Standing By
By David E. Bessom, BS, RT(R)(MR)(ARRT), MRSO(MRSC)
Radiology Today
Vol. 25 No. 4 P. 14

Parental presence during pediatric MRI procedures can have a variety of effects on patients and practitioners.

Patients experience substantial anxiety in medical settings due to fear of the unknown and a lack of control, as well as discomfort associated with many procedures. For children, having their parents with them during this process can alleviate some of this anxiety and, if necessary, the use of anesthesia can help successfully complete their procedure, whether surgery, diagnostic imaging, or simply a difficult examination. Some facilities utilize both options and allow parents to accompany their children until they are asleep. This is known as parental presence during induction of anesthesia (PPIA). Studies have been conducted to investigate this practice, with mixed results.

Many studies reported no benefit to patients or parents. Many providers believe the presence of more people in the room makes the induction process less safe. Currently, no formal governance exists recommending or prohibiting PPIA, and the decision is ultimately up to each individual facility or practice. However, there are some important factors to consider in the decision to allow PPIA, and the risks vary depending on the location of induction.

The MRI environment is inherently dangerous, involving more than just the risk of projectiles caused by the static magnetic field. Safety (of patients, staff, and visitors) must be the top priority, and all decisions should be made with safety in mind. Facility policies addressing PPIA in MRI should involve the MR safety officer (MRSO) or the MR medical director (MRMD) for the site, as well as anesthesia personnel and hospital administrators. The decision and associated instructions should be clearly communicated to all staff and visitors.

New Environments
Health care settings can be intimidating and full of complicated jargon and esoteric routines, which can create a sense of helplessness among patients. This anxiety can be even more pronounced in children. The unknown environment, strangers, and the very nature of medical procedures can be frightening or uncomfortable. Having the support of parents or guardians can help but, sometimes, more substantial intervention is required. Anesthesia can provide patients the ability to successfully complete difficult, uncomfortable, or time consuming procedures (such as MRI exams, which are lengthy and require the patient to remain completely still), that are needed for effective diagnosis and treatment. Parental support is an important piece of the puzzle but not always the safest option during certain portions of a child’s health care journey.

Safety First
Anesthesia comes with many risks. Medications can have negative side or aftereffects, and induction of anesthesia can cause disinhibition and movement or struggling against providers. Stage two, the period between the brain and body going to sleep (when patients move but are otherwise unconscious), is considered one of the most dangerous points in anesthesia induction. Risks include physical harm from patients’ movements, airway emergencies, and medication reactions. Highly trained and prepared professionals work together as a team to reduce these dangers and keep patients and team members safe and comfortable.

Within the MRI space, the static magnetic field poses a serious threat of projectile injuries from ferrous objects, and everyone (patients, staff members, and visitors) who enters the scanner room (“Zone IV”) must be screened to ensure they have no medical devices or implants that could pose a hazard. In the event of an emergency, care must be taken to maintain the integrity of and limit access to Zone IV, even while addressing the emergency. The ACR states that in the event of an emergency in Zone IV, the technologist’s first action should be to move the patient to Zone II and secure Zone IV. It is far too easy for a responder to carry with them a tool, device, or oxygen tank, which can become a deadly missile in the magnetic field.

Mixed Results
Studies have been conducted to measure the potential benefits of PPIA. Sites have experimented with virtual PPIA as well, allowing parents to communicate with their child via a hospital-owned and secure iPad.

These studies monitored and recorded subjective observations of parental and patient anxiety levels (using standardized clinical anxiety scales) before and during induction among cohorts including PPIA, preprocedure anxiolysis with midazolam (“Versed”), neither, or both. Some studies went further and documented surgical procedure times and the time from surgery completion to discharge (recovery time). Some of these studies demonstrated significant reduction in parental anxiety with PPIA, while others showed no significant difference for parents or children, but no study concluded that PPIA had any significant effect on preprocedure patient anxiety or recovery times. At least one study demonstrated that parental anxiety worsened the anxiety of the child, causing a more difficult induction and increased likelihood of perianesthesia and postanesthesia complications such as emergence delirium and longterm trauma responses.

Individual anesthesia provider preferences are also mixed. Many anesthesiologists and certified registered nurse anesthetists, advanced practice nurses, or doctorate practitioners who administer the anesthetic and maintain and monitor the patient’s vital signs and care, feel that the operating suite is no place for untrained persons. Relative time from parental separation to full sedation (or sedation beyond the point of awareness or remembering the presence of a parent) is quick, often only two or three minutes. Monitoring parents to ensure they do not inadvertently (or deliberately) touch or interfere with equipment, as well as the need for an extra staff member to escort them from the room after induction, makes PPIA a potentially dangerous inconvenience. A parent’s anxiety during preprocedure events can exacerbate their child’s anxiety, leading to a more difficult (and dangerous) induction, and there is also the possibility of an adverse event involving the parent. Fainting, stroke, a cardiac event, falls, or anything that draws attention away from the patient creates an additional, preventable risk. One study documented a case where a parent was allowed to accompany her child for induction, and once the child was asleep, the parent became upset and picked her child up, shaking him and calling his name, attempting to wake him.

Policy Considerations
With the evidence so far supporting the conclusion that any benefits of PPIA apply only to parents, that does not necessarily rule it out as an option. Family-centered care aims to provide comfort and care to patients and their families. If a parent can be safely brought along with their child and their anxiety eased, there is an overall positive outcome to the interaction. However, if the same reduction in parental anxiety can be achieved through methods deemed safer and less interruptive to the anesthesia team, these options should be explored. For example, much of the anxiety surrounding anesthesia relates to a lack of understanding of the process and a loss of control. Education and preparation prior to induction can substantially improve anxiety for parents and children. A provider taking the time to explain their process and everything the parent or child can expect to happen during induction can be far more effective than allowing a parent to simply watch the process, and having these conversations prior to the induction process (rather than during it) allows the anesthesia team to concentrate wholly on their patient.

Given the dearth of definitive study results and the varied professional opinions on the subject, there have not been any universal rules implemented governing PPIA. Thus, it is up to each site to allow PPIA, virtual PPIA, neither, or both. These decisions should consider all factors, including patient/ parent/staff preferences, availability of nonsterile induction locations, and the safety of everyone present, as well as alternate methods of reducing or otherwise addressing the anxiety of parents and patients.

Several alternatives have been identified as effective substitutions for PPIA. Many sites now utilize some form of scented anesthesia mask, which has been shown to decrease patient anxiety and ease acceptance of the mask. Some sites employ child life specialists, specially trained personnel whose job is to offer support and guidance to patients and families as they navigate the stressful experiences in the hospital. These specialists can assist with anesthesia induction procedures by helping prepare and support the families. They can even accompany the child into Zone IV in place of a parent and provide distraction measures; having undergone appropriate MRI safety training, their presence is less of a risk than that of a parent. Proper parent education and preparation is also an effective alternative to PPIA, easing anxieties and allaying fears prior to induction.

MRI Safety
Within pediatrics, most anesthesia services are used for surgeries or other surgical-adjacent procedures (bone marrow biopsies, chemotherapeutic lumbar punctures, etc). However, there is a moderate segment of the patient population who also require anesthesia for MRI examinations, whether due to age, medical anxiety, clinical claustrophobia, or simply because some MRI exams require the patient be perfectly still for several hours at a time. While the MRI suite is not sterile like an operating room, all the same risk factors apply, as well as several other significant safety considerations to include in the decision to allow PPIA or not.

The MRI suite, specifically Zone IV (the scanner room itself), embodies one of the most dangerous spaces in the hospital. While the lack of ionizing radiation has led to MRI being known as “the safe modality,” many consider this to be a misleading and dangerous misnomer. The static magnetic field poses a constant and unrelenting hazard to those who may bring ferrous objects or certain unsafe biomedical implants into the room. Ignorance of or disregard for proper safety protocols has been the cause of numerous sentinel events, with outcomes ranging from expensive equipment damage to fatalities.

Safety is paramount in every department, whether in a hospital or an outpatient facility. In an MRI department, it is at the core of every aspect of every action. The MRI technologist is responsible for screening everyone who enters Zone III for safety and to ensure they do not carry any items, implants, or devices in their body that could pose a danger to others or to themselves. Limiting the number of people allowed through Zone III and into Zone IV (ie, the number of people the MRI technologist is responsible for monitoring) is the first and easiest step in creating and maintaining a safe MRI environment.

With the limited staff allowed into Zone IV, there are fewer team members available to respond in the event of an emergency involving an attending parent. If they suffer a fall, or faint, or anything at all, providing emergency care to the parent has a direct effect on the care of the patient. And if the emergency involves the patient, things become even more strained. In addition to the emergency, a team member must manage the parent to ensure they do not interfere with the emergency intervention and to remove them from the space. It can be especially difficult to convince a hysterical parent to leave during a medical emergency involving their child, but at that point, parental presence can only increase the risk to the child.

The decision to allow PPIA in your MRI department must involve collaboration and discussion between MRI (preferably an MRSO and/or MRMD), anesthesia, and hospital administration. The reasoning for the decision should be clear and easily communicated to patients and families. It is not imperative that surgical areas and MRI come to the same decision regarding PPIA, but it is recommended that the operating room and MRI maintain parity of standards and rules regarding parental presence. This will help avoid confusion and questions among patients and families. Whatever choice your facility makes, it should be driven by the goal of creating a better, safer experience for everyone involved.

Future Considerations
Studies have demonstrated that the anxiety of a parent can exacerbate the anxiety of a child, which can worsen difficulties with induction of anesthesia, as well as postanesthesia effects. Many studies identified PPIA as a valid method of reducing parental anxiety, but alternative approaches are also effective. Scented anesthesia masks and child life specialists are two options shown to be effective in reducing patient anxiety, and preparation and education can reduce parental anxiety prior to anesthesia induction.

These alternatives should be considered before the decision is made to allow PPIA, particularly within the MRI environment, where hazards are multiplied by the presence of the large static magnetic field. It is therefore incumbent upon hospital staff and administration to weigh all the risks and potential benefits before finalizing a decision regarding PPIA, and to ensure the safety of all involved, regardless of which choice they make.

David E. Bessom, BS, RT(R)(MR)(ARRT), MRSO(MRSC), is an MRI technologist at the VCU Children’s Hospital of Richmond Pavilion in Richmond, Virginia.

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