Pediatric imagaing anesthesia protocol

[Perrotfish]

So, I'm a Pediatric resident, and I'd like to float an idea to my hospital to create a credentialing process for Pediatric residents/staff to administer sedation for Pediatric imaging and simple procedures. Particularly phenobarb vs propofol for MRIs and CTs and versed/fentanyl vs. Ketamine for simple procedures like laceration repairs. I would want this procedure to be for a situation where a general (not Pediatric) anethesiologist is available for emergencies in the hospital but not actually in the room. Right now our procedure is pretty much to call the anesthesia team, which I think sucks both because it makes ordering MRIs a nightmare and because it deprives residents of one of their best opportunities to practice on non-emergent non-neonatal pediatric airways. Right now there's a good chance that your first real experience bag masking and/or intubating a 5 year old will be in a code. The anesthesia team doesn't seem to be a big fan of the situation either.

So, my questions:

1) If you were designing a training protocol for something like this, what kind of experience would you guys want to see before someone was practicing independently? How many intubations? How many sedations with anestheiology in the room? How many hours do you think someone would need to put into training for this?

2) What agents would you design this protocol for? For MRIs in particular, what do you think is the best way to sedate a child under the age of 10?

3) Do you think there any hard and fast rules about what kind of patients Anesthesiology should always manage? Would patient's with a history or respiratory problems (severe asthma) be on the list?

Obviously this is going to get researched and pitched to our anesthesiologists many times before I even mention it to my own program, at which time I will still be months away from becoming reality, but I figured I would ask SDN first. Thanks in adavance.

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[imfrankie]

So, I'm a Pediatric resident, and I'd like to float an idea to my hospital to create a credentialing process for Pediatric residents/staff to administer sedation for Pediatric imaging and simple procedures. Particularly phenobarb vs propofol for MRIs and CTs and versed/fentanyl vs. Ketamine for simple procedures like laceration repairs. I would want this procedure to be for a situation where a general (not Pediatric) anethesiologist is available for emergencies in the hospital but not actually in the room. Right now our procedure is pretty much to call the anesthesia team, which I think sucks both because it makes ordering MRIs a nightmare and because it deprives residents of one of their best opportunities to practice on non-emergent non-neonatal pediatric airways. Right now there's a good chance that your first real experience bag masking and/or intubating a 5 year old will be in a code. The anesthesia team doesn't seem to be a big fan of the situation either.

So, my questions:

1) If you were designing a training protocol for something like this, what kind of experience would you guys want to see before someone was practicing independently? How many intubations? How many sedations with anestheiology in the room? How many hours do you think someone would need to put into training for this?

2) What agents would you design this protocol for? For MRIs in particular, what do you think is the best way to sedate a child under the age of 10?

3) Do you think there any hard and fast rules about what kind of patients Anesthesiology should always manage? Would patient's with a history or respiratory problems (severe asthma) be on the list?

Obviously this is going to get researched and pitched to our anesthesiologists many times before I even mention it to my own program, at which time I will still be months away from becoming reality, but I figured I would ask SDN first. Thanks in adavance.

Check out the Society for Pediatric Sedation: www.pedsedation.org
You can get on the listserv and follow discussions about it everyday.

 

[michigangirl]

Right now there's a good chance that your first real experience bag masking and/or intubating a 5 year old will be in a code. The anesthesia team doesn't seem to be a big fan of the situation either..

The biggest gap-- pediatricians who do sedations should not be getting experience masking or intubating children-- if they are, it'll still be in a CODE situation, where the sedation went wrong. Routine sedations by pediatric hospitalists generally only involve a NC/face mask +/- ETCO2 monitoring-- and no airway manipulation if the sedation goes well.

There's too much to learn during pediatric residency without adding pediatric sedations to the list. It sounds like your hospital needs to look into training peds hospitalists in sedation. Do your peds ER attendings do sedations for minor ortho procedures, lacs, etc. in the actual ED?

Propofol is a whole other ball game. You'll find it very difficult for a pediatrician sedation protocol to include this drug-- too much room for error...and the requisite bag/masking, intubating scenario.

 

[Perrotfish]

The biggest gap-- pediatricians who do sedations should not be getting experience masking or intubating children-- if they are, it'll still be in a CODE situation, where the sedation went wrong. Routine sedations by pediatric hospitalists generally only involve a NC/face mask +/- ETCO2 monitoring-- and no airway manipulation if the sedation goes well.

It wasn't that I thought that we would be bag masking or intubating during routine sedation, but rather that I'd been that if I was going to do sedation I would probably need more airway training so I'd be comfortable managing one if things went wrong. So to make this happen I figured I would need an anesthesia rotation. Thoughts?

 

[michigangirl]

I am of the strong opinion that every pediatric resident should do an anesthesia rotation during their 3rd year. Virtually all of our peds residents do here. It gives them a minimum of 2 weeks (some do a month) to do exactly as you said-- get experience doing elective airways , intubations, LMAs, see how to deal with laryngospasm, wakeups, etc.

It's a great experience especially for those going into non-ICU jobs (fellowship will train them in this stuff) like peds hospitalists who will cover the ED, those working in EDs for a year to "find themselves", and even general pediatrics where a kid might show up in respiratory distress.

This can all be done outside the monumental task of trying to set up a sedation credentialing process at your hospital. If there is no specific peds anesthesia elective available to peds residents, that would be a great addition to your program!

 

[Perrotfish]

This can all be done outside the monumental task of trying to set up a sedation credentialing process at your hospital. If there is no specific peds anesthesia elective available to peds residents, that would be a great addition to your program!

We have the elective in place, we just need a way to tie that in with us handling our own sedation in the hospital when we're working on wards. The reasons why I think we need a credenitaling process is that I think its both ridiculous and an enormous waste of time that we're trying to coordinate between two services everytime we need to set up an MRI. I think over the course of residency we probably waste at least a full week or two on that one administrative task. I'm sure that there are other process improvements we could do to fix the situation, but having us administer our own sedation seems like the most direct solution.

I'm hoping this won't be a monumental task. It's very much an in house process, and it seems like it would only involve a few meetings between half a dozen people.

 

[Mman]

while a noble goal, I see zero chance of developing a way to credential pediatric residents to provide sedation for imaging procedures. I mean a resident can't do anything without being supervised legally speaking. An anesthesia resident can't provide sedation for pediatric imaging without an anesthesiologist supervising them.

What you can do is provide a pathway to credentialing pediatric staff. Our hospital has a pediatric sedation team staffed by Peds ED attendings and Peds ICU attendings. They will handle the majority of peds imaging sedation and defer to anesthesia on potentially difficult airways or if their mild to moderate sedation attempts fail.

 

[Mman]

I think over the course of residency we probably waste at least a full week or two on that one administrative task. I'm sure that there are other process improvements we could do to fix the situation, but having us administer our own sedation seems like the most direct solution.

I don't know how your hospital works, but the biggest problem the peds services have had in hospitals I've worked at is timing. By the time the peds team finishes rounds and starts doing work for the day and bothers to call anesthesia to coordinate an MRI, it's already afternoon and our day is mostly filled up by then. It's much easier to make things happen the same day when we hear about it before 9 AM. The majority of our workday starts and finishes much earlier than a Peds resident tends to realize.

 

[Perrotfish]

while a noble goal, I see zero chance of developing a way to credential pediatric residents to provide sedation for imaging procedures. I mean a resident can't do anything without being supervised legally speaking. An anesthesia resident can't provide sedation for pediatric imaging without an anesthesiologist supervising them.

That's an interesting point, I hadn't really thought about the supervision aspect. You're right that technically the residents can't be 'credentialed', only qualified to provide sedation in a way that would meet the credentialing process. I guess the goal would make this a three year program where the residents would have met the requirements of credentialing when they graduated to being staff.

BTW this is a military hospital, so rather than scattering to the four winds upon graduation a significant percentage of the graduating residents become the staff. So training the residents to do this procedure is a way to ultimately train the ward attendings to supervise it.

I don't know how your hospital works, but the biggest problem the peds
services have had in hospitals I've worked at is timing. By the time the peds
team finishes rounds and starts doing work for the day and bothers to call
anesthesia to coordinate an MRI, it's already afternoon and our day is mostly
filled up by then. It's much easier to make things happen the same day when we
hear about it before 9 AM. The majority of our workday starts and finishes much
earlier than a Peds resident tends to realize.

I don't think the problem is that we don't realize it, the problem is we can't do anything about it. Rounds are when they are and unless we start working 4-4 rather than 7-7 (*shudder*) we can't start calling for a lot of advanced imaging until the attending is done reviewing the patients. Anyway we have to coordinate with the day radiology team as well as anesthesia and they get in even later than we do.

 

[IlDestriero]

We have peds hospitalists and sedation NPs do sedation for imaging and some simple procedures. They don't use propofol. They also screen for basically any reason at all to punt to us. We are in NORA sites every day already, but that still doesn't mean we can do non urgent add on cases. Trying to start this at a non peds hospital without the, likely very difficult to obtain, blessing of the anesthesia department will be a waste of time. Find a champion in the anesthesia department, a peds trained guy/gal, to help get their team on board first.
You can pm me if you want any specifics.

 

[michigangirl]

What I'm hearing is that your hospital needs an MRI anesthesia coordinator. For non-emergent MRIs (which the anesthesia team should do anyway), you call a central coordinator who is in the MRI department who works with the anesthesia schedule to fit thiese kids into the schedule. The peds anesthesiologists have specific days they are in MRI-- and "urgent" (needs to be done in the next day or two) get added on to the elective schedule. While I'm sitting in MRI doing elective cases, this coordinator will come to me to talk about an MRI that the floor team requested, I'll tell her what I need to get the case done, we'll talk about the add on schedule for the day and make it happen either that day or the next.

I've been there as a peds resident, trying to coordinate anesthesia for MRIs. It seemed like a black box. We finally got this MRI coordinator and it took one phone call-- done. happy to provide specifics prn.

 

[fakin' the funk]

So, I'm a Pediatric resident, and I'd like to float an idea to my hospital to create a credentialing process for Pediatric residents/staff to administer sedation for Pediatric imaging and simple procedures. Particularly phenobarb vs propofol for MRIs and CTs and versed/fentanyl vs. Ketamine for simple procedures like laceration repairs.

I'm shocked that the response from this board has been so blunted and friendly.

Can you imagine the IM residents floating around on SDN if we'll help them create a propofol-based sedation protocol for adults? We'd laugh them off the board and tell them something like "If you want to give anesthesia, become an anesthesiologist."

 

[Socrates25]

I'm shocked that the response from this board has been so blunted and friendly.

Can you imagine the IM residents floating around on SDN if we'll help them create a propofol-based sedation protocol for adults? We'd laugh them off the board and tell them something like "If you want to give anesthesia, become an anesthesiologist."

The problem that I've seen at several hospitals is that anesthesia generally doesnt like doing sedations for MRIs and other procedures -- they want to be in the ORs and they feel it is a waste of their time to be doing procedural sedations. They give a lot of flack to the ward attendings for this.

On the other hand, they dont want to teach any procedural sedation because they think the peds attendings will screw it up -- which they very well may do.

I dont think you can have it both ways -- if you dont want general peds to do sedations because you think they are incompetent, then the anesthesia group as a whole needs to take steps to be available to do them yourself without giving the requesting team a lot of flack. And I'm not talking about last minute add on cases at 4 PM in the afternoon either, I've seen anesthesiologists give a lot of grief even for MRIs scheduled the next day or two in advance.

 

[BobBarker]

while a noble goal, I see zero chance of developing a way to credential pediatric residents to provide sedation for imaging procedures. I mean a resident can't do anything without being supervised legally speaking.

A resident can be credentialed to do anything if they have their own license. Of course, they wouldn't be functioning as a resident! However, I certainly don't this is a good idea.

 

[urge]

We have the elective in place, we just need a way to tie that in with us handling our own sedation in the hospital when we're working on wards. The reasons why I think we need a credenitaling process is that I think its both ridiculous and an enormous waste of time that we're trying to coordinate between two services everytime we need to set up an MRI. I think over the course of residency we probably waste at least a full week or two on that one administrative task. I'm sure that there are other process improvements we could do to fix the situation, but having us administer our own sedation seems like the most direct solution.

I'm hoping this won't be a monumental task. It's very much an in house process, and it seems like it would only involve a few meetings between half a dozen people.

Indeed it is. Nobody ever seems to agree on what sedation is, and who should provide it. You need a busier ped mri room to become more efficient. We have one running every day with anesthesia for kids and adults with special needs.

 

[IlDestriero]

Indeed it is. Nobody ever seems to agree on what sedation is, and who should provide it. You need a busier ped mri room to become more efficient. We have one running every day with anesthesia for kids and adults with special needs.

What's your preferred recipe?
We usually just do propofol with a NC and monitor CO2. Babies always get a tube. With the other guys if they are still obstructing after induction, or it will take over 2 hours, they get an LMA and gas.

 

[Perrotfish]

What I'm hearing is that your hospital needs an MRI anesthesia coordinator. For non-emergent MRIs (which the anesthesia team should do anyway), you call a central coordinator who is in the MRI department who works with the anesthesia schedule to fit thiese kids into the schedule. The peds anesthesiologists have specific days they are in MRI-- and "urgent" (needs to be done in the next day or two) get added on to the elective schedule. While I'm sitting in MRI doing elective cases, this coordinator will come to me to talk about an MRI that the floor team requested, I'll tell her what I need to get the case done, we'll talk about the add on schedule for the day and make it happen either that day or the next.

I've been there as a peds resident, trying to coordinate anesthesia for MRIs. It seemed like a black box. We finally got this MRI coordinator and it took one phone call-- done. happy to provide specifics prn.

We do have two set days a month for non urgent peds imaging. That's always been easy to arrange. For the urgent stuff I don't think we have enough volume to convince anyone we need dedicated support staff. Also, practically, I'm not getting them change their system by making someone else do what has traditionally been my work and I'd probably get a reputation as a lazy ass if I tried. On the other hand I might convince them to let me train in a new procedure.

 

[Perrotfish]

I'm shocked that the response from this board has been so blunted and friendly.

Can you imagine the IM residents floating around on SDN if we'll help them create a propofol-based sedation protocol for adults? We'd laugh them off the board and tell them something like "If you want to give anesthesia, become an anesthesiologist."

I'd like to thank everyone for that courtesy. This advice has been very helpful.

 

[jwk]

I don't know how your hospital works, but the biggest problem the peds services have had in hospitals I've worked at is timing. By the time the peds team finishes rounds and starts doing work for the day and bothers to call anesthesia to coordinate an MRI, it's already afternoon and our day is mostly filled up by then. It's much easier to make things happen the same day when we hear about it before 9 AM. The majority of our workday starts and finishes much earlier than a Peds resident tends to realize.

This isn't just a peds problem. It's a radiology/cardiology/GI problem. I'm fine with doing scheduled cases. I'm fine with doing emergent cases, or even those that are truly urgent. Where I have an issue, and what really kills us, is the non-emergent/urgent add-on case. All of these outside-the-OR areas and their assorted physicians just assume we're sitting around doing absolutely nothing except waiting for them to call so we'll actually have something to do. They get truly pissed if we can't either come immediately to do their case, or give them a specific time when we can. "Sometime after 5? Whaddaya mean after 5? The radiologist goes home at 3 - he won't want to stay that late!" We get this constantly, multiple times a day. I covered five add-on cardiology cases the other day, none of them urgent, much less emergent. Three cardioversions and two AICD's. "Oh we forgot to schedule them - but you can come in 15 minutes, right?" It KILLS us!!!

 

[Mman]

A resident can be credentialed to do anything if they have their own license. Of course, they wouldn't be functioning as a resident! However, I certainly don't this is a good idea.

Yes, they do have a license. But in the hospital they are a resident at, their hospital credentials require them to be supervised by an attending. The only way they could get around it is to be at a different hospital from where they are a resident and be on staff at that other hospital.

As to the other post's sentiment about IM people trying to sedate adults for MRIs, there is a big difference. The vast majority of kids needing sedation for imaging are pretty much normal healthy kids. That's not all of them, but that's most of them. Adults are a different story. Normal healthy adults don't need sedation for an MRI or a CT. The ones that do are usually either crazy, morbidly obese, mentally challenged, or some combination.

It is far easier and safer to sedate most children for imaging procedures compared to most adults amongst the population of both that need it.

 

[Arch Guillotti]

What's your preferred recipe?
We usually just do propofol with a NC and monitor CO2. Babies always get a tube. With the other guys if they are still obstructing after induction, or it will take over 2 hours, they get an LMA and gas.

Same thing except don't always tube babies. Propofol for nearly all comers.

 

[Mman]

We do have two set days a month for non urgent peds imaging. That's always been easy to arrange. For the urgent stuff I don't think we have enough volume to convince anyone we need dedicated support staff. Also, practically, I'm not getting them change their system by making someone else do what has traditionally been my work and I'd probably get a reputation as a lazy ass if I tried. On the other hand I might convince them to let me train in a new procedure.

It probably isn't convincing them that you "need dedicated support staff". It's probably convincing them that they should spend lots of money on giving you dedicated support staff. I don't know how your anesthesia department is staffing those things, but the cost to us to give one dedicated CRNA for 8 hours 5 days a week is something around $250K per year when you factor in benefits and vacation and sick days. That doesn't count the anesthesiologist.

If they have 3-4 offsite locations that they are working with: GI, EP/cath labs, MRI/CT, etc. Coordinating the cases so that 1 or maybe 2 at a time can be done instead of letting all 3 or 4 go whenever they want can save lots of money. Providing open scheduling to all of them is horribly inefficient because you end up with lots of people sitting around getting paid lots of money and doing nothing most of the time.

 

[urge]

What's your preferred recipe?
We usually just do propofol with a NC and monitor CO2. Babies always get a tube. With the other guys if they are still obstructing after induction, or it will take over 2 hours, they get an LMA and gas.

Pretty much everyone gets an LMA & gas.

 

[michigangirl]

The problem that I've seen at several hospitals is that anesthesia generally doesnt like doing sedations for MRIs and other procedures -- they want to be in the ORs and they feel it is a waste of their time to be doing procedural sedations. They give a lot of flack to the ward attendings for this.

On the other hand, they dont want to teach any procedural sedation because they think the peds attendings will screw it up -- which they very well may do.

I dont think you can have it both ways -- if you dont want general peds to do sedations because you think they are incompetent, then the anesthesia group as a whole needs to take steps to be available to do them yourself without giving the requesting team a lot of flack. And I'm not talking about last minute add on cases at 4 PM in the afternoon either, I've seen anesthesiologists give a lot of grief even for MRIs scheduled the next day or two in advance.

These anesthesiologists are just being plain dumb, then. Its too bad. We get to bill for MRI anesthesia just like anything else, and it's actually kind of a nice day doing a day of MRI (in my opinion)-- fast turnover, induce, LMA/tube, go! In my experience peds anesthesiologists understand that almost every kid is going to need sedation/GA for MRI, but they may give you grief if you insist it needs to be done TODAY vs. tomorrow-- bottom line is, are you going to make a medical decision based on the MRI you need within 8 hours of calling to schedule it?

Sometimes our PICU gets grief for sending sick as crap kids to MRI with anesthesia for urgent/emergent MRIs, since there are intensivists available to do the sedations. But when the PICU acuity is terribly high and there are no personnel to take the kid, anesthesia needs to lend a hand.

Most of our kids get LMA/tube and gas. It's just easier. nothing like a little inhalational for muscle relaxation and a high quality study.

 

[Arch Guillotti]

Most of our kids get LMA/tube and gas. It's just easier. nothing like a little inhalational for muscle relaxation and a high quality study.

I disagree. Propofol infusion only is the only way to fly!

 

[IlDestriero]

I disagree. Propofol infusion only is the only way to fly!

Keep in mind that our patient population is probably different from yours.😉

 

[imfrankie]

I disagree. Propofol infusion only is the only way to fly!

no IV = vapor +/-

 

[Arch Guillotti]

Keep in mind that our patient population is probably different from yours.😉

Probably but we staff a fair number of MRI's. I think propofol infusion is the way to go on all but the sickest and the smallest.

 

[HalO'Thane]

Probably but we staff a fair number of MRI's. I think propofol infusion is the way to go on all but the sickest and the smallest.

Dexmedetomidine is a good way to go for those small infants you describe. Minimal effects on airway tone and fairly stable hemodynamics when titrated SLOWLY; assuming no contraindications such as 2nd and 3rd degree heart block, digoxin use, and hypotension/shock. For all others I agree that a propofol infusion is the way to go because of its fast onset, predictability, and quick offset. We very rarely use an LMA or ETT. To efficiently use gas on every case you better have a flawless system in place with experienced nurses and anesthesia providers, an induction room, and an anesthesia tech dedicated to your offsite locations. Without the full backing of your hospital that can be a pain in the arse.

 

[urge]

Dexmedetomidine is a good way to go for those small infants you describe. Minimal effects on airway tone and fairly stable hemodynamics when titrated SLOWLY; assuming no contraindications such as 2nd and 3rd degree heart block, digoxin use, and hypotension/shock. For all others I agree that a propofol infusion is the way to go because of its fast onset, predictability, and quick offset. We very rarely use an LMA or ETT. To efficiently use gas on every case you better have a flawless system in place with experienced nurses and anesthesia providers, an induction room, and an anesthesia tech dedicated to your offsite locations. Without the full backing of your hospital that can be a pain in the arse.

How much load are you giving them? 1 mcg/kg, 2mcg/kg? Plus an infusion?

How long does it take for them to go back to baseline/discharge? Might be like 2 hrs with high doses.

 

[HalO'Thane]

How much load are you giving them? 1 mcg/kg, 2mcg/kg? Plus an infusion?

How long does it take for them to go back to baseline/discharge? Might be like 2 hrs with high doses.

Usually a 1-2 mcg/kg load injected over 5 minutes. It takes about 5-10 minutes to take effect. I rarely need to give an infusion as this will last about 45 minutes. Therefore the only scans that tend to run longer are extremity MRI's and combined brain and total spines. In that case I either rebolus or run them on a dex drip at 1mcg/kg/hr. Our cardiac MRI's are also long but we intubate those patients for breath holding. I've found that it takes patients 45 min - 1 hour to wake up from these doses of dex and another 20 minutes to discharge, which is again why I prefer propofol in most situations.

 

[HollywdAnesth]

I did hundreds of pediatric imaging cases at my training program. We tried using dexmed for the MRIs, but it was just too damn loud and kids were waking up. That is if you could get them to tolerate wearing the headphones.

MRIs all got an LMA and gas. You say you worry about turnover, but if you have an experienced PACU, then you can pull them LMA deep as soon as the study is done and let the kid wake up in recovery.

CT scans were different. We would spray dex med into the child's nose (small children). 5 mcg/kg. Then you put the child with his/her parents in a quiet place, then 20 mins later the child goes to sleep. This nap will last over an hour. No IV. No airway. This wasn't always 100% successful. Those kids would end up getting LMAs.

The problem I see with this whole scenario is that you're asking us to predict the future. Pilot run into problems even when the weather is great. I've had healthy kids laryngospasm. I've had supposedly NPO children throw up after induction. Radiology is a dangerous place to anesthetize anyone, even healthy children. You're isolated from your regular rescue sources, and its often ignored by the people that stock the carts because outta sight outta mind.

To answer your question, there is no magic number of intubations or LMAs.

As far as patients that anesthesia should always see. I'd have to say any kid with GI pathology resulting in reflux, children with difficult airways, respiratory pathology. I know I'm leaving some out. Great topic for discussion.

 

[HalO'Thane]

I did hundreds of pediatric imaging cases at my training program. We tried using dexmed for the MRIs, but it was just too damn loud and kids were waking up. That is if you could get them to tolerate wearing the headphones.

MRIs all got an LMA and gas. You say you worry about turnover, but if you have an experienced PACU, then you can pull them LMA deep as soon as the study is done and let the kid wake up in recovery.

CT scans were different. We would spray dex med into the child's nose (small children). 5 mcg/kg. Then you put the child with his/her parents in a quiet place, then 20 mins later the child goes to sleep. This nap will last over an hour. No IV. No airway. This wasn't always 100% successful. Those kids would end up getting LMAs.

The problem I see with this whole scenario is that you're asking us to predict the future. Pilot run into problems even when the weather is great. I've had healthy kids laryngospasm. I've had supposedly NPO children throw up after induction. Radiology is a dangerous place to anesthetize anyone, even healthy children. You're isolated from your regular rescue sources, and its often ignored by the people that stock the carts because outta sight outta mind.

To answer your question, there is no magic number of intubations or LMAs.

As far as patients that anesthesia should always see. I'd have to say any kid with GI pathology resulting in reflux, children with difficult airways, respiratory pathology. I know I'm leaving some out. Great topic for discussion.

If you claim that your patients were waking up on Dex and could not tolerate the noise or headphones then chances are that you and your attending were either: a) Not giving a high enough dose or b) Not giving it enough time to work. If you don't believe me then look at the data out there on the use of Dex for pediatric MRI's. Kiera Mason out of Boston Children's Hospital has probably done more pediatric imaging cases than all of us combined:

MASON, K. P., ZURAKOWSKI, D., ZGLESZEWSKI, S. E., ROBSON, C. D., CARRIER, M., HICKEY, P. R. and DINARDO, J. A. (2008), High dose dexmedetomidine as the sole sedative for pediatric MRI. Pediatric Anesthesia, 18: 403–411. doi: 10.1111/j.1460-9592.2008.02468.x

In her case she used a bolus dose of up to 3mcg/kg Dex and an infusion of up to 2mcg/kg/hr when Dex was used as the sole sedative.

Again, I myself prefer propofol to dex but I feel that Dex has its place in my practice in the right patient because of its minimal effects on airway tone and respiratory drive compared to both propofol and gas.

I don't have anything against the use of gas with an LMA and ETT for every case but I just want to reiterate that it will be a lot more costly and labor intensive for the hospital and your department compared to IV propofol/dex with NC and ETc02. It takes a lot of work and advanced planning to get a system like that going in a remote location when starting from scratch. You need to purchase a whole new set of MRI compatible anesthesia machines and intubating equipment; you need space for a designated induction room and another anesthesia machine in that holding room; and you need to hire more techs to aid in your turnover. If the hospital was already designed without this system in mind then it may be hard to implement. As you already alluded to, it is easy to be ignored down there. Instrumenting each and every patient's airway is not always the safest rout when it is not needed, particularly in a remote location. These are things I didn't think about as a trainee but have now had to consider as an attending whose group is in the process of revamping its sedation service.

 

[Mman]

I don't have anything against the use of gas with an LMA and ETT for every case but I just want to reiterate that it will be a lot more costly and labor intensive for the hospital and your department compared to IV propofol/dex with NC and ETc02.

Why is it cheaper? The dexmeditomidine is far more expensive than sevoflurane. And you bill the same for a MAC as a GA.

 

[HalO'Thane]

Why is it cheaper? The dexmeditomidine is far more expensive than sevoflurane. And you bill the same for a MAC as a GA.

Gas is definitely cheaper, especially compared to dex (another reason why it is not my first choice). I was thinking more about the equipment costs of needing more anesthesia machines and possibly the creation of an induction room if one is not already there.

 

[Mman]

Gas is definitely cheaper, especially compared to dex (another reason why it is not my first choice). I was thinking more about the equipment costs of needing more anesthesia machines and possibly the creation of an induction room if one is not already there.

Why do you need an induction room? We induce in the MRI room with MRI compatible laryngoscopes. And anesthesiologists tend to like having anesthesia machines around when doing MAC cases so not sure how many people will be doing peds sedation without the same equipment around.

For us, GA is cheaper than a MAC with precedex. It's also quite effective.

 

[HalO'Thane]

Why do you need an induction room? We induce in the MRI room with MRI compatible laryngoscopes. And anesthesiologists tend to like having anesthesia machines around when doing MAC cases so not sure how many people will be doing peds sedation without the same equipment around.

For us, GA is cheaper than a MAC with precedex. It's also quite effective.

We used gas with an lma/ett where I trained as a resident and fellow. In both places we had an induction area. This allowed greater access to equipment and drugs during induction (I do not know of any MRI compatible anesthesia carts) and saved time. Usually while the first patient was finishing up the scan and extubating the second patient was being induced and ready to go. Even if that saves 5 minutes a patient with 12- 15 scans per day that can add up. In contrast with IV propofol and NC if your nurses can place the IV in preop your inductions are 30 seconds and you merely have to turn the drip off and wheel them to recovery. I also feel that we are still practicing safe medicine. I do agree that you still need a backup anesthesia machine and cart available. If you are doing fine without an induction room then that is great.