General anesthesia or deep sedation is often used to assure that the infant remains motionless for the length of the scan. General anesthesia is a very valuable and indispensable intervention for multiple procedures. However, providing general anesthesia to keep an infant still for a scan requires careful consideration, since it has inherent risks and complications that are magnified by the anatomy and physiology of an infant. Parents and family members often express anxiety regarding the possible risks of general anesthesia for the sole purpose of keeping an infant still.
The pediatric services team at Cottage Children’s Hospital meets monthly to discuss various issues, including improving the care and safety of our patients and families. This collaborative team includes the pediatric hospitalists, the pediatric intensivists, the pediatric clinical nurse manager, the director of children’s services, the pediatric clinical nurse specialist (CNS), the pediatric clinical pharmacist and the pediatric respiratory therapy supervisor. Considering the risk involved with the use of general anesthesia or deep sedation for infants undergoing MRI, pediatric hospitalist Kathy Lou Reynolds, MD, suggested investigating the use of an infant immobilizer as an alternative option.
Implementation of infant immobilizer at CCH
Following the guidelines provided by the approved evidence-based practice model, the pediatric CNS evaluated the evidence to support the practice change. The immobilizer was successfully implemented into use with the assistance of the multidisciplinary team, including our radiology department. The device consists of an air-tight, chambered bag filled with tiny, evenly spaced beads. The bag is wrapped around the infant and secured by straps. A pump then evacuates the air in the bag, causing it to become rigid around the infant, without squeezing or applying pressure, but restricting any movement.
Patients were carefully evaluated for any complications related to the use of the immobilization device. Imaging scans were also monitored to assure that additional scans were not required due to movement artifact. With assistance from our finance department, we calculated an associated average savings of $647 per patient related to the use of the immobilizer for MRI compared with the use of general anesthesia.
More important than the financial impact is the opportunity to avoid additional stress for the patient’s family. The event in an infant’s life that leads up to the necessity for an MRI alone creates fear and anxiety for the family. Explaining the possible complications related to general anesthesia or deep sedation adds additional stress on the family. The team at Cottage Children’s Hospital is fortunate to be able to offer a safe alternative for MRI and support the welfare of our patients and their families.
Opiate use nationally is growing to epidemic proportions, with upwards of 25 percent of Newborn Intensive Care Unit (NICU) babies in many institutions admitted for opiate withdrawal. Opiate use and abuse is increasingly being observed in mothers at all socio-economic levels. Mothers who have used opiates or tested opiate-positive may continue breastfeeding their newborn babies. In fact, it has been shown that, even for babies who undergo withdrawal, breastfeeding significantly decreases the number of days in the hospital. However, for mothers who are not part of a methadone maintenance program, care should be taken in choosing to breastfeed because they may be using, knowingly or unknowingly, other illegal drugs in addition to heroin.
Care should be taken when discharging a baby exposed to maternal opiates, as the infant may not demonstrate signs of withdrawal until the third day of life, or later. The likelihood of withdrawal is not dose-dependent. Many newborns can experience withdrawal even when their mothers have only been prescribed a low dose of opiate medication.
Much more information about maternal drug exposure and its effect on the newborn infant is expected to be forthcoming, as there is extensive ongoing research in this area. In the meantime, it is vital to discuss with the mother the potential risk of exposure to the baby, and educate her thoroughly about the risk and benefit of breastfeeding in this population of infants.