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Scientific and Technological Research
Adverse events in paediatric patients taken to magnetic resonance imaging under sedation or anaesthesia
Eventos adversos en pacientes pediátricos sometidos a resonancia magnética bajo sedación o anestesia
Carlos Eriel Largo-Pineda
Corresponding author
cegopimed@gmail.com

Corresponding author at: Instituto de Alta Tecnología Médica (IATM), Carrera 81 No. 30A-99, Medellín, Colombia.
, Iván Darío Arenas-Correa, Gabriel Jaime Ángel-González, Jorge Mario Vélez-Arango, Victor Daniel Calvo-Betancur, Andrés Nahúm Arango-Zapata
Instituto de Alta Tecnología Médica (IATM), Medellín, Colombia
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high frequency electromagnetic waves&#44; high noise levels&#44; and low lighting&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a> The most significant limitations come from the electromagnetic field which precludes the use of many of the devices used regularly in anaesthesia&#44; given the risk that they may become projectiles inside the machine because of their ferromagnetic characteristics&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">1&#44;5</span></a> This requires instituting safety measures to reduce the incidence of adverse events in the resonance imaging area&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The following safety measures are described in the world literature<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">1&#44;5&#44;6</span></a> for reducing the incidence of adverse events&#58;</p><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Hazard zone</span>&#58; The MRI area is access-restricted in accordance with hazard zones&#46; See <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">In patients under 15 years of age or high risk patients&#44; sedation &#40;moderate or profound&#41; and anaesthesia are given by the anaesthesia specialist&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Equipment brought into Zone 4 must be approved by the manufacturer before use&#44; including the anaesthesia machine and all airway devices&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">A fully equipped basic and advanced cardiovascular resuscitation area must be available in Zone 2&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In the search for continuous improvement of the safety and efficiency measures implemented at Fundaci&#243;n Instituto de Alta Tecnolog&#237;a M&#233;dica &#40;IATM&#41; in Medell&#237;n-Colombia&#44; a study was conducted to describe the incidence of adverse events over the past 5 years in patients under 15 years of age taken to magnetic resonance imaging under sedation or anaesthesia given by the attending anaesthetist&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Materials and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Patient selection for sedation or anaesthesia</span><p id="par0045" class="elsevierStylePara elsevierViewall">Retrospective observational descriptive study in patients under 15 years of age taken to magnetic resonance imaging &#40;1&#46;5 and 3&#46;0<span class="elsevierStyleHsp" style=""></span>T machines&#41; under sedation or anaesthesia given by a specialist in anaesthesia during the time period between 2010 and 2014 at IATM&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Patients were classified according to mutually exclusive age groups<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">7</span></a>&#59; neonates &#40;1&#8211;30 days&#41;&#44; infants &#40;&#62;1 month to &#60;1 year&#41;&#44; toddlers &#40;1&#8211;2 years&#41;&#44; pre-schoolers &#40;3&#8211;4 years&#41;&#44; school children &#40;5&#8211;10 years&#41; and adolescents &#40;11&#8211;14 years&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Data recording and verification</span><p id="par0055" class="elsevierStylePara elsevierViewall">Data were taken from the clinical record completed by the nurse and from the anaesthesia record&#46; The former includes identification&#44; informed consent for entering the MRI machine area&#44; patient interview &#40;background information&#44; clinical record summary and order from the treating physician&#41;&#44; and anthropometric data&#46; The information was verified with the radiologist&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The anaesthesia record completed by the anaesthetist includes patient identification&#44; date&#44; classification of the anaesthetic risk &#40;ASA classification&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">8</span></a> personal history and physical examination&#46; Basic ASA monitoring &#40;or advanced&#44; depending on the physical condition&#41;&#44; was performed during anaesthesia and the variables &#40;blood pressure&#44; oximetry&#44; heart rate and capnography&#41; were documented in a paper form that also included timing and dosing of medications&#44; which were administered at the therapeutic doses recommended in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">9</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">After collecting the information&#44; the study population was described and adverse events were identified and classified according to the complexity of the outcome &#40;mild&#44; moderate or severe&#41;&#46; They were also characterised by sex&#44; age&#44; type of study performed&#44; length of the procedure and ASA level&#46; This study included all adverse outcomes of allergic origin as well as moderate to severe outcomes of non-allergic origin&#46; See <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">After the adverse event&#44; all patients were followed-up by phone at 48<span class="elsevierStyleHsp" style=""></span>h through their relatives &#40;parents or companions&#41; or by the nursing staff in hospitalised patients&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Analysis plan</span><p id="par0075" class="elsevierStylePara elsevierViewall">Absolute and per cent distributions were used for the descriptive analysis&#46; Likewise&#44; the rate of adverse events indicator was also used&#44; where the numerator is the number of adverse events during the time period and the denominator is the number of paediatric patients&#44; multiplied by a constant of 1000&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Ethical considerations</span><p id="par0080" class="elsevierStylePara elsevierViewall">After review&#44; approval and authorisation by the Research Ethics Committee of IATM&#44; the data from the clinical record were collected from the Radiology Information System &#40;RIS&#41;&#46; In accordance with the Declaration of Helsinky&#44; the Belmont Report and Colombian Resolution 8430 of 1993&#44; this research was classified as no-risk and&#44; for this&#44; reason&#44; no informed consent was obtained before patient inclusion&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">General considerations</span><p id="par0085" class="elsevierStylePara elsevierViewall">Overall&#44; 4786 patients under 15 years of age taken to MRI and requiring care from an anaesthetist for deep sedation or general anaesthesia were identified during the time period between 2010 and 2014&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Of the total number of patients 57&#46;2&#37; were males&#46; Age groups according to sex are shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">The most frequent MRI studies performed were&#58; standard brain MRI&#44; 47&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2291&#41;&#59; contrast-contrast-enhanced brain MRI&#44; 16&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>813&#41; and cardiac MRI&#44; 6&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>287&#41;&#46; See <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Adverse events</span><p id="par0100" class="elsevierStylePara elsevierViewall">This study identified 12 adverse events&#44; including 6 serious &#40;0&#46;12&#37;&#41;&#44; 4 moderate &#40;0&#46;08&#37;&#41; and 2 mild &#40;0&#46;04&#37;&#41; adverse events over a five-year period &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">There were 6 serious cardiorespiratory arrest adverse events&#46; The patients were given all basic cardiopulmonary resuscitation measures&#44; with a successful outcome in 4 patients who recovered and two unsuccessful outcomes in patients who died&#46; Serious adverse events were classified as ASA II &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41;&#44; ASA III &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#41; and ASA IV &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The other four patients suffering from serious adverse events who recovered spontaneous circulation and breathing as a result of cardiopulmonary resuscitation had been previously classified as ASA II &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41; and ASA III &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#41;&#46; Two of these cases were neonates with a diagnosis of dysmorphic syndrome&#44; one of which occurred during brain MRI &#40;8 months of age&#41; due to hypoxic encephalopathy&#44; and the last case was a 36-month old child during a study for dilated cardiomyopathy&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Regarding moderate adverse events&#44; there were three cases of laryngospasm&#46; The first event occurred during brain MRI in an 8-year old female patient classified as ASA II&#59; the second case occurred during brain angio-MRI in a 7-month old patient classified as ASA III&#59; and the third event occurred during cardiac MRI in a 2-year old patient&#46; This latter moderate event was due to accidental extubation with no repercussions on the patient&#39;s basal status &#40;it was the only event classified as preventable&#41;&#46; See <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">There was evidence of two mild allergic events in the form of skin rash which did not require admission to hospital or scaling up of therapy&#46; One of these occurred during a standard brain MRI with the use of chloral hydrate in a patient classified as ASA II&#59; the second event occurred during contrast-enhanced brain MRI in an ASA I patient who received lidocaine&#44; midazolam&#44; ketamine and propofol&#46; Both episodes took place after the patients were discharged from the institution and were reported by phone when the parents called to ask for instructions&#46; On follow-up after 48<span class="elsevierStyleHsp" style=""></span>h&#44; the patients were reported to be asymptomatic and did not require in-hospital management&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Commonly used anaesthetics were give to the patients who experienced the adverse events&#44; including lidocaine&#44; midazolam&#44; ketamine&#44; propofol&#44; fentanyl and chloral hydrate&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Discussion</span><p id="par0130" class="elsevierStylePara elsevierViewall">MRI diagnostic yield depends to a large extent on the quality of the image obtained&#46; For this reason&#44; the patient is required to remain still for a long period of time&#44; a condition that is not possible to achieve in the majority of paediatric patients&#46; Hence the need to use medications at sedative or even anaesthetic doses&#44; administered by an attending anaesthetist&#44; given the risk entailed&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">In Colombia&#44; there are few studies describing the incidence of adverse events associated with high-complexity diagnostic tests as is the case of nuclear magnetic resonance&#46; Delgado et al&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a> conducted a review on the use of deep sedation by an anaesthetist in paediatric patients &#40;&#60;15 years&#41; during 2009&#46; The review included 113 patients and found an incidence of non serious adverse events of 4&#46;4&#37;&#46; Internationally&#44; the reported frequency of adverse events in the paediatric population ranges between 0&#46;3 and 20&#46;1&#37; for diagnostic imaging services&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">11&#8211;18</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Rangamani et al&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">15</span></a> reported an 8&#37; incidence of adverse events in MRI&#46; Of these&#44; 0&#46;69&#37; were serious adverse events occurring in association with angio-MRI or cardiac MRI in patients under 120 days of age over a 10-year period&#46; Dorfman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">17</span></a> found 22 adverse events in 1334 cardiovascular MRI scans &#40;1&#46;6&#37;&#41;&#44; including 14 &#40;63&#46;5&#37;&#41; minor&#44; 7 &#40;32&#37;&#41; moderate and 1 &#40;4&#46;5&#37;&#41; serious&#46; In turn&#44; Kannikeswaran et al&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">14</span></a> reported an 11&#46;9&#37; incidence of adverse events in paediatric patients with impaired neurologic development&#44; and of 7&#46;9&#37; in patients with no impaired neurological development&#46; However&#44; they excluded patients classified as ASA<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>III or who required general anaesthesia&#46; In this study&#44; the incidence of adverse events was 0&#46;25&#37;&#44; without including mild&#44; non-allergic events&#59; most of the serious adverse events occurred in patients with a higher risk &#40;ASA III and IV&#41;&#44; consistent with what has been described in the literature by Metzner et al&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">18</span></a> and other authors<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">15&#44;19&#44;20</span></a> in the sense that the frequency of serious complications is higher in patients with a higher risk level&#46; In terms of adverse events in hospitalised paediatric patients&#44; this study showed a proportion of 66&#37;&#44; a figure that is higher than the 32&#37; reported by Dorfman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">17</span></a> in hospitalised patients&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">In terms of mortality&#44; there were two deaths in this study&#46; The first occurred in 2012 in a 37-month old female patient&#44; ASA III&#44; with underlying heart failure who went into cardiac arrest 35<span class="elsevierStyleHsp" style=""></span>min into de anaesthetic procedure for cardiac MRI&#46; The second case occurred in 2013 in a 48-month old female patient classified as ASA IV&#44; with a posterior fossa tumour who was taken to contrast-enhanced brain MRI and went into cardiopulmonary arrest 10<span class="elsevierStyleHsp" style=""></span>min into the start of anaesthesia&#46; The two patients received all basic and advanced cardiopulmonary resuscitation measures under the direction of the anaesthesia specialist&#46; It is difficult to find mortality information in studies on adverse events in the paediatric population seen in imaging services&#46; One of the few studies reporting this fact is the one by Vitiello et al&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">20</span></a> which assessed 4952 patients and reported 7 deaths associated with cardiac catheterisation in critically ill paediatric patients&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Although some MRI studies require greater depth of anaesthesia and even short periods of apnea in order to minimise movement artefacts from diaphragmatic displacement&#44; this research did not show a relationship between the complexity of the study and the occurrence of serious adverse events&#46; These events occurred in 4 cases of brain MRI &#40;requiring less depth of anaesthesia&#41; and in 2 cases of cardiac MRI &#40;more demanding in terms of anaesthesia&#41;&#46; The two fatal cases occurred during different MRI studies &#40;brain MRI and cardiac MRI&#41;&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Moderate adverse events in this study included 3 cases of laryngospasm &#40;0&#46;06&#37;&#41;&#44; in two of which a supraglottic device was used&#59; the events happened during emergence from anaesthesia&#46; In the third case&#44; there was no airway device associated and the event occurred in a patient under light sedation&#46; All the cases were solved with positive pressure ventilation given through the facial mask&#44; and two of them required additional administration of propofol&#46; No sequelae secondary to these outcomes were found in the study&#46; Malviya et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">16</span></a> in a study with 922 patients&#44; found a 0&#46;1&#37; incidence of laryngospasm&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Unlike the report by Malviya et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">21</span></a> with a reaction before discharge&#44; this research found two allergic reactions after the end of care&#46; On the other hand&#44; in the study by Delgado et al&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">22</span></a> there are no reports of these types of reactions&#46; These events were classified as mild&#44; in the form of only a skin rash in both cases&#44; and did not require hospital admission&#46; The fist case was associated with chloral hydrate&#44; an unpredictable medication with a long half life which is no longer widely used in our setting&#46; The second event was associated with concomitant use of gadolinium&#44; making it difficult to identify the culprit agent&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Schulte-Uentrop et al&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">23</span></a> reported general anaesthesia as the preferred technique for performing MRI in patients under 3 years of age or with major comorbidities who require some form of sedation&#46; These factors were associated with a higher risk at the time of the diagnostic test&#46; In our practice&#44; a larger number of adverse events have been found only in patients with major comorbidities at the time of the scan&#44; and no association was found with age &#40;patients under 3 years of age&#41;&#59; however&#44; an adequate assessment requires a causality study which is outside the scope of this study&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">In this study&#44; the whole group of adverse events included 12 patients &#40;10 females and 2 males&#41; and the majority of adverse events occurred in females&#46; As for serious adverse events&#44; there were four in females and two in males&#46; The study design does not allow to determine causal relationship but it is worth noting that the majority of adverse events occurred in females&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Limitations</span><p id="par0175" class="elsevierStylePara elsevierViewall">The data for this study came from databases&#46; Considering that in mild non-allergic events there is evidence or underecording&#44; these outcomes were not considered&#46; Such is the case of occasional venous line leak identified at the time of the saline solution test but without drug administration&#44; desaturation for short periods of time &#40;&#60;1<span class="elsevierStyleHsp" style=""></span>m&#41; or bradycardia that improved rapidly depending on the cause &#40;&#60;3<span class="elsevierStyleHsp" style=""></span>min&#41;&#44; without drug administration&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conclusion</span><p id="par0180" class="elsevierStylePara elsevierViewall">Magnetic resonance imaging studies performed under sedation or anaesthesia given by the anaesthetist in paediatric patients under 15 years of age is a safe procedure with a risk as low as 0&#46;25&#37; of adverse events&#46; However&#44; as reported in the literature&#44; hospitalised or decompensated patients require an in-depth risk-benefit assessment and consideration of the best option for each individual patient&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Ethical disclosures</span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Protection of human and animal subjects</span><p id="par0185" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Confidentiality of data</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Right to privacy and informed consent</span><p id="par0195" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Funding</span><p id="par0200" class="elsevierStylePara elsevierViewall">With their own resources the Instituto de Alta Tecnolog&#237;a M&#233;dica &#40;IATM&#41; financed the creation of the database and the time dedicated by researchers&#46; No external resources were received&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Conflicts of interest</span><p id="par0205" class="elsevierStylePara elsevierViewall">The authors declare not having any conflicts of interest&#46;</p></span></span>"
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          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec784549"
          "palabras" => array:5 [
            0 => "Anestesia"
            1 => "Sedaci&#243;n"
            2 => "Pediatr&#237;a"
            3 => "Imagen por resonancia magn&#233;tica"
            4 => "Ni&#241;o"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Nuclear magnetic resonance is a technique requiring breath holding or staying still for long periods of time for image acquisition&#46; For this reason&#44; paediatric patients need to be given sedation or anaesthesia&#44; creating additional risks to those found in other areas&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To describe the incidence of adverse events in paediatric patients in the magnetic resonance service with the presence of an anaesthetist&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Materials and methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Descriptive observational study to assess the incidence of adverse events in 4786 patients under 15 years of age taken to magnetic resonance imaging with an attending anaesthetist for sedation or anaesthesia at Instituto de Alta Tecnolog&#237;a M&#233;dica between 2010 and 2014&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">There were 12 adverse events with a rate of 2&#46;5 for every 1000 paediatric patients&#46; Of these&#44; there were 6 serious&#44; 4 moderate and 2 mild adverse events&#46; The proportion of mortality was 0&#46;04&#37;&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusion</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Performing magnetic resonance imaging studies under sedation or anaesthesia given by an anaesthetist in patients under 15 years of age is safe&#46; However a risk-benefit analysis is required in hospitalized or decompensated patients&#44; in order to assess the best option&#46;</p></span>"
        "secciones" => array:5 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Objective"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Materials and methods"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Results"
          ]
          4 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Conclusion"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La resonancia magn&#233;tica es una t&#233;cnica donde se requieren apneas o periodos de inmovilidad considerables para la adquisici&#243;n de im&#225;genes&#46; Inmovilidad que por condiciones de los pacientes pedi&#225;tricos son dif&#237;ciles mantener&#44; requiriendo administraci&#243;n de sedaci&#243;n o anestesia generando riesgos adicionales a los existentes en otras &#225;reas&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Describir la incidencia de eventos adversos en pacientes pedi&#225;tricos en el servicio de resonancia magn&#233;tica bajo asistencia por anestesi&#243;logo&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Materiales y m&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional descriptivo&#44; donde se valor&#243; la incidencia de eventos adversos en 4786 pacientes menores de 15 a&#241;os que fueron llevados a resonancia bajo asistencia por anestesi&#243;logo para sedaci&#243;n o anestesia en el Instituto de Alta Tecnolog&#237;a M&#233;dica entre los a&#241;os 2010-2014&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Se presentaron 12 eventos adversos&#44; con un &#237;ndice de 2&#46;5 por cada 1000 pacientes pedi&#225;tricos&#44; de los cuales 6 eventos adversos fueron graves&#44; 4 moderados y 2 leves&#46; La proporci&#243;n de mortalidad fue del 0&#46;04&#37;&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusi&#243;n</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Realizar estudios de resonancia magn&#233;tica bajo sedaci&#243;n o anestesia por anestesi&#243;logo en pacientes menores de 15 a&#241;os es seguro&#44; sin embargo en pacientes hospitalizados o descompensados debe hacerse un an&#225;lisis riesgo - beneficio y valorar la mejor opci&#243;n&#46;</p></span>"
        "secciones" => array:5 [
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            "identificador" => "abst0030"
            "titulo" => "Introducci&#243;n"
          ]
          1 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Objetivo"
          ]
          2 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Materiales y m&#233;todos"
          ]
          3 => array:2 [
            "identificador" => "abst0045"
            "titulo" => "Resultados"
          ]
          4 => array:2 [
            "identificador" => "abst0050"
            "titulo" => "Conclusi&#243;n"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Please cite this article as&#58; Largo-Pineda CE&#44; Arenas-Correa ID&#44; &#193;ngel-Gonz&#225;lez GJ&#44; V&#233;lez-Arango JM&#44; Calvo-Betancur VD&#44; Arango-Zapata AN&#46; Eventos adversos en pacientes pedi&#225;tricos sometidos a resonancia magn&#233;tica bajo sedaci&#243;n o anestesia&#46; Rev Colomb Anestesiol&#46; 2017&#59;45&#58;8&#8211;14&#46;</p>"
      ]
    ]
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        "fuente" => "<span class="elsevierStyleItalic">Source</span>&#58; Instituto de Alta Tecnolog&#237;a M&#233;dica &#8211; IATM&#44; authors&#46;"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Age group distribution according to sex in the paediatric population&#59; IATM&#44; 2010&#8211;2014&#46;</p>"
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        "identificador" => "fig0010"
        "etiqueta" => "Fig&#46; 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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        "fuente" => "<span class="elsevierStyleItalic">Source</span>&#58; Instituto de Alta Tecnolog&#237;a M&#233;dica &#8211; IATM&#44; authors&#46;"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Absolute distribution of magnetic resonance imaging procedures in the paediatric population&#59; IATM&#44; 2010&#8211;2014&#46;</p>"
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        "etiqueta" => "Table 1"
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          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>&#58; Adapted from the American Society of Anesthesiologists<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a> and Kanal et al&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">6</span></a></p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Hazard zone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Description&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Zone 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Includes areas of free access to the public&#44; usually located outside the MRI suite&#44; where patients and healthcare staff that assist during the procedure enter the MRI setting&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">1&#44;6</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Zone 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Transition between Zone 1 &#40;free access&#41; and Zone 3 &#40;controlled access&#41;&#46; This is where notes are entered in the clinical record and questions are answered&#46; The patients remain under permanent observation by the healthcare staff&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">1&#44;6</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Zone 3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Restricted access area for untrained staff and ferromagnetic objects because of the risk of injury from their interaction with static or variation of the MRI machine magnetic field&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">1&#44;6</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Zone 4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Restricted access area inside the MRI machine room&#44; located inside Zone 3&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">1&#44;6</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">MRI hazard zones&#46;</p>"
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        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>&#58; Adapted from the Ministerio de la Protecci&#243;n Social&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">10</span></a></p>"
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Complexity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Description&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mild&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Injury&#47;complication not giving rise to admission or a longer length of stay&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Requiring admission to hospital or increasing length of stay by at least 1 day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Severe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Any of the following situations&#58;<br><span class="elsevierStyleHsp" style=""></span>&#8226; Directly associated with sequelae&#46;<br><span class="elsevierStyleHsp" style=""></span>&#8226; Requiring leave of absence as a result of the adverse event for a period of time longer than needed for recovery or compensation of the underlying disease&#46;<br><span class="elsevierStyleHsp" style=""></span>&#8226; Cardiorespiratory arrest&#46; Any event requiring code blue activation&#46;<br><span class="elsevierStyleHsp" style=""></span>&#8226; Adverse event requiring surgical management&#46;<br><span class="elsevierStyleHsp" style=""></span>&#8226; Death&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Classification of adverse events&#46;</p>"
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      4 => array:8 [
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        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Table "
            "rol" => "short"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>&#58; Instituto de Alta Tecnolog&#237;a M&#233;dica &#8211; IATM&#44; authors&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cases of adverse events&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Paediatric patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">740&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">795&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1061&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">913&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1277&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rate of adverse events<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>1000 patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Distribution of cases&#44; patients and rates of adverse events in the paediatric population&#59; IATM&#44; 2010&#8211;2014&#46;</p>"
        ]
      ]
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        "etiqueta" => "Table 4"
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            "identificador" => "at4"
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          "leyenda" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">F&#58; female&#59; M&#58; male&#59; H&#58; in-hospital&#59; A&#58; outpatient&#59; IHE&#58; ischaemic hypoxic encephalopathy&#59; CS&#58; completed scan&#46; TE&#58; time to event in minutes &#40;time between the start of the anaesthetic intervention and the occurrence of the event&#41;&#46; Non spec&#58; non-specified&#59; CPA&#58; cardiopulmonary arrest&#59; OT&#58; orotracheal tube&#59; LM&#58; laryngeal mask&#59; NC&#58; nasal cannula &#40;these patients were in moderate and deep sedation&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleSup">2nd</span>&#58; second dose&#46; Mi&#58; midazolam&#46; Ke&#58; ketamine&#46; Li&#58; lidocaine&#46; Pro&#58; propofol&#46; Fen&#58; fentanyl&#46; CH&#58; chloral hydrate&#46; At&#58; atropine&#46; No airway &#40;the patient had a decompensation at the time of induction for intubation&#44; and went on to recover spontaneous breathing&#41;&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Age &#40;months&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Weight &#40;kg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">ASA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Type of admission&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Indication&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Drug dose &#40;mg&#47;kg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Type of adverse event&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Study&#47;airway management&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">TE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">H&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IHE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mi&#58; 0&#46;08 Ke&#58; 0&#46;83&#44; Li&#58; 0&#46;41&#44; Pro&#58; 0&#46;83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CPA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Standard brain MRI&#47;OT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Post-operative cardiac dysfunction<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mi&#58; 0&#46;07 Ke&#58; 0&#46;71 Li&#58; 0&#46;71 Pro&#58; 2&#46;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Laryngospasm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cardiac MRI&#47;LM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurological developmental delay&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mi&#58; 0&#46;06<br>Ke&#58; 0&#46;66&#44; Li&#58; 0&#46;33 Pro&#58; 0&#46;33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Skin rash&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Contrast-enhanced brain MRI<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&#47;NC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">EF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">H&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dilated cardiomyopathy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mi&#58; 0&#46;03<br>Ke&#58; 0&#46;35&#44; Li&#58; 0&#46;28&#44; Pro&#58; 0&#46;28&#44; sevorane&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CPA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cardiac MRI&#47;OT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">H&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Posterior fossa tumour&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mi&#58; 0&#46;06&#44; Ke&#58; 0&#46;63&#44; Li&#58; 0&#46;63&#44; Pro&#58; 2&#46;53<br>Fen&#58; 1&#46;89 <span class="elsevierStyleSup">2nd</span>Mi&#58; 0&#46;03&#44; <span class="elsevierStyleSup">2nd</span>Ke&#58; 0&#46;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Death&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Contrast-enhanced brain MRI<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&#47;OT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">H&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Workup for orbital mass&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pro&#58; 0&#46;86 <span class="elsevierStyleSup">2nd</span>Pro&#58; 0&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Laryngospasm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Brain angio-MRI&#47;LM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">H&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dysmorphic syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mi&#58; 0&#46;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CPA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Contrast-enhanced brain MR<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&#47;No airway&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sin Info&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">H&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dilated cardiomyopathy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mi&#58; 0&#46;04<br>Ke&#58; 0&#46;2<br>Li&#58; 0&#46;08&#44; Pro&#58; 0&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Death&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cardiac MRI&#47;OT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">H&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Microcephaly&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mi&#58; 0&#46;03&#44; Ke&#58; 0&#46;35&#44; Pro&#58; 0&#46;35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Extubation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Contrast-enhanced brain MRI<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&#47;OT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Non spec&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">H&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dysmorphic syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mi&#58; 0&#46;07<br>At&#58; 0&#46;07 Ke&#58; 0&#46;98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CPA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Standard brain MRI&#47;OT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Convulsive syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CH&#58; 60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Skin rash&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Standard brain MRI&#47;NC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Corpus callosum agenesis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mi&#58; 0&#46;05<br>Ke&#58; 0&#46;57&#44; Li&#58; 0&#46;38&#44; Pro&#58; 0&#46;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Laryngospasm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Standard brain MRI&#47;NC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
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Article information
ISSN: 22562087
Original language: English
DOI:10.1016/j.rcae.2016.11.007
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