for their caries treatment, those who received SDF would show a longer time to first sedation or GA than children who did not. ResultsAmong 175,824 children included, SDF use increased the time to first sedation or GA encounter by 63 days when treated by different dentists (405 days vs 342 days; P < .001) and by 91 days when treated by the same dentist (337 days vs 246 days; P < .001), after controlling for the effects of age at first encounter, sex, and region of the country. ConclusionChildren treated with SDF had a longer time to first sedation or GA, which was magnified when treatment was performed by the same dentist. Practical ImplicationsWithin an individualized caries management plan, SDF could provide benefits for patients, dental offices, and health systems.

Impact of young age on outcomes of emergency department procedural sedation.

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 (≤ 2years) and the incidence of sedation-related adverse events. This is a secondary analysis of a prospective cohort study of children 0 to 18years undergoing parenteral procedural sedation in six Canadian pediatric emergency departments (ED). The primary risk factor was age≤2years. 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. Of the 6295 patients included, 946 (15%) were ≤2years. Children 13-24months comprised 90% of the young age group. Children≤2years 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≤2years (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≤2years vomited less frequently (OR 0.24, 95% CI 0.1 to 0.6). Young age, specifically between 13 and 24months, was not associated with a significant difference in the incidence of adverse events.

Efficacy of intranasal ketamine and midazolam for pediatric sedation: A double-blind, randomized clinical trial.

Background:Pediatric patients feel significant fear and anxiety when undergoing surgeries. The ideal drug and its administration route have not been found yet. The aim of this study was to compare the efficacy and safety of intranasal (IN) ketamine and midazolam as premedication in children.Methods:We studied 71 eligible pediatric patients undergoing elective urologic surgeries, aged 2 to 6 years. The degree of sedation and separation scores was compared between the two groups. Additionally, hemodynamic parameters, before premedication, after induction of anesthesia, and during surgery were documented and compared between two groups. Postoperatively, any side effect was recorded as well.Results:Finally, the data from 71 children were analyzed. Recovery time was significantly longer in group K (ketamine) compared to group M (midazolam); 27.86±4.42 vs 38.19± 6.67 minutes respectively (P=0.01). No significant difference was observed in terms of sedation score between two groups of K & M; 3.29±0.78 vs 3 ±0.71 respectively (P=0.17), and not regarding separation score; 2.51±0.61 & 2.31±0.52 respectively (P=0.01). Vital signs were kept within the physiological limits in both groups with no marked fluctuations.Conclusion:To produce sedation in young children, both midazolam and ketamine were effective and safe by IN route.

The Chft+ Sensor: A Novel Method to Measure Perfusion Abnormalities in Sickle Cell Disease

Introduction: Peripheral perfusion limitation is a potential biomarker of the severity and progression of sickle cell disease (SCD). Currently, there exists no direct means of quantifying perfusion deficits in SCD patients. Transcranial doppler ultrasonography offers a surrogate measure of perfusion and is highly operator dependent. Routine clinical screening of perfusion abnormalities with alternative modalities (e.g., positron emission tomography and magnetic resonance imaging) is challenging given high cost, requirement for sedation in young children, and need for trained personnel. The Combined Heat-Flux Temperature Sensor (CHFT+) is a novel noninvasive bio-heat perfusion sensor that measures peripheral perfusion in real time at depths of up to 1 cm by applying a minimal amount of heat to the skin surface. Because perfusion limitation is a hallmark of SCD, an improved understanding of its pathophysiology could potentially empower both patients and their physicians. The aim of this study was to evaluate the ability of the CHFT+ to detect differences in peripheral perfusion between healthy volunteers and patients with SCD. Materials and Methods: The present study is an ongoing, non-randomized pilot study that aims to test the CHFT+ sensor's ability to detect impaired perfusion is pediatric SCD patients. We are actively enrolling pediatric patients (age 3-17) with SCD and healthy volunteers from 2 pediatric clinics to test the sensor. Peripheral perfusion measurements were obtained at 5 locations on the body (e.g., forehead, forearms, palms). All measurements were normalized against forehead perfusion values to account for individual variations. An independent-samples t-test was conducted to compare average rates of perfusion in patients with SCD and in healthy volunteers. The goal enrollment for this study is 52 patients (26 with SCD, 26 healthy controls) to detect a two-fold difference in perfusion with a power of 0.80. Interim Results and Discussion: To date, 31 participants have been enrolled, 10 (32%) of whom were patients with SCD. Overall, average perfusion rates were lower in the SCD group when compared to the healthy group, although these differences were not statistically significant. Representative measurements of perfusion in the right and left forearms, normalized against forehead rates, are shown in Figure 1. Normalized left forearm perfusion in healthy controls vs. SCD patients: avg = 1.77, SD = 0.95 vs. avg = 1.28, SD = 0.52, respectively [t(27) = 1.80, p = 0.08]; see Fig. 1a. Normalized right forearm perfusion in healthy controls vs. SCD patients: avg = 1.80, SD = 1.01 vs. avg = 1.31, SD = 0.60, respectively [t(25) = 1.55, p = 0.13]); see Fig. 1b. Conclusions:At this time, our data suggest that the novel CHFT+ sensor is capable of detecting a modest difference in peripheral perfusion in children with SCD versus healthy controls, but this difference is not statistically significant due to limited enrollment. Additional enrollment will further define the utility of the CHFT+ sensor in this clinical population. Future studies should evaluate the sensor's capability to detect perfusion deficits in the adult SCD population, as well as measure perfusion variations that occur during SCD vaso-occlusive crises. Disclosures Diller: FluxTeq:Other: Partner.

Unsupervised MRI Homogenization: Application to Pediatric Anterior Visual Pathway Segmentation.

Deep learning strategies have become ubiquitous optimization tools for medical image analysis. With the appropriate amount of data, these approaches outperform classic methodologies in a variety of image processing tasks. However, rare diseases and pediatric imaging often lack extensive data. Specially, MRI are uncommon because they require sedation in young children. Moreover, the lack of standardization in MRI protocols introduces a strong variability between different datasets. In this paper, we present a general deep learning architecture for MRI homogenization that also provides the segmentation map of an anatomical region of interest. Homogenization is achieved using an unsupervised architecture based on variational autoencoder with cycle generative adversarial networks, which learns a common space (i.e. a representation of the optimal imaging protocol) using an unpaired image-to-image translation network. The segmentation is simultaneously generated by a supervised learning strategy. We evaluated our method segmenting the challenging anterior visual pathway using three brain T1-weighted MRI datasets (variable protocols and vendors). Our method significantly outperformed a non-homogenized multi-protocol U-Net.

Pediatric headache and neuroimaging: experience of two tertiary centers.

Headache is a frequent complaint in children and adolescents. Decision-making for neuroimaging should take into account the cost and the need for sedation in young children. To evaluate the yield of MRI in pediatric headache patients seen in two large tertiary hospitals. Data were retrospectively collected from patient records (n = 613) and neuroimaging reports. Headache was classified according to International Headache Society guidelines. There were 346 children with imaging studies (MRI n = 281, CT n = 65). Of patients who had at least one MRI study, 29% demonstrated an abnormal finding. Findings altering the management were obtained in 21 (7%) patients: the majority (n = 17, 80%) had headache for less than 3months. On the other hand, four patients with headache longer than 3months (19%) and 12 patients with normal neurological examination (57%) had significant MRI results affecting management. None of the children in whom the diagnosis of migraine could be made on clinical grounds (n = 40) had a significant MRI finding. Neuroimaging should be performed selectively in children with headache seen in pediatric neurology clinics, especially in headache of short duration (< 3months) and features atypical for migraine. A normal neurological examination should not reassure the clinician.

Safety and effectiveness of intranasal midazolam and fentanyl used in combination in the pediatric emergency department

ObjectiveTo examine the safety and effectiveness of intranasal midazolam and fentanyl used in combination for laceration repair in the pediatric emergency department. MethodsWe performed a retrospective chart review of a random sample of 546 children less than 18 years of age who received both intranasal midazolam and fentanyl for laceration repair in the pediatric emergency department at a large, urban children's hospital. Records were reviewed from April 1, 2012 to June 31, 2015. The primary outcome measures were adverse events and failed laceration repair. ResultsOf the 546 subjects analyzed, 5.1% had multiple lacerations. Facial lacerations were the most common site representing 70.3%, followed by lacerations to the hand (9.9%) and leg (7.0%). The median length of lacerations was 1.5 cm [1.0–2.5]. The median dose of fentanyl was 2.0 μg/kg [1.9–2.0] and midazolam was 0.2 mg/kg [0.19–0.20].There were no serious adverse events reported. The rate of minor side effects was 0.7% (95% CI 0.2% to 1.9%); 0.5% (95% CI 0.1% to 1.6%) experienced anxiety and 0.2% (95% CI 0.0% to 1.0%) vomited. No patients developed hypotension or hypoxia. Of the 546 patients, 2.4% (95% CI 1.3% to 4.0%) experienced a treatment failure. 2.0% (95% CI 1.3% to 4.0%) required IV sedation and 0.4% (95% CI 0.0% to 1.3%) were repaired in the operating room. ConclusionsOur results suggest that the combination of INM and INF may be a safe and effective strategy for procedural sedation in young children undergoing simple laceration repair.

Rapid-sequence brain magnetic resonance imaging for Chiari I abnormality

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

Safe Deep Sedation with Midazolam and Propofol for Cerebral MRI in Young Children with Sickle Cell Disease Is Safe: A Single Center Experience in Belgium

▪IntroductionCerebral angio-MRI is required in children with Sickle Cell Disease (SCD) in case of abnormal blood flow velocities or lack of acoustic window at Trans-Cranial Doppler Echography (TCD) and to screen the presence of silent infarcts. MRI in young children requires deep sedation and could potentially lead to hypoxemia and increase the risk of SCD-related complications. For this reason, we studied whether deep sedation (DS) for cerebral MRI in young children with SCD might be associated with more frequent adverse events during and within 30 days after the procedure.MethodsWe identified all patients with SCD who were investigated by MRI under DS in our center (Hôpital Universitaire des Enfants Reine Fabiola, Brussels, Belgium) from Augustus 2005 to March 2016. Demographic data as well as data about the anaesthetic procedure and acute clinical events 30 days before and after sedation have been collected retrospectively. The anaesthetic procedure for patient with SCD was based on midazolam as premedication followed by propofol for deep sedation. Supplementary oxygen was added to all children to maintain FiO2 > 40%. No prophylactic red blood cell transfusion/exchange were administered before sedation. Data were analyzed for normality; parametric values were assessed by mean and SD, non-parametric values were assessed as medians and interquartile ranges. Student test was used to analyse continuous variable and Chi-square test for discrete variable.ResultsSeventy four SCD children were identified in whom 147 procedures were performed. 53% were female; 94% were HbSS or HbSβ0. Most of them have already experienced one or more previous acute clinical event (dactylitis 32.4%, vaso-occlusive crisis [VOC] 45.9%, acute chest syndrome [ACS] 32.4%). Hydroxyurea has been prescribed to 39 patients (52.7%) at a median age of 2.4 years (range: 0.6- 4.9 years) mainly for recurrent VOC/ ACS. Five patients were on chronic transfusion program beginning at a median age of 2.6 years (range: 2.1-4.7 years) for primary and secondary stroke prevention.Median age at procedure was 3.1 years (range: 0.9 - 6.1 years). The median number of MRI under DS per patient was 1.8 (range: 1-5).Seven MRI were associated to an incident linked to the DS: 3 episodes of agitation/irritability, 4 desaturations < 95% (with 1 requiring transient manual mask ventilation). Median saturation during the procedure was 100% (range: 84-100%).28 clinical events (19%) occurred within the 30 days before DS while 16 (11%) occurred within the 30 days after DS. Considering hospitalisations, the number were 16 (11%) and 11 (7.5%) before and after respectively. Considering only VOC and ACS, the numbers were 8 (5.4%) before and 6 (4%) after DS. Patients developing SCD complications after DS were less frequently treated with hydroxyurea (18.8% vs. 44.3%, P=0.06), had longer procedure while Hb level, WBC count, MCV, HbF and LDH were not significantly different.DiscussionDeep sedation with midazolam and propofol for Cerebral angio-MRI in SCD children was safe, with few side-effects and no increase of VOC and ACS within one month of sedation. Only one study analyzed the safety of deep sedation in young children with SCD (Belmont et al. J Pediatr May 2015; 166:1226-32) but reported a possible trend of increased complications after sedation with midazolam, phenobarbital and fentanyl. Compared to the series of Belmont (Table 1), our patients were younger, more often treated with hydroxyurea and had a shorter procedure duration with less deep desaturation. The combination of propofol with midazolam seems to be better tolerated by children with SCD than midazolam, pentobarbital and fentanyl and appears to be safe in very young children. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

American Clinical Neurophysiology Society Guideline 5: Minimum Technical Standards for Pediatric Electroencephalography.

This revision to the EEG Guidelines is an update incorporating the current electroencephalography technology and practice. It was previously published as Guideline 2. Similar to the prior guideline, it delineates the aspects of Guideline 1 that should be modified for neonates and young children. Recording conditions for photic stimulation and hyperventilation are revised to enhance the provocation of epileptiform discharges. Revisions recognize the difficulties involved in performing an EEG under sedation in young children. Recommended neonatal EEG montages are displayed for the reduced set of electrodes only since the montages in Guideline 3 should be used for a 21-electrode 10-20 system array. Neonatal documentation is updated to use current American Academy of Pediatrics term "postmenstrual age" rather than "conceptional age." Finally, because therapeutic hypothermia alters the prognostic value of neonatal EEG, the necessity of documenting the patient's temperature at the time of recording is emphasized.

Dream Doctor Intervention Instead of Sedation: Performing Radionuclide Scanning Without Sedation in Young Children: A Study in 142 Patients.

Dream Doctors (DDs; professional medical clowns) are expanding their activities in pediatric wards. DDs were introduced as an alternative to sedation among children undergoing kidney imaging after urinary infection. The imaging requires that the patient lie completely still under the camera during the scan; otherwise the image cannot be interpreted. It is extremely difficult to get these children to cooperate, and pediatricians have to provide sedation to get good results. Giving sedation requires medical observation, and it can take hours until the child can be safely released from the hospital. A DD intervention was introduced in an attempt to avoid sedation in these young children. The DD tried to gain the child's cooperation during the procedure. Each study was subsequently scored by a radionuclide physician to assess study quality and interpretation. A total of 142 patients were studied over a 14-month period. The mean age was 2 ± 1.6 years. During the study, in the presence of the DD, only five (3.2%) patients required pharmacologic sedation compared with 100% before the study. The introduction of DDs proved to be a good alternative to sedation in cases where the procedure does not involve pain and only requires the child's cooperation.

MRI Customized Play Therapy in Children Reduces the Need for Sedation--A Randomized Controlled Trial.

To evaluate the effectiveness of an MRI-specific play therapy intervention on the need for sedation in young children. All children in the age group of 4-10 y, who were advised an MRI scan over a period of one year were randomized. Exclusion criteria included children with neurodevelopmental disorders impairing cognition and children who had previously undergone diagnostic MRI. A total of 79 children were randomized to a control or an intervention condition. The intervention involved familiarizing the child with the MRI model machine, listing the steps involved in the scan to the child in vivid detail, training the child to stand still for 5min, and conducting several dry runs with a doll or a favorite toy. The study was approved by the Institute ethical committee. The need for sedation was 41% (n = 16) in the control group and this declined to 20% (n = 8) in the intervention group (χ(2) = 4.13; P = 0.04). The relative risk of sedation decreased by 49% in the intervention group as compared to the control group (RR 0.49; 95% CI: 0.24-1.01) and this difference was statistically significant (P = 0.04). The absolute risk difference in sedation use between intervention and control group was 21% (95% CI 1.3%-40.8%). Even on adjusting for age, relative risk of sedation remained significantly lower in children undergoing play therapy as compared to the control (RR 0.57, 95% CI: 0.32-0.98) with P value of 0.04. The use of an MRI customized play therapy with pediatric patients undergoing diagnostic MRI resulted in significant reduction of the use of sedation.

Safety of Deep Sedation in Young Children with Sickle Cell Disease: A Retrospective Cohort Study

To assess the rates and types of complications associated with deep sedation in children with sickle cell disease (SCD) and to explore potential risk factors. This was a retrospective cohort study of children with SCD and a comparison group of children without SCD who underwent magnetic resonance imaging with deep sedation. The rates of general and SCD-associated sedation complications were calculated, and potential associated clinical and laboratory variables were assessed. A total of 162 sedation records in 94 subjects with SCD and 324 sedation records in 321 subjects without SCD were assessed (mean age, 4.3years in both groups). Pentobarbital, fentanyl, and midazolam were used in the majority of sedation episodes without routine presedation transfusion. Sedation-related complication rates did not differ significantly between the SCD and comparison groups. Within 1month after the sedation procedure, 17 children (10%) experienced a vaso-occlusive pain episode (VOE), and 2 children (1.2%) developed acute chest syndrome. Preprocedure and postprocedure rates of these complications did not differ significantly. Subjects who developed VOE after sedation had a significantly higher VOE rate before sedation, but no other significant clinical or laboratory risk factors were identified. Deep sedation in young children with SCD using a standard protocol is safe, with a sedation-related complication rate comparable to that of the general pediatric population. The observed rate of VOE, although not significantly higher than expected, warrants further investigation.

How important is early magnetic resonance imaging of the temporomandibular joint for the treatment of children with juvenile idiopathic arthritis: a retrospective analysis

Background: Temporomandibular joint (TMJ) arthritis is common in children with juvenile idiopathic arthritis (JIA), but often clinically asymptomatic. Magnetic resonance imaging (MRI) is the most reliable examination method, but requires sedation in young children. The aim of our study was to evaluate whether early TMJ MRI will change the treatment of patients with newly diagnosed JIA. Methods: Single center chart review of all patients with a diagnosis of JIA between January 2007 and December 2010. Results: We found 147 patients with newly diagnosed JIA during this period. In 111 (76%) at least 1 MRI of the TMJ was available. Reasons why no TMJ MRI was done were parents’ refusal (10), MRI of other locations (7), fixed dental appliances (16) and unclear cause (3). A diagnosis of TMJ arthritis based on increased joint enhancement on MRI was made in 91/111 (82%) patients. The first MRI was done at a median interval of 5 months from the diagnosis of JIA, and 61/111 patients (55%) required sedation for their first MRI. TMJ arthritis was diagnosed in 53/61 (87%) requiring sedation and in 34/50 (68%) patients without sedation (p = 0.003). Following the first TMJ MRI, intra-articular steroid injections were performed into 107 TMJs of 60 patients. 48/147 (33%) patients received at least one DMARD to control their disease, and in 9/48 (19%) the first DMARD was started following the first TMJ MRI. Factors associated with TMJ involvement as demonstrated by MRI were JIA subtype (p = 0.007) and a younger age at diagnosis of JIA (p = 0.04). Conclusion: In our cohort of newly diagnosed JIA patients TMJ arthritis was very common. Early TMJ MRI led to changes in treatment in 62% of patients with additional joint injections in 60 patients and start of systemic medication in 9 patients. We especially recommend performing TMJ MRI in young children even if they require sedation, as they have an increased rate of TMJ involvement.

Handheld Optical Coherence Tomography During Sedation in Young Children With Optic Pathway Gliomas

Monitoring young children with optic pathway gliomas (OPGs) for visual deterioration can be difficult owing to age-related noncompliance. Optical coherence tomography (OCT) measures of retinal nerve fiber layer (RNFL) thickness have been proposed as a surrogate marker of vision but this technique is also limited by patient cooperation. To determine whether measures of circumpapillary RNFL thickness, acquired with handheld OCT (HH-OCT) during sedation, can differentiate between young children with and without vision loss from OPGs. This cross-sectional analysis of a prospective observational study was conducted at a tertiary-care children's hospital. Children with an OPG (sporadic or secondary to neurofibromatosis type 1) who were cooperative for visual acuity testing, but required sedation to complete magnetic resonance imaging, underwent HH-OCT imaging of the circumpapillary RNFL while sedated. Area under the curve of the receiver operating characteristic, sensitivity, specificity, positive predictive value, and negative predictive value of the average and quadrant-specific RNFL thicknesses. Thirty-three children (64 eyes) met inclusion criteria (median age, 4.8 years; range, 1.8-12.6 years). In children with vision loss (abnormal visual acuity and/or visual field), RNFL thickness was decreased in all quadrants compared with the normal-vision group (P < .001 for all comparisons). Using abnormal criteria of less than 5% and less than 1%, the area under the curve was highest for the average RNFL thickness (0.96 and 0.97, respectively) compared with specific anatomic quadrants. The highest discrimination and predictive values were demonstrated for participants with 2 or more quadrants meeting less than 5% (sensitivity = 93.3; specificity = 97.9; positive predictive value = 93.3; and negative predictive value = 97.9) and less than 1% (sensitivity = 93.3; specificity = 100; positive predictive value = 100; and negative predictive value = 98.0) criteria. Measures of RNFL thickness acquired with HH-OCT during sedation can differentiate between young children with and without vision loss from OPGs. For young children who do not cooperate with vision testing, HH-OCT measures may be a surrogate marker of vision. Longitudinal studies are needed to delineate the temporal relationship between RNFL decline and vision loss.

Comparison Of Ultrasound Versus Magnetic Resonance Venography For Diagnosis Of Catheter-Related Thrombosis In Children: A Multicenter Multinational Study

BackgroundVenous thrombotic events (VTE) in children are related to central venous catheters and occur predominantly in the upper venous system. In routine clinical practice, ultrasound (US) is the most frequently used imaging technique for diagnosis of VTE in children because of its ease of use and non-invasiveness. However, US is known to be relatively insensitive for detection of VTE in the central upper venous system. Magnetic resonance venography (MRV) is a promising alternative as MRV can comprehensively image the central venous system, is minimally invasive and does not involve radiation. However, MRV involves high technical and logistic demands, and requires sedation in young children. ObjectivesTo compare the feasibility and diagnostic accuracy of US and MRV for diagnosis of central venous catheter related VTE in children. MethodsStudy Design: Cross-sectional diagnostic study. Study population: Children 0-<18 years of age with a central venous catheter in place for any reason were recruited prospectively and consisted of i) children who are asymptomatic for VTE: children who were screened for central venous catheter-related VTE within 20-60 days of catheter placement ii) children who are symptomatic for VTE: children presenting with signs and symptoms of central venous catheter related VTE within 7 days of symptom onset (all study-related imaging tests were completed within this time period). Children were excluded in case of i) systemic anticoagulant or antiplatelet therapy, and ii) inability to undergo contrast MRV. Imaging tests: Each participant had three imaging tests performed i) Doppler compression US ii) MRV without contrast iii) MRV with gadolinium contrast. All imaging studies were performed within 48 hours of each other. Data collection included clinical and demographic information on each subject, imaging and video documentation of each US and MRV. Central Adjudication Committee: All imaging studies were blinded and independently reviewed and interpreted by a central adjudication committee for the presence or absence of VTE. Outcomes: The two main study outcomes were 1) Feasibility of performing each test: assessed by a) the number of children who completed each diagnostic study and b) the number of evaluable studies; and 2) Diagnostic accuracy of each diagnostic test: assessed by the proportion of VTE identified by the respective test in relation to the total number of VTE identified by any imaging modality. ResultsA total of 152 children were enrolled from 24 centers in 9 countries: Argentina, Brazil, Mexico, United States, Canada, United Kingdom, Netherlands, Austria and Germany. The median age (range) for children was 11 years (2 months to 17 years). Fourteen (9.2%) children had clinical symptoms of VTE. One hundred and thirty three (88%) children had US completed, 113 (74%) had MRV without contrast and 113 (74%) had MRV with contrast. 18 subjects withdrew from the study before any test was performed for various reasons. Adjudication and analysis are ongoing, and will be completed by October 14th, 2013. Therefore, final results regarding the feasibility and diagnostic accuracy of each test will be available at the time of presentation. ConclusionWe have completed the largest and most comprehensive study to date comparing the feasibility and diagnostic accuracy of currently available non-invasive imaging modalities for detecting central venous catheter related VTE in children. Ultrasound demonstrated better feasibility than MRV, however, MRV still proved feasible in nearly three-quarters of pediatric subjects and was performed without sedation in individuals as young as 2 months old. The overall feasibility and diagnostic accuracy of each test will be reported after final adjudication and analysis are complete. The study findings will be used to formulate an effective pediatric diagnostic algorithm for diagnosis of central venous catheter-related VTE. The algorithm will be used as guidance for clinical practice as well as outcome assessments for clinical trials of antithrombotic agents in children. Disclosures:Male:Bristol Myer Squibb: Consultancy. Yee:Bristol Myer Squibb: Research Funding. Loewe:Bristol Myer Squibb: Consultancy. Krishnamurthy:Koninklijke Philips NV: Research Funding; Bristol Myer Squibb: Consultancy. Chalmers:Bristol Myer Squibb: Consultancy. Newburger:Merck: Consultancy; Janssen Pharmacutical: Consultancy; Bristol Myer Squibb: Consultancy. Ramirez:Bristol Myer Squibb: Employment. Portman:Bristol Myer Squibb: Employment. Mitchell:Bristol Myer Squibb: Consultancy; Eisai: Consultancy; Boehringer Ingelheim: Consultancy.