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Transitioning from CT to MR for Equivocal Pediatric Appendicitis: A Successful QI Project Implementation

Shifting from CT to MR imaging for equivocal pediatric appendicitis presents a promising alternative, as demonstrated by a successful quality improvement project at CHCO. This transition was driven by concerns regarding the potential risks associated with pediatric CT radiation exposure. The QI project showcased a significant decrease in CT utilization and a substantial increase in rapid sequence MRI (rsMRI) adoption post-implementation. Through collaborative efforts among providers, radiologists, and technologists, an algorithm was devised to optimize image selection, ensuring timely and effective diagnosis while maintaining pediatric patient safety.

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Transitioning from CT to MR for Equivocal Pediatric Appendicitis: A Successful QI Project Implementation

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  1. Transitioning from CT to MR for Transitioning from CT to MR for equivocal pediatric appendicitis US equivocal pediatric appendicitis US Will Pryor, III MD

  2. Background Background • Acute appendicitis is the most common cause of emergency abdominal surgery in pediatric patients: ~80k/year in the US! • American College of Radiology recommends US for 1stline imaging to diagnose acute appy • American College of Pediatric agrees with US 1st, however recommends CT abd/pelvis to confirm or exclude acute appy

  3. Background Background • Sept 2023 publication in Nature Medicine followed a multinational cohort of 948,174 individuals who underwent CT before 22 yoa in 9 European countries • Associated found between cumulative dose and risk of all hematologic malignancies • Excess relative risk of 1.96 (95% CI of 1.10 to 3.12) per 100 mGy • Concluded that there should be continued justification for pediatric CT even at low dose

  4. Background Background • QI project published in Journal of Pediatric Surgery conducted at CHCO demonstrated successful campaign to decreased CT and increased rapid sequence MRI (rsMRI) for acute appy • From pre-implementation (Jan 2016-Apr 2021) to post-implementation (May 2021-Apr 2022): CT decreased by factor of 0.4 rsMRI increased by factor of 9.5 • Biggest initial concern from providers was time necessary to complete MRI • • 85.7% cited preferred reason for CT was that “it can be done quickly” Greatest obstacle to obtaining MRI was inability to obtain images in <120 min of order (47.2%) • •

  5. Solution Solution • CHCO solution was to create an algorithm to allow cooperation between providers, radiologists, and technologists to optimize image selection • Exclusion criteria for rsMRI included: • Pt <7 years of age • Known or suspected abscess on US • Studies performed after normal MRI technologist hours (MRI unavailable overnight at CHCO) CHCO algorithm

  6. Rapid Sequence MRI Protocol Rapid Sequence MRI Protocol • Non-sedated, Non-contrast MRI abd/pelvis • Axial and Coronal T2 (SS-TSE) from lung base to pubic symphysis (mid liver to PS on coronal) • Axial and Coronal T2 (SS-TSE) with Fat Saturation from lung base to pubic symphysis (mid liver to PS on coronal) • Axial DWI/ADC (b value = 500s/mm2) from lung base to pubic symphysis Axial SS-TSE T2 FS slice demonstrating acute appendicitis. From Brian et al.

  7. References References Bosch de Basea Gomez M, Thierry-Chef I, Harbron R, Hauptmann M, Byrnes G, Bernier MO, Le Cornet L, Dabin J, Ferro G, Istad TS, Jahnen A, Lee C, Maccia C, Malchair F, Olerud H, Simon SL, Figuerola J, Peiro A, Engels H, Johansen C, Blettner M, Kaijser M, Kjaerheim K, Berrington de Gonzalez A, Journy N, Meulepas JM, Moissonnier M, Nordenskjold A, Pokora R, Ronckers C, Schüz J, Kesminiene A, Cardis E. Risk of hematological malignancies from CT radiation exposure in children, adolescents and young adults. Nat Med. 2023 Nov 9. doi: 10.1038/s41591-023-02620- 0. Epub ahead of print. PMID: 37946058. • Brian JM, Moore MM. (Sep 07, 2017). MRI for appendicitis in pediatric patients. Appl Radiol. 2017; 46(9):18-24 • Lyttle BD, Reppucci ML, Prendergast C, Ziogas IA, Tong S, Acker SN, Milla S, Tutman JJ, Rutherford A, Orsborn J, Bennett TD, DeCamp L, Diaz-Miron JL. Quality Improvement Campaign Improved Utilization of Rapid Sequence MRI for Diagnosis of Pediatric Appendicitis. J Pediatr Surg. 2023 Nov;58(11):2171-2180. doi: 10.1016/j.jpedsurg.2023.05.026. Epub 2023 Jun 2. PMID: 37353392. • Moore MM, Kulaylat AN, Hollenbeak CS, Engbrecht BW, Dillman JR, Methratta ST. Magnetic resonance imaging in pediatric appendicitis: a systematic review. Pediatr Radiol. 2016 May;46(6):928-39. doi: 10.1007/s00247-016-3557-3. Epub 2016 May 26. PMID: 27229509 •

  8. Rapid Sequence MRI Pediatric Appendicitis Rapid Sequence MRI Pediatric Appendicitis Guidelines Guidelines Equivocal US • Above 7 years of age • During business hours (8am-5pm) • Non-sedated • Non-contrast MRI abd/pelvis Protocol Protocol • Axial T2 (SS-TSE) 4mm • Coronal T2 (SS-TSE) 4mm • Axial T2 (SS-TSE) Fat Sat Fat Sat 4mm • Coronal T2 (SS-TSE) Fat Sat Fat Sat 4mm • Axial DWI/ADC (b value = 500s/mm2) • Axial coverage = lung base to pubic symphysis • Coronal coverage = mid liver to pubic symphysis •

  9. THANK YOU!!

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