Does your unit use sedation free MRI techniques?
“Sedation-Free”, “unsedated,” and the ever popular, “feed and swaddle” method. These are all names for a technique that utilizes comfort, feeding, and containment instead of sedation during lengthy MR imaging studies.
Why go sedation free?
In 2016, the U.S. Food and Drug Administration (FDA) released a report that called into question a common practice in neonatal intensive care units (NICUs), the routine use of sedation for radiologic studies (access the full report here).
The agency issued a warning that commonly used sedatives had neurotoxic effects on the developing brain of children under the age of 3, including the developing fetus.
How did that report impact neonatal care?
Over the past decade, in an effort to minimize the radiation exposure for neonates, the use of MRI has all but replaced CT for routine neonatal brain imaging. However, an unintended consequence has emerged from this radiation minimizing principle, known as ALARA (radiation dose As Low As Reasonably Achievable), because of the time and transport conerns required to complete MR imaging sequences. With the best intentions of minimizing radiation exposure, we were also placing neonates at risk from exposure to neurotoxic sedatives.
Enter the “Sedation-Free” MRI
Years prior to the 2016 FDA report, Dr. Terrie Inder and a group of researchers at the St. Louis Children’s Hospital at the Washington University School of Medicine published a protocol for conducting “Sedation-Free MRI” in the neonate.
At the time of their 2008 article, they had been offering non-sedated MRI’s for over 14 years. In fact, data suggests that when proper nonsedated techniques are used, 90-95% of neonatal brain MRI’s can be obtained without substantial motion artifact.
So why are so many NICUs still struggling with non-sedated protocols in 2019? Like so many things in the NICU, the answer is complicated, but according to Dr. Inder’s group, success lies in the details. Having a standardized protocol is key to completing unsedated MR imaging that results in high quality data without the risks of neurotoxic sedatives.
What are the keys to a successful unsedated MRI?
You can access Dr. Inder’s full protocol here, but let’s talk about some key features to get started – equipment, personnel, procedure.
- Equipment: Of course we need MR compatible respiratory support, IV pumps, leads, etc…but sedation free MRI also requires a few special items for the neonate. A head-stabilizing product such as the VacFix vacuum cushion or Medivac vacuum bag allow for the swaddled neonate to be further contained and immobilized. Ear muffs provide noise attenuation. Finally, a head coil specifically for neonates or an MR compatible incubator are ideal; alternatively the smallest quadrature RF coil available may be used.
- Personnel: It is essential that a NICU nurse or neonatal trained ICU transport nurse accompanies the baby to MRI and monitors the baby throughout the exam. Additionally, any neonate requiring ventilator support should also be accompanied by a neonatal provider (fellow, NNP, attending neonatologist), as well as a respiratory therapist. Finally, a radiologist should be available to review the MR images in real time so that the neonate is not moved out of the scanner until all necessary images are obtained.
- Procedure: Allowing ample prep time is key to success. Ideally forty five minutes prior to departure, the baby should be stabilized on the MRI compatible ventilator support to be used during the study. Any infusions required during transport should be kept to a minimum. The baby should be dressed in their diaper, and transferred to MRI compatible leads, pulse oximeter probes, and temperature probes. Their ear muffs can be placed, and they can be wrapped in one or two blankets. Finally, the vacuum bag or cushion can be wrapped around the baby. For babies that are feeding, adjust the feed schedule so that they eat 30-45 minutes prior to the scheduled scan time.
What challenges have you faced in implementing the feed and swaddle technique at your institution?
New Bedside Technology!
Recently, Aspect Imaging has released the Embrace Neonatal MRI, the first FDA approved neonatal MRI scanner. This new technology allows for safe and efficient MRI scanning right in the NICU! Check out this exciting new technology at https://www.embracemri.com/
Want to learn more about the feed-and-swaddle technique?
Register for our Brain Cooling Course, where in one of the bonus modules, three nurses from Brigham & Women’s Hospital NICU describe their successful MRI wrapping protocol. Just click the image below.