SCOTT SHEPARD

From left, Dr. Katharine Cox, MD, patient Brandon Hickman and Lisa Booth, RN

Le Bonheur Children’s Medical Center has begun using a new, $3 million, 3-Tesla GE Excite HDx MRI unit, the second MRI for the hospital, where 90 percent of imaging is for neurological cases; most of the rest are for cardiology.

Emergency medicine physician Jay Pershad had been using the sedation drug propofol in emergency cases for several years. The white fluid, known as ‘Milk of Amnesia,’ rapidly calms trauma patients and blocks short-term memory so they have no recollection of getting a broken bone set or a deep laceration sewn shut.

Two years ago, when Pershad’s group, Pediatric Sedation Specialists PC, began anesthesiology services at Le Bonheur, he set out to determine whether the drug could improve quality of care in diagnostic imaging.

Until they become teens and can lie still, patients must be sedated in order to get clear MRI images of soft neuro tissue. Pershad was the principal investigator in comparing propofol with pentobarbitol, which is already proven safe, effective and predictable. Results of the study, nothing short of significant, were published in the September 2007 issue of the peer-review journal, Pediatrics.

Pershad found that propofol induces sleep in less than 60 seconds, compared to 15 minutes for the barbiturate, and the patient begins to recover almost immediately after the drip is stopped; it saves more than an hour of recovery time compared to the other drug.

“With pentobarbitol, the patients don’t recover smoothly, but wake up agitated,” he said. “With propofol, they don’t wake up euphoric, but they are pleasant, and they don’t remember anything.”

That went a long way toward improving satisfaction levels, which was one of the study’s objectives.

Le Bonheur conducted 1,700 imaging procedures in the last year with sedation; a second magnet means that volume will likely grow to 3,000. Pershad has not calculated the finances yet, but saving 15 minutes on the front end and 60 minutes in recovery on each procedure could exceed 10,000 professional man hours each year. Inducing sleep faster also maximizes MRI utilization, as patients can be sedated and ready within minutes of the previous scan.

The drug study reflects a philosophy of continuous quality improvement, which Le Bonheur adopted in 2002 when Peggy Troy was named president, said pediatric neurologist James Wheless, director of the Comprehensive Epilepsy Program and Neuroscience Institute at Le Bonheur. In 2006, Troy was named COO of Le Bonheur’s parent, Methodist Healthcare, Inc.

“We are the only hospital in the area that routinely performs MRIs in children with sedation, since many children cannot hold still for the 45 minutes,” Wheless said. “Our sedation team members are experts in sedating children in the best possible way.”

With growth of the epilepsy, autism and other neurology programs at Le Bonheur, Wheless believes he’ll need a third magnet by 2010, when a new $327 million hospital is set to open. By treating its own patients and those from St. Jude Children’s Research Hospital, Le Bonheur hosts the nation’s largest brain tumor surgery center in the nation.

It was a tall order to determine if a drug everyone is familiar with can be replaced, Pershad said. The study was complicated by the reality that most of the MRI procedures are elective, and everyone is queasy when it comes to clinical trials involving children.

“This wasn’t experimental; propofol has been used in children for about 10 years, in the operating room and then the Emergency Department, so there are no unknown factors,” he said. “We went through the usual IRB process.”

The Institutional Review Board stressed the need for vigilance: propofol has a higher incidence of respiratory depression, and in 10 percent of patients it has a burning sensation going in. The board also stressed the importance of informed consent on the part of parents.

Pershad was persuasive. Of the 62 patients that fit the study profile, the families of only two declined to participate. Sixty seems like a small sample, but is statistically valid for the objectives. The results are also clear enough that investigators in other cities, if they are interested, should get similar outcomes.

“These are children who are already here because there’s something wrong and their parents are concerned,” Pershad said. “It takes a lot of time to explain the protocol, but I also had Le Bonheur’s reputation working for me. This is what we do for a living.”

His next research project will build on this one. Pershad will calculate the time savings from propofol and give it a dollar figure.



October 2007