After the warning of the American Food and Drug Administration in the 2016 about the potential negative effects of general anaesthetics and sedation drugs on developing brain , and the subsequent prompt reaction by many Societies of Anaesthesiologists [16–17], unicity of MRI setting has been the ideal “battlefield” to deal with this issue. Moreover, we are witnessing a change in literature: no more papers about techniques, but reviews about strategy to minimize sedation in paediatric MRI. Despite author’s efforts, the quality of evidence has not increased in the last years.
The need of a Survey focused on these topics comes from all the above mentioned considerations and follows the heels of two previous national Surveys, carried out in the United Kingdom  and in the United States . The first one sadly lacks of details, and the second one considered a sample of only 58 tertiary NICU of the whole country. On the contrary, our data present more widespread, including low profile centers too. The investigation we promoted meant to be a step forward in the analysis of the main aspects involved in MRI management. Despite of the limitations of a phone survey (contact center response could not match exactly with objective data), the emerging picture raises the concern that there is still an extensive room for improvement.
The first data to comment is a fragmented nature of Centers activity, with a large amount of low volume Institutions, where the number of procedures performed would not allow an adequate training and skilling of the teams involved. In the face of many Institutions working whit low-volume, there are only 26 Centers (mostly University and/or Paediatric Hospitals) guaranteeing a flow of almost 10 paediatric patients a week. In the same way, among the 65 Centers able to treat NICU’s neonates, only 12 do more than 3 weekly procedures on that range of age.
MRI for NICU’s patients involves neonatologists in a large proportion (40% vs anaesthesiologists 58%), e and just in a few cases (2%) a cooperation with anaesthesiologists is provided. The volume of neonates treated does not modify the rate of neonatologists (40% in HV centers and 41% in LV Center). Unfortunately, we have no data about the presence of residents in the site.
Anaesthesiologists look after children in almost all sites, independently of a NICU staff. Very few centers entrust this service to paediatricians, so the assistance of children and neonates in MRI largely rely on Anaesthesia Services, which should always offer high levels of skillness and safety.
Looking at the data of the Survey, the centralization of paediatric activity tabled by National Anaesthesiologists Societies (BLINDED) and (BLINDED)in shared Documents , is an aim only partially achieved, and MRI for paediatric patients is still too fragmented in the(BLINDED)Hospitals.
A dedicated nurse is absent in almost a quarter of the Centers included in the Survey, but surprisingly the lack of a specific nurse assistance is greater when NICU’s patients are treated. Probably neonatologist support and/or NICU nurses accompanying the patients, would explain the difference.
IN, OUT and DH access to MRI are the usual ways to manage young patients for MRI. IN and DH are equally the commonest, and the choice of these models is probably due to the possibility of a postprocedural monitoring after sedation, even if data from literature do not suggest a safer profile with these models of care .
The respondents to this survey were also asked about monitoring and availability of specific devices. Despite several international recommendations , adverse events analysis , and national guidelines , the equipment is often obsolete and incomplete. The data emerging by the Survey confirm a general "technological" inadequacy in a setting otherwise so complex and challenging.
The results showed an extensive use of pulse oximetry and EKG , not only inside the MRI suite. Remarkably, EndTidal capnography is not used in quite 20% of the Centers, despite deep sedation is the technique of choice. While pulse oximetry is not reliable to detect promptly respiratory depressions occurring during deep sedations, capnography would be able to recognize a condition of hypoventilation and apnea. Recent guidelines mandate the implementation of Capnography for moderate-to-deep sedation both in adults and paediatric patients . Respiratory complications are the commonest adverse events in paediatric/neonatal anaesthesia and their prevention is recommended, especially in Non Operating Room Anesthesia (NORA) settings .
Hemodynamics control is based mainly in EKG because the non invasive blood pressure monitoring is unavailable (often for the lack of adequate sizes) in almost 40% of centers. This absence could result life threatening, primarily considering the wide use of drugs as propofol or dexmedethomidine , which have a significant impact on mean blood pressure. Literature strongly suggests that a little control on this value can worsen the outcome of children and neonates [28–29].
A complete monitoring is available in just over half of centers (n = 68/106, 64%). This data is improved in correlation with: HV vs LV paediatric centers (n = 19/26, 73% vs n = 45/80, 56%); HV vs LV NICU centers (n = 10/12, 80% vs n = 33/53, 53%); the specialty of NICU performer (Anaesthesiologist 74% vs neonatologist 50%). It is difficult to explain the reason of such a limited monitoring, even in Centers with HV MRI activity. Moreover, dealing neonates do not improve the availability of monitoring devices. It is out of doubt that expensive amagnetic devices are often not available for economic restrictions, but a cultural issue is to be taken into account, which involves primarily the role of the Chiefs of the Anaesthesia Services and Departments. Actually they should be the first movers for an outstanding anaesthesiological support.
If a compatible MRI ventilator is present in almost all cases, curiously the availability of vaporizers for Sevoflurane is not equally confirmed, as it is absent in a percentage varying between 14% and 18% of the Centers. Sevoflurane is the first choice agent for the induction in uncooperative paediatric patients , and its deficiency restricts pharmacological choices to intravenous drugs, increasing the difficulty to manage the young patients, above all during the induction phase. Moreover, many MRI suites have not an adequate room scavenging system for halogenated (only 72% of centers are equipped with scavenger systems), causing a dangerous environmental pollution, above all in HV Centers.
Also the option to administer intravenous drugs are inadequate. Less than 40% of MRI rooms are indeed equipped with syringe pumps for intravenous infusion in a magnetic environment, obliging the use of single shot drugs or repeated boluses. To face this lack, it is quite common to use an external common pump outside the MRI room, connected to the patient by many extension sets . A good alternative would be the use of traditional syringe pumps allocated into amagnetic boxes, which allow the anaesthetist to infuse sedative drugs near the patient .
In the 11% of centers there are neither halogenated vaporizers nor infusion pumps. The general sensation is disappointing because the traditional drawbacks of NORA apply totally to a qualified and critical setting such as MRI in paediatric age. Obsolete and incomplete devices and monitoring systems, increase the risks of adverse events in far environments where anaesthetists work alone, without expert personnel supporting them .
This study has several limitations and at the same time much food for thought. Our phone survey investigated a single western Country experience and contacted anaesthetists in charge, anyway we deemed it could be a starting point to monitor the further evolution of approach to children and neonates in MRI suite. We described a diversified model of organization, with an extreme variations in in/outpatients pathways. Unfortunately our information is not sufficient to identify the best option, and this aspect was not an objective of our survey. Although it would be interesting to verify the degree of expertise of providers, we considered this survey an inadequate tools to investigate this item.
The current rate of a dedicated nurse supporting the performer is still unsatisfactory, but we have no data about a possible involvement of residents.
For which concern monitoring and tool (BLINDED) centers need to quick improve their supplies, which in many cases are clearly below the threshold of Minimum Standard . Further analysis of our data will be focused on this topic to evaluate if there is a correlation between monitoring and tools availability and sedation choices.
NORA represents an increasing activity because offers the possibility to decrease the in hospital charge, and to optimize costs and time for diagnosis and treatments. Quality and safety are two essential goals of our practice, as well as an adequate training and skill of the involved staff. Paediatric patients need particular care, MRI procedures are not the safer theater where to deal these patients, but its indications are expanding and constitute a growing challenge for our discipline. The aim of our survey was to offer a realistic picture of the “state of the art” in order to promote a more qualified approach. Statements and recommendations by national and international Societies are warranted, but their strength and feasibility should rely on the daily experience and practice, as our data show.