Reader response and Happy Easter and Passover
Myron Yaster MD
From all of us on the PAAD’s executive council Happy Easter and Passover!
https://www.bluemountain.com/view/r12331dd400c844598c9f40efcbe6221e?source=bma999
From David E. Mandelbaum, MD, PhD, Professor, Child Neurology, Brown University
Myron, I share your exasperation about diagnostic imaging for global developmental delay. For 40 years I have been trying to stop my ER colleagues from getting CT scans on children who are awake and alert (my admonition: The C in CT scan stands for Coma!) with very little success. In addition to the risk of sedation there is compelling literature on the adverse effects of ionizing radiation on cognition (I liken a CT scan to a concussion or maybe multiple concussions; would you hit the kid in the head with a baseball bat? Yes, if it was necessary to save his or her life, otherwise, not so much). Indeed, in a Swedish study[1] of 3,094 men who had received radiation for cutaneous hemangioma before age 18, the authors found that the proportion of boys who attended high school decreased with increasing doses of radiation to both the frontal and the posterior parts of the brain from about 32% among those not exposed to around 17% in those who received > 250 mGy. The authors concluded that “Low doses of ionising radiation to the brain in infancy influence cognitive abilities in adulthood.”
Also as discussed in a previous PAAD, there is also compelling evidence that ONE CT is enough to raise the risk of brain tumors.[2, 3] In that study, Smith-Bindman et al. concluded that at current utilization and radiation dose levels, CT examinations in 2023 were projected to result in approximately 103 000 future cancers over the course of the lifetime of exposed patients. If current practices persist, CT-associated cancer could eventually account for 5% of all new cancer diagnoses annually.
On the other hand, there is some evidence of progress,[4] more so on the peds side than adult side, but there are still way too many CT scans being done in the ER. (When I ask why it was done the usual answer is: “It could be a bleed” to which I answer: “a. No it can’t, given the history, and b. if the kid is awake it can wait for an MRI!”
Moving on to MRI, the guidelines for the workup of a child with neurodevelopmental delay have changed and the initial recommended evaluation is genetic studies (unless there is evidence of a condition that can be tested for specifically with blood work e.g. hypothyroidism). In the case of a static encephalopathy the likelihood of an actionable lesion on MRI is exceedingly low. What I tell parents, even if anesthesia is not going to be necessary: If the likelihood of getting killed in the car on the way to the MRI scan exceeds the likelihood of an actionable finding, I’m not sending you. As for scans requiring anesthesia, your summary cited the very overall low risk of anesthesia in ASA physical status 1-3 patients is about 1 death/ 250,000. But no matter how small the numerator, if the benefit is zero (or approaches that) the risk/benefit ratio is still infinite. It’s a very interesting finding regarding which specialists consider the risk to be higher or lower. (Another saying of mine: “The road to disaster is paved with ‘Ah, what the heck’”.) Determining the potential for benefit is where clinical judgement comes in; I contend to my patients’ parents that I am smarter than an MRI and don’t always need one to make a diagnosis or provide appropriate care. You mention the possibility of financial motivation on the anesthesia/radiology end; on the ER/Pediatrician/Neurologist end, I think it’s motivated by fear of litigation and lack of confidence (or ability?) in the clinical assessment.
One last thought: When getting an MRI without anesthesia, the potential risk (aside from the car ride) is the contrast, so, absent a clinical reason for contrast, I get it without contrast (won’t even need an IV). If, based on the non-contrast study, it needs to be repeated with contrast, no big deal. (Hopefully a radiologist is doing real time review and can intervene and add the contrast study if deemed advisable). If I’m getting an MRI with anesthesia, the risk is the anesthesia, so I order it with and without contrast, as the child will need an IV and, more importantly, I don’t want to have to repeat the anesthesia. (An exception is if my question will, in no way, be impacted by contrast, e.g. following up on ventricular size or some such thing).
And one more thing: I just looked it up: motor vehicle traffic fatalities: 12.9 deaths per 100,000 population per year So it’s literally true that the car ride to the MRI scan is the most dangerous aspect. As discussed with the anesthesia risk of 1/250,000, no matter how low the risk, if the benefit is zero, the risk/benefit is infinity.
Thanks for the opportunity to vent!
PS from Myron: I met Dr. David Mandelbaum on my first day of high school and we’ve been friends ever since. I knew I needed a pediatric neurologist to review my rantings, so I asked David, who is one of the smartest doctors that I know for his thoughts. I should also add, he has now become a regular reader of the PAAD!
References
1. Hall P, Adami HO, Trichopoulos D, Pedersen NL, Lagiou P, Ekbomrmbert D, Lang E, Dowling S: A Systematic Review of Interventions to Reduce CompF548–560.
From Ethan L Sanford, MD, Pediatric Anesthesiology and Pediatric Critical Care Medicine, UT Southwestern and Children’s Medical Center, Dallas, TX
A note of praise for the article on risk perceptions of sedated MRI and non-sedated CT. It shines light on an issue that is obvious to any pediatric anesthesiologist. The difference in risk perception is alarming. These episodes of care occur thousands of times internationally. Discerning best practice may carry enormous impact. While severe complications are rare, the combined effects of minor complications and resource allocation really deserve more analysis in comparison to the benefits of sedated MRI. Hoping the authors and other interested parties keep digging to show us how to best provide a service that helps without incurring unnecessary risk, costs, and personnel allocation.
From Brian P. Kell, Supervisor Anesthesia Mat & Equip, Cer. A.T.T.
Dr. Yaster, my name is Brian Kell and I work as a Certified Anesthesia Technologist in Nashville at Vanderbilt’s Children Hospital. I am the Supervisor for all of our inventory and equipment. I felt compelled to reach out to let you know how refreshing it is to hear someone else as passionate as I am to being a good steward to the MOUNTAIN of plastic and cost associated with Anesthesia supplies. I personally have been fighting against going the full Laryngoscope disposable route. I have convinced our department to continue to Autoclave the blades to save money and waste. The breathing circuits and the even the sample lines are another story. It seems like there is a tremendous need for a cultural shift when it comes to bringing back reusable products. The mountains of studies that find bacteria on reusable products seems very biased and driven to force us to buy disposable. The reality is (as you know) that the margin of improvement by in large is not worth the environmental and literal price tag on this 100% single use mentality. Not to mention when our stock does not come in, we have to pivot and make new protocols. (thanks for letting me vent) I am curious what feedback you have got from this article since posting. Also, about some of your current work flows to see how we can benefit by sharing ideas on efficiency. Feel free to email, text, or call. Thank you for your candid article.