Cystograffin Contrast, Connector Tubing, Octistop, Two Velcro Restraints, and Flashlight

VCUG

Supplies needed:

Cystograffin contrast, connector tubing, Octistop, two velcro restraints, and flashlight

All patients who are of the appropriate size to fit on the Octistop should be placed on the Octistop. Either parents or nurse should restrain the patient's hands or they should be placed in the Octistop next to the child's head. One velcro strap should be fastened across the chest and the second across the legs, leaving the pelvis exposed. A catheter should be placed in the urinary bladder prior to the child's arrival in the department.

For infantsless than one year of age, three cycles of filling and voiding should be performed. If the expected bladder capacity is exceeded (30cc for newborns; age in years + 2 x 30cc for all other children), then fewer cycles of filling and voiding can be performed. If a child refluxes bilaterally on the first cycle of filling and voiding, the examination may then be terminated in order to avoid over-distension of the upper collecting systems.

Images to be obtained:

1.Early filling bladder AP.

2.Bilateral obliques of the bladder at near bladder capacity.

3.Post-void image of the entire abdomen.

4.Lateral voiding film of the urethra in all male patients. This may be obtained either with the catheter in place or as the catheter is removed. It is critical that the posterior urethra is fully distended at the time this image is taken.

All catheters should be removed at the termination of the examination unless otherwise directed by the referring physician. Dictations must include the number of cycles of filling and voiding performed, the volume of contrast material used, and whether reflux was observed during the examination.Clear description of the height of the refluxed contrast column and presence of dilation of calices/ureter should be included.

INTUSSUSCEPTION

General information:

Supine and either upright or left lateral decubitus films must be obtained prior to the initiation of the examination to exclude the presence of perforation. Patients must be either admitted to Pediatrics or come from the Emergency Department with an IV in place in the event a complication arises. A pediatric surgeon must have knowledge of the patient, again in the event a complication arises. Do not accept orders for intussusception examinations on outpatients unless the referring physician agrees to admit the child to Pediatrics for observation or send them through the Emergency Department for observation in that location. Intussusception examinations should not be performed in the outpatient facilities (such as the imaging centers).

Supplies needed:

Octistop, two velcro restraining straps, air reduction kit or Hypaque enema solution (at the discretion of the physician performing the examination), various sizes of Foley catheters, silk tape or stretchy pressure dressing tape

If, on the scout images, there is a large amount of gas in the distal small bowel loops in the right lower quadrant, it may be technically easier to perform a Hypaque enema rather than an air enema. The Hypaque aids in visualization of terminal ileum reflux when a large amount of air is already present in the right lower quadrant.

Technique:

The rectum should be catheterized with an appropriate size Foley catheter. If the balloon retention device is to be used, it must be inflated under direct fluoroscopic guidance to avoid over-inflation. Many times, the balloon is not necessary if the catheter is taped securely in place.

For water soluble enemas:

Three attempts at reduction may be made, keeping the enema bag no more than three feet above the tabletop. The contrast may be left in the colon for three minutes during each attempt. After three minutes, the contrast should be drained and the colon decompressed for several minutes prior to reattempt at reduction. If at any time the child experiences respiratory distress during the examination, the colon should be drained to relieve pressure from the abdomen. Again, an intussusception is not considered successfully reduced nor is an examination considered completed until documented reflux into the terminal ileum is seen.

Sedation for all intussusception examinations is done at the discretion of the physician performing the examination. The majority of children's hospitals do not use sedation in order to expedite the procedure. If an intussusception is encountered and it is unable to be reduced by the enema, a repeat attempt at reduction may be performed following sedation of the child (with nursing monitoring) in order to help achieve smooth muscle relaxation. A certain percentage of radiologically non-reducible intussusceptions will reduce spontaneously at the induction of general anesthesia in the operating room.

If a clinician is reluctant to admit the child to Pediatrics or the Emergency Department for observation prior to the procedure, they should be informed that this is the consensus decision between pediatric surgeons and radiologists as to the proper procedure for safest monitoring of these children. The potential complications from intussusception can be life-threatening, and the child needs to be in a hospital setting with IV access in the event of a complication so that s/he may be properly treated in an expedient manner.

SKELETAL SURVEY FOR TRAUMA

Films to be obtained:

1.AP and Lateral of the skull.

2.AP and Lateral of the cervical spine.

3.AP and Lateral of the thoracolumbar spine.

4.AP views of the chest and abdomen (may be obtained on the same film if approximately less than one year of age).

5.AP view of the pelvis.

6.AP view of each upper extremity, including the hands.

7.AP view of the lower extremities, including feet. These views must be obtained with the knees and ankles directed straight forward. The toes should be pointed enough to keep the feet from overlying the ankle on the AP view.

All radiographs must be well penetrated enough to see the osseous structures. Critical areas to concentrate on in achieving proper radiographic technique are the knees, ankles, and wrists. When obtaining films of the pelvis and abdomen, the child's diaper should be removed as this creates a large amount of overlying artifact which can obscure the bony structures.

UPPER GI/ESOPHAGRAM

All patients of the appropriate size should be placed on the Octistop. The head should be securely fastened within the foam cushions. Either the parents or the nurse should hold the hands up beside the head, or the arms should be placed in the sponge holder next to the head. The body should be strapped securely to the Octistop by one or two velcro restraining devices. A bottle containing warm, thin barium suspension should be prepared. A bottle of glucose water should be kept at hand in case the physician performing the examination desires the child to drink water. Several different sizes of small pediatric feeding tubes should also be kept available in the event the child refuses to drink, and the study must be performed through a feeding tube.

Technique:

1.Always remember, if the child is crying, they are not swallowing and therefore you do not need to fluoroscope them.

2.Two full column AP and two full column Lateral views of the esophagus should be obtained.

3.The child should be placed in the right lateral decubitus position and contrast should be allowed to enter the duodenum. Once the contrast is seen in the descending duodenum, turning toward the transverse portion of the duodenum, the child should be quickly placed back in the supine position. It is critical to have a straight AP projection when assessing the position of the Ligament of Treitz. The ligament should be positioned adjacent to or lateral to the left pedicle of the spine. The ligament should be located posterior to the antrum of the stomach in the cradiocaudal direction. On the lateral view, the descending duodenum and the turn to the transverse duodenum should all be seen posteriorly (in the retroperitoneum).

4.Once the position of the Ligament of Treitz is determined, the child should be allowed to drink from the bottle without fluoroscopic observation. The amount of barium ingested depends on the normal amount of fluid the child ingests at a normal feeding. Once the child has ingested approximately the amount of barium that it would normally take at a feeding, intermittent fluoroscopy of the GE junction should be performed to assess for reflux. The intermittent fluoroscopy should be performed while turning the child in the Octistop from one lateral decubitus position to the other.

5.Final overhead film (fluoro stored) of the entire abdomen should be obtained to assess for reflux and to assess the position and caliber of the proximal small bowel loops.

6.Total fluoroscopy time for uncomplicated cases should not exceed 30-45 seconds.

Upper GI for pyloric stenosis:

Technique:

Patient should ingest barium by bottle, with acquisition of AP and Lateral images of the esophagus in full column. The stomach usually needs to be well distended to ensure emptying, position of Ligament of Treitz is not as important as on routine UGI examinations.
If stomach empties readily, obtain views of the Ligament. If stomach emptying is delayed, a feeding tube can be inserted and the child turned into the right lateral decubitus position. Air can be pushed into the stomach to encourage emptying of barium with subsequent evaluation of the antrum/pylorus.
Final overhead fluoro stored image can be obtained, particularly on those with normal gastric emptying, to display position and caliber of upper SB loops.

Hip Ultrasound:

Generally can be performed on babies less than 6 months of age. After this time, calcification in the femoral head may impede visualization of the acetabulum. High frequency linear transducer is preferred. Parents and/or technologist frequently will need to assist with holding the baby in the lateral decubitus positions for optimal scanning.

Technique:

Begin in one lateral decubitus position, whichever the baby seems happiest. Coronal images (3-4 sets) of the hip should be obtained first with the leg extended. The wing of the ileum should form a straight horizontal line on the screen with the roof of the acetabulum descending toward the bottom of the screen. In a normal hip, the largest diameter of the femoral head will naturally line up with the iliac wing in this plane. Transducer will be angled in an oblique coronal plane to the body, with the cephalad portion of the transducer more posteriorly angled (i.e. along the true coronal plane of the anterior iliac wing). Alpha angles can either be measured on the US machine during the exam or later on Stentor. Normal angle is greater than or equal to 60 degrees.
Transverse images of the hip are next acquired with the leg extended, taking care to have the largest portion of the femoral head in the image – in a normal hip this will be centered over the triradiate cartilage.
Transverse image of the hip should be acquired with the leg flexed at the hip to assess for subluxation of the femoral head out of the acetabulum.
Baby should be turned supine and a transverse image of the hip obtained under stress, again to assess for subluxation/dislocation of the head. To apply stress, flex the hip and with the hand on the knee, press the leg straight down – the force therefore applied down the shaft of the femur into the acetabulum.
Repeat steps 1-4 on the opposite hip.

Spine US:

Exam generally requested for infants with sacral dimple or pit, known Chiari malformation, or anal atresia. US a valid option until approximately 6 months of age, depending on patient size. After this, degree of calcification in the spinous processes impedes visualization of segments of the cord. The exam is frequently challenging due to patient motion and the need to go back to reconfirm the level of T12. High frequency linear transducer preferred. Patient placed in the prone position on the table. Uncooperative patients may be held by the parent in a face down position or may nurse during the exam facing the mother if the operator is comfortable with this

Technique:

In transverse, locate the level of the kidneys first. Move laterally from midline in long axis to locate the 12th rib level. This can then be followed back to midline to determine the T12 level. It is generally assumed all patients have 12 ribs and 5 lumbar segments, recognizing in a very small population this is not true. A mark can be left on the skin at the T12 level if desired to assist in reproduction of this level consistently.
Several long axis images should be obtained at the midline of the cord, with vertebral levels labeled, sequentially imaging all lumbar segments. Normal cord termination is above L2 (may be at L2-3 in neonates and progress upward as the patient ages). The cord should fall to the dependant portion of the canal (varies by patient position) and will move with CSF pulsation. Tethered cords are usually positioned in the anatomic posterior aspect of the canal and have decreased motion with CSF pulsation.
Transverse images of the cord should be obtained at each level from T12 to the sacrum. Central canal should be easily visible as an echogenic dot in the center of the cord. Make note of presence of syrinx on these views.
Make note of pulsation of the cauda equina and echogenicity of the filum terminale. Generally the filum is indistinguishable from other nerve roots. When a lipoma is present, it will be echogenic and larger than the nerve roots. Nerve roots should float freely in the CSF and pulsate within the canal.
If a sacral dimple or pit is present, superficial scanning must be performed over the area to assess for a sinus tract or fistula. This may require a standoff pad in some patients.

Revised July 2005.