RESUMO
Background Fluoroscopy is an imaging modality associated with a wide range of dose levels, characterized using a variety of dose metrics, including effective dose. However, for clinical procedures, effective dose is a seldom-used and unregulated metric in the United States, and thus, it is not extensively studied in radiology despite potentially large clinical implications for patients, especially children and infants. Purpose To formulate and report a dose catalog across all diagnostic and interventional radiology (IR) fluoroscopy examination or procedure types at a specialized tertiary care pediatric hospital. Materials and Methods In this retrospective study, dose metrics taken from radiation dose structured reports of fluoroscopy between October 2014 and March 2023 were analyzed. The reports included fluoroscopy across 18 diagnostic examination types and 24 IR procedure types. The National Cancer Institute dosimetry system for Radiography and Fluoroscopy Monte Carlo software was used to estimate age-specific effective dose from dose-area product (DAP). The DAP-to-effective dose conversion factors were estimated per IR procedure type and diagnostic fluoroscopy examination type based on age. Results A total of 11 536 individual diagnostic fluoroscopy examinations (18 types) and 8017 individual IR procedures (24 types) were analyzed. Median effective dose values per diagnostic fluoroscopy examination type ranged from 0.0010 to 0.44 mSv (mean, 0.0808 mSv ± 0.0998 [SD]). Calculated DAP-to-effective dose conversion factors ranged from 0.04 to 2.48 mSv/Gy · cm2 (mean, 0.758 mSv/Gy · cm2 ± 0.614) across all diagnostic fluoroscopy examination types. Median effective dose values per IR procedure type ranged from 0.0007 to 3.90 mSv (mean, 0.6757 mSv ± 0.8989). Calculated DAP-to-effective dose conversion factors ranged from 0.001 to 0.87 mSv/Gy · cm2 (mean, 0.210 mSv/Gy · cm2 ± 0.235) across all IR procedure types. Conclusion A pediatric fluoroscopy dose catalog was created, including age-specific effective dose, using a repeatable robust method based on accurate clinical data. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Borrego and Balter in this issue.
Assuntos
Hospitais Pediátricos , Radiologia Intervencionista , Lactente , Humanos , Criança , Estudos Retrospectivos , Fluoroscopia , Fatores EtáriosRESUMO
PURPOSE: To compare radiation dose index distributions for fluoroscopically guided interventions in interventional radiology from the American College of Radiology (ACR) Fluoroscopy Dose Index Registry (DIR-Fluoro) pilot to those from the Radiation Doses in Interventional Radiology (RAD-IR) study. MATERIALS AND METHODS: Individual and grouped ACR Common identification numbers (procedure types) from the DIR-Fluoro pilot were matched to procedure types in the RAD-IR study. Fifteen comparisons were made. Distribution parameters, including the 10th, 25th, 50th, 75th, and 95th percentiles, were compared for fluoroscopy time (FT), cumulative air kerma (Ka,r), and kerma area product (PKA). Two derived indices were computed using median dose indices. The procedure-averaged reference air kerma rate (Ka,r¯) was computed as Ka,r / FT. The procedure-averaged x-ray field size at the reference point (Ar) was computed as PKA / (Ka,r × 1,000). RESULTS: The median FT was equally likely to be higher or lower in the DIR-Fluoro pilot as it was in the RAD-IR study, whereas the maximum FT was almost twice as likely to be higher in the DIR-Fluoro pilot than it was in the RAD-IR study. The median Ka,r was lower in the DIR-Fluoro pilot for all procedures, as was median PKA. The maximum Ka,r and PKA were more often higher in the DIR-Fluoro pilot than in the RAD-IR study. Ka,r¯ followed the same pattern as Ka,r, whereas Ar was often greater in DIR-Fluoro. CONCLUSIONS: The median dose indices have decreased since the RAD-IR study. The typical Ka,r rates are lower, a result of the use of lower default dose rates. However, opportunities for quality improvement exist, including renewed focus on tight collimation of the imaging field of view.
Assuntos
Radiografia Intervencionista , Radiologia Intervencionista , Humanos , Radiologia Intervencionista/métodos , Doses de Radiação , Fluoroscopia , Radiografia Intervencionista/efeitos adversos , Sistema de RegistrosRESUMO
PURPOSE: To update normative data on fluoroscopy dose indices in the United States for the first time since the Radiation Doses in Interventional Radiology study in the late 1990s. MATERIALS AND METHODS: The Dose Index Registry-Fluoroscopy pilot study collected data from March 2018 through December 2019, with 50 fluoroscopes from 10 sites submitting data. Primary radiation dose indices including fluoroscopy time (FT), cumulative air kerma (Ka,r), and kerma area product (PKA) were collected for interventional radiology fluoroscopically guided interventional (FGI) procedures. Clinical facility procedure names were mapped to the American College of Radiology (ACR) common procedure lexicon. Distribution parameters including the 10th, 25th, 50th, 75th, 95th, and 99th percentiles were computed. RESULTS: Dose indices were collected for 70,377 FGI procedures, with 50,501 ultimately eligible for analysis. Distribution parameters are reported for 100 ACR Common IDs. FT in minutes, Ka,r in mGy, and PKA in Gy-cm2 are reported in this study as (n; median) for select ACR Common IDs: inferior vena cava filter insertion (1,726; FT: 2.9; Ka,r: 55.8; PKA: 14.19); inferior vena cava filter removal (464; FT: 5.7; Ka,r: 178.6; PKA: 34.73); nephrostomy placement (2,037; FT: 4.1; Ka,r: 39.2; PKA: 6.61); percutaneous biliary drainage (952; FT: 12.4; Ka,r: 160.5; PKA: 21.32); gastrostomy placement (1,643; FT: 3.2; Ka,r: 29.1; PKA: 7.29); and transjugular intrahepatic portosystemic shunt placement (327; FT: 34.8; Ka,r: 813.0; PKA: 181.47). CONCLUSIONS: The ACR DIR-Fluoro pilot has provided state-of-the-practice statistics for radiation dose indices from IR FGI procedures. These data can be used to prioritize procedures for radiation optimization, as demonstrated in this work.
Assuntos
Radiografia Intervencionista , Radiologia Intervencionista , Humanos , Doses de Radiação , Projetos Piloto , Fluoroscopia , Radiologia Intervencionista/métodos , Sistema de Registros , Radiografia Intervencionista/efeitos adversosRESUMO
PURPOSE: To provide guidance on the use of anticoagulant and antithrombotic agents in pediatric patients undergoing interventional radiology procedures. MATERIALS AND METHODS: A multidisciplinary writing group conducted a comprehensive literature search to identify studies on the topic of interest. Recommendations were developed for procedural risk and medication dosage and withholding. A modified Delphi technique was used to achieve consensus agreement on the recommendations. RESULTS: A total of 24 studies, including systematic reviews and meta-analyses, randomized controlled trials, and prospective and retrospective cohort studies, were identified as relevant. The expert writing group agreed on procedural risk categorization, laboratory testing thresholds, and medication dosage and withholding recommendations specific to pediatric practice. They additionally described the nuances of anticoagulation in clinical conditions specific to pediatrics. CONCLUSIONS: The Society of Interventional Radiology recommends following the guidance provided in the document when developing multidisciplinary management protocols for anticoagulation and antithrombotic treatment in pediatric patients undergoing interventional radiology procedures.
Assuntos
Trombose , Humanos , Criança , Estudos Retrospectivos , Estudos Prospectivos , Trombose/diagnóstico por imagem , Trombose/etiologia , Trombose/prevenção & controle , Anticoagulantes , Consenso , Radiologia IntervencionistaRESUMO
BACKGROUND: Spinal administration of medications is challenging in patients with complete posterior spinal fusion. We describe percutaneous image-guided intrathecal port placement for administration of the antisense oligonucleotide nusinersen for children and young adults with spinal muscular atrophy. OBJECTIVE: To describe and present our initial experience with a new technique for administering nusinersen in patients with spinal muscular atrophy and posterior spinal fusion. MATERIALS AND METHODS: We reviewed medical records of 13 patients who received intrathecal ports using DynaCT, biplane fluoroscopy and iGuide from April 2018 through June 2019, and we describe the clinical course over 1 year. RESULTS: Image-guided catheter and port implantation was successful in all cases. Two ports were subsequently removed, one for persistent cerebrospinal fluid leak and one for superficial infection. The other 11 have functioned successfully for a minimum of 23 months. CONCLUSION: We report our experience with image-guided intrathecal port placement in children with complete posterior spine fusion. The implanted port permits dosing in an outpatient setting and avoids the need for multiple future radiologic procedures, and it reduces discomfort, procedural costs and potential risks and sequelae of multiple anesthetics and radiation exposures. Further studies are needed to define the relative risks and benefits of intrathecal ports compared to other approaches such as repeated transforaminal lumbar punctures.
Assuntos
Atrofia Muscular Espinal , Fusão Vertebral , Catéteres , Criança , Humanos , Injeções Espinhais , Atrofia Muscular Espinal/diagnóstico por imagem , Atrofia Muscular Espinal/tratamento farmacológico , OligonucleotídeosRESUMO
OBJECTIVE: To report MRI findings of changes seen in aneurysmal bone cysts after percutaneous sclerotherapy treatment. MATERIALS AND METHODS: After applying exclusion criteria, a total of 36 patients who had aneurysmal bone cysts and undergone percutaneous sclerotherapy were included in this study. The pre-treatment and post-treatment MRIs were reviewed and multiple pre-determined MRI findings were evaluated. The presence of each post-treatment finding, as well as the time for each finding to develop, was recorded. RESULTS: Early post-sclerotherapy changes include increased perilesional edema and enhancement, which appear on MRI on average 5.1 months after the initial sclerotherapy. This is followed by decreased cystic areas, which can be seen on average 5.9 months after the initial treatment. The presence of fibrosis, improved cortical integrity, and improving mass effect are later post-treatment changes and appear on MRI on average 9.7 months, 10.6 months, and 16.1 months after the initial sclerotherapy, respectively. CONCLUSION: The early and late post-sclerotherapy MR findings of aneurysmal bone cysts were reported in this study.
Assuntos
Cistos Ósseos Aneurismáticos , Escleroterapia , Cistos Ósseos Aneurismáticos/tratamento farmacológico , Cistos Ósseos Aneurismáticos/terapia , Humanos , Imageamento por Ressonância Magnética , Soluções Esclerosantes/uso terapêutico , Resultado do TratamentoRESUMO
BACKGROUND: The objective of this study was to develop a response scale for aneurysmal bone cysts (ABCs) treated with sclerotherapy and determine its inter-rater reproducibility. METHODS: Patients treated with sclerotherapy for an ABC between 1993 and 2014 were identified. An attending orthopaedic surgeon and an attending interventional radiologist independently reviewed the radiographic series for each patient and determined response to treatment using a novel grading system. Pain scores were collected from each visit. Inter-rater reliability was assessed using the intraclass correlation coefficient (ICC). General estimating equations analysis was used to evaluate the relationship between radiographic and pain scores and outcome, to develop an algorithm for the study patient population. A receiver operating characteristic curve was constructed to evaluate the diagnostic performance of the radiographic and pain scores in identifying the necessity of further treatment. To quantify the diagnostic utility, the area under the receiver operating characteristic curve was estimated along with a 95% confidence interval (CI). RESULTS: The inter-rater reliability was excellent for magnetic resonance imaging (ICC=0.83; 95% CI=0.74-0.89) and good for computed tomography/x-ray (ICC=0.69; 95% CI=0.51-0.81). The radiographic and pain scores proved to be independent predictors of treatment (P<0.001 and 0.004, respectively). An algorithm to determine the predictive probability for treatment versus observation in the study population was developed and tested based on these assessments. The area under the receiver operating characteristic curve of 0.85 (95% CI=0.79-0.92) indicated the good diagnostic performance of the algorithm. CONCLUSIONS: This novel grading system for radiographic response to sclerotherapy treatment demonstrates excellent to good inter-rater reliability giving providers a platform for discussion among themselves and with patients/parents. When incorporated with an assessment of pain, a predictive algorithm shows how this information could be used to determine the next steps after sclerotherapy treatment. LEVEL OF EVIDENCE: Level IV-case series.
RESUMO
OBJECTIVE: Following percutaneous liver biopsy performed at our institution on an outpatient basis, children traditionally were observed for 4âhours then discharged after verifying a stable hematocrit level. In June 2015, we adopted a quality improvement project with shorter 2-hour observation for patients with no known risks and the hematocrit test was abandoned.The purpose of this study is to evaluate the clinical and economic outcomes of early discharge of children following liver biopsy. METHODS: We analyzed data on 2 groups of children who underwent ultrasound-guided nontargeted core needle liver biopsy performed on outpatient basis. Group A (100 procedures with 4-hour postprocedural observation time and hematocrit test) was compared with group B (100 procedures with 2-hour observation without hematocrit test). RESULTS: Group A consisted of 92 patients (43 boys; 49 girls) with a mean age of 11.1 years and mean weight of 52.6âkg. Group B had 92 patients (47 boys; 45 girls) with a mean age of 8.9 years and mean weight of 40.5âkg. The mean length of observation was 281 minutes (range 204-540 minutes) and 147 minutes (range 86-332 minutes) for groups A and B, respectively. The mean recovery charges were reduced by 35% per procedure in group B. The tissue obtained was sufficient for pathologic diagnosis in all procedures. There were no biopsy-related complications in either group. CONCLUSIONS: Enhanced recovery with early discharge of low-risk children after 2-hour observation following percutaneous liver biopsy can be safely implemented without adversely affecting the outcome. Shorter postbiopsy observation can be cost-saving and may potentially improve patient satisfaction.
Assuntos
Biópsia Guiada por Imagem , Melhoria de Qualidade , Biópsia por Agulha , Criança , Feminino , Humanos , Fígado/diagnóstico por imagem , Masculino , Estudos Retrospectivos , UltrassonografiaRESUMO
This case series describes a novel method for showing the preoperative anatomy of children with anorectal malformations using ultrasound contrast, which we have termed "contrast-enhanced colosonography (ceCS)." Six patients with anorectal malformations without a perineal fistula were studied both by fluoroscopic distal colostography and ceCS, and their results were confirmed surgically. Contrast-enhanced CS precisely showed the complex anatomic relationships in all cases. Compared to traditional fluoroscopic studies, ceCS has the benefit of no associated ionizing radiation and thus is safer for children.
Assuntos
Anus Imperfurado/diagnóstico por imagem , Meios de Contraste , Aumento da Imagem/métodos , Ultrassonografia/métodos , Canal Anal/diagnóstico por imagem , Canal Anal/cirurgia , Anus Imperfurado/cirurgia , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Estudos ProspectivosRESUMO
BACKGROUND: The diagnosis and management of vascular anomalies of the extremities can be challenging as these disorders are uncommon and may clinically overlap. The aim of this paper is to describe the clinical, radiologic, and histopathologic features of fibro-adipose vascular anomaly (FAVA), a previously unrecognized disorder of the limb. METHODS: The clinical, imaging, operative, and histopathologic data from patients with a unique intramuscular lesion of the extremities comprising dense fibrofatty tissue and slow-flow vascular malformations were retrospectively reviewed. RESULTS: Sixteen patients diagnosed with FAVA of the extremity (3 male and 13 female individuals) met the clinical, radiologic, and histopathologic inclusion criteria. The age at presentation ranged from the time of birth to 28 years. The locations of the lesions were: calf (n=10), forearm/wrist (n=3), and thigh (n=3). Fourteen patients presented with severe pain. Seven of the patients with calf lesions had limited ankle dorsiflexion. On imaging, the complex intramuscular lesions replaced muscle fibers with fibrofatty overgrowth and phlebectasia (dilation of the veins). The extrafascial component comprised fatty overgrowth, phlebectasia, and an occasional lymphatic malformation. The histopathologic features comprised dense fibrous tissue, fat, and lymphoplasmacytic aggregates within atrophied skeletal muscle. Adipose tissue also infiltrated skeletal muscle at the periphery of the lesion. There were large, irregular, and sometimes excessively muscularized venous channels and smaller, clustered channels. Other findings include organizing thrombi, a lymphatic component, and dense fibrous tissue-encircled nerves. CONCLUSIONS: The constellation of clinical, radiologic, and histopathologic features constitutes a distinct entity comprising fibrofatty infiltration of muscle, unusual phlebectasia with pain, and contracture of the affected extremity. The clinical and radiologic findings permit the diagnosis of FAVA with major therapeutic implications. LEVEL OF EVIDENCE: Level III.
Assuntos
Músculo Esquelético/patologia , Doenças Vasculares Periféricas/congênito , Doenças Vasculares Periféricas/diagnóstico , Malformações Vasculares/diagnóstico , Tecido Adiposo/irrigação sanguínea , Tecido Adiposo/patologia , Adolescente , Adulto , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Seguimentos , Humanos , Extremidade Inferior/irrigação sanguínea , Extremidade Inferior/diagnóstico por imagem , Extremidade Inferior/patologia , Angiografia por Ressonância Magnética , Masculino , Músculo Esquelético/irrigação sanguínea , Músculo Esquelético/diagnóstico por imagem , Doenças Vasculares Periféricas/patologia , Radiografia , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento , Extremidade Superior/irrigação sanguínea , Extremidade Superior/diagnóstico por imagem , Extremidade Superior/patologia , Malformações Vasculares/cirurgia , Adulto JovemRESUMO
A 14-Year-Old Girl with Dyspnea and Chest PainA 14-year-old girl presented for evaluation of shortness of breath and chest pain after recent travel to the Caribbean. How do you approach the evaluation, and what is the diagnosis?
Assuntos
Dor no Peito , Dispneia , Feminino , Humanos , Adolescente , Tórax , Diagnóstico Diferencial , Região do CaribeRESUMO
OBJECTIVE: To describe our technique and share our experience with image-guided transrectal drainage (TRD) of pelvic abscesses in children. MATERIALS AND METHODS: Retrospective review and analysis of indications for image-guided TRD and examination of procedural outcomes in pediatric patients with pelvic abscesses over 8 years. RESULTS: A total of 69 patients (33 males and 36 females) with symptomatic pelvic abscesses underwent image-guided TRD. The median age and weight of the patients were 11.5 years (range, 3-18) and 46.8 kg (range, 15.1-118.0), respectively. The etiologies of the pelvic abscesses were perforated appendicitis (72.5%) and post-operative collections (27.5%). All patients presented with abdominal pain. Fever, emesis, and diarrhea were also common symptoms. The size of the pelvic abscesses ranged from 24.0 to 937.1 mL (median, 132.7). Technical success was achieved in 68 of 69 TRD procedures (98.6%). Clinical improvement was observed in all patients with technically successful TRD. The TRD catheter dwell time ranged from 0 to 10 days (median, 4.0). Most patients who underwent TRD for perforated appendicitis subsequently underwent elective appendectomy after the resolution of the pelvic abscess (84.0%). The median time from TRD to elective appendectomy was 2.8 months (range, 0.3-6.1). There were no procedure-related complications. CONCLUSION: Image-guided TRD is a safe and effective procedure with high technical and clinical success rates for the treatment of pelvic abscesses in children.
RESUMO
OBJECTIVE: The purpose of this study was to evaluate the safety and efficacy of sonography-guided percutaneous core needle liver biopsy in infants and children. MATERIALS AND METHODS: We conducted a retrospective analysis of all patients who underwent sonography-guided percutaneous core needle liver biopsies over a 7.5-year period by pediatric interventionalists at a single tertiary center. RESULTS: A total of 597 procedures were performed in 470 patients (270 male and 200 female), with a mean age of 10.5 years (age range, 1 month-21 years). The main indications for biopsies were abnormal liver enzymes (n=129, 21.6%), grading and staging of chronic hepatitis B or C (n=105, 17.6%), evaluation of transplanted liver (n=111, 18.6%), iron overload (n=73, 12.2%), miscellaneous other diffuse parenchymal abnormalities (n=124, 20.7%), and focal hepatic lesions (n=55, 9.2%). The procedures were performed either under sedation (n=311, 52.1%) or general anesthesia (n=286, 47.9%). Diagnostic yield was obtained in 596 biopsies (99.8%) from an average of 2.4 cores in patients with diffuse disease (n=541, 90.6%) and 6.5 cores in patients with focal disease (n=55, 9.2%). Ten patients (1.7%) experienced a major complication, including pneumothorax (n=1, 0.2%), abdominal wall pseudoaneurysm (n=1, 0.2%), and symptomatic bleeding (n=8, 1.3%). Five of these children required transfusion, two were only admitted for observation, and one required surgical evacuation. There were no procedure-related deaths. Minor complications (n=49, 8.2%) included a symptomatic subcapsular hematoma (n=35) and stable small hemoperitoneum (n=9). CONCLUSION: Sonography-guided percutaneous core liver biopsy is a safe and effective procedure in children that has a high diagnostic yield and very low complication rate.
Assuntos
Biópsia por Agulha/métodos , Hepatopatias/patologia , Ultrassonografia de Intervenção , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Estudos Retrospectivos , Adulto JovemRESUMO
BACKGROUND: Pediatric interventional oncology (PIO) is a growing field intended to provide additional or alternative treatment options for pediatric patients with benign or malignant tumors. Large series of patients treated uniformly and subjected to rigorous endpoints for efficacy are not available. METHODS: We designed a collaborative initiative to capture data from pediatric patients with benign and malignant tumors who underwent a therapeutic interventional radiology procedure. Modified Response Evaluation Criteria in Solid Tumors (mRECIST) was utilized as a measure of radiologic response and data were collected regarding improvement in pain and functional endpoints. Cumulative incidence of progressive disease was calculated using both the treated site and the patient as the analytic unit. FINDINGS: Forty patients, 16 with malignant tumors and 24 with benign tumors, underwent a total of 88 procedures. Cryo- and radiofrequency ablation were the most frequently utilized techniques for both cohorts of patients. A complete or partial response, or prolonged disease stability, were achieved in approximately 40% of patients with malignant tumors and 60% of patients with benign tumors. No patients had progressive disease as their best response. Resolution of pain and improved mobility with return-to-baseline activity were demonstrated across patients from both cohorts. Only minor complications were experienced. INTERPRETATION: Interventional radiology-guided interventions can serve as an alternative or complementary approach to the treatment of benign and malignant tumors in pediatric patients. Prospective, multi-institutional trials are required to adequately study utility, treatment endpoints, and durability of response.
Assuntos
Neoplasias , Humanos , Criança , Adulto Jovem , Estudos Prospectivos , Neoplasias/terapiaRESUMO
BACKGROUND: Lumbar puncture (LP) may be challenging for patients with scoliosis and other conditions following previous posterior fusion and instrumentation from thoracic to sacral levels. Interventional radiologists have described CT approaches to transforaminal LP. We hypothesized that combined C-arm fluoroscopy and ultrasound could be a feasible approach to transforaminal LP for interventional pain physicians and regional anesthesiologists. METHODS: With institutional review board approval, we reviewed medical records and imaging of six patients with spinal muscular atrophy and prior spine fusion. Non-cutting needles of 24 or 25 gage were advanced through 20-gage introducers. Prior imaging guided selection of a preferred side and spinal level. Initial procedures were performed in the interventional radiology suite. Subsequent procedures were performed in an operating room (OR). We report on technical success and complications and describe a case using this approach for spinal anesthesia. RESULTS: Six patients underwent a total of 54 transforaminal LPs, including 51 for administration of the antisense oligonucleotide nusinersen, 2 for myelography, and 1 for spinal anesthesia; 45 of these procedures were performed using OR C-arm fluoroscopy and ultrasound. Transient paresthesias and short-term headaches occurred; none required intervention. No other complications were noted. CONCLUSIONS: Transforaminal LP appears technically feasible for patients with full-spine fusions using a straight-needle approach with combined fluoroscopy and ultrasound guidance. Larger case series and prospective studies may better define the success rates, risks, and benefits of this approach relative to alternative approaches to intrathecal access for patients with previous long-segment posterior spine fusions.
Assuntos
Raquianestesia , Atrofia Muscular Espinal , Fluoroscopia/métodos , Humanos , Estudos Prospectivos , Punção Espinal/efeitos adversosRESUMO
Purpose: The purpose of this study is to compare pediatric hip aspiration in the operating room under general anesthesia or via bedside aspiration under moderate sedation and delineate the anesthetic time required. Methods: A database query conducted at two academic institutions identified all patients under the age of 17 who underwent hip aspiration between 2000 and 2017. At one institution, aspiration was performed in the operating room under general anesthesia. Patients were kept anesthetized until cell count was complete. At the second institution, aspiration was performed in the emergency room at bedside under sedation. The medical record was reviewed for demographic data, hip aspiration results, diagnoses, treatment, and anesthesia time. Results: A total of 233 patients (233 hips) with a mean age of 7.2 years were identified. Seventy-five patients underwent aspiration in the operating room, and 158 patients underwent bedside aspiration. Patients with a negative aspiration averaged 87 min under anesthesia when performed in the operating room and 29 min under sedation when performed at bedside. Patients with a negative aspiration performed in the operating room after 5 pm averaged 99 min under anesthesia, and 73 min under anesthesia when performed between 7 am and 5 pm (p < 0.01). Seventy-eight (49%) patients who underwent bedside aspiration did not require operative intervention and therefore avoided general anesthesia. Conclusion: Pediatric hip aspiration performed in the operating room results in prolonged anesthesia times while synovial fluid is transported and processed. Anesthesia times are significantly longer after 5 pm. Bedside aspiration resulted in significantly less anesthesia exposure, with half of patients undergoing bedside aspiration avoiding general anesthesia altogether. Level of evidence: Level III.
RESUMO
BACKGROUND: Spinal deformity and prior spinal fusion pose technical challenges to lumbar puncture (LP) for nusinersen administration for patients with spinal muscular atrophy (SMA). In this retrospective study over two study phases, we evaluated (1) factors associated with difficult LP or unscheduled requirement for image guidance and (2) effectiveness of a triage pathway for selective use of image guidance and nonstandard techniques, particularly for patients with spinal instrumentation/fusion to the sacrum. METHODS: With institutional review board approval, electronic health records, imaging, and administrative databases were analyzed for patients receiving nusinersen from January 2012 through September 2021. Descriptive statistics and univariate analyses were used. RESULTS: From January 2012 to March 2018 (phase 1), among 82 patients with SMA, 461 of 464 (99.4%) LP attempts were successful. Univariate analyses associated difficulty with prior spinal instrumentation, higher body mass index, and severity of the spinal deformity. Based on this experience, starting in April 2018 (phase 2), 125 patients were triaged selectively for ultrasound, fluoroscopy, or Dyna computed tomography. Patients with spinal instrumentation/fusion to the sacrum were treated primarily via intrathecal ports (137 doses) or transforaminal LP (55 doses). From April 2018 through September 2021, 704 of 709 (99.3%) LPs were successful. In total from January 2012 to September 2021, 1415 doses were administered. Over 50% of LPs were performed by neurology nurse practitioners without image guidance. Safety outcomes were excellent. CONCLUSIONS: A stratified approach resulted in successful intrathecal nusinersen delivery and efficient resource allocation for patients with SMA, with or without complex spinal anatomy.
Assuntos
Lipopolissacarídeos , Atrofia Muscular Espinal , Humanos , Injeções Espinhais , Lipopolissacarídeos/uso terapêutico , Atrofia Muscular Espinal/diagnóstico por imagem , Atrofia Muscular Espinal/tratamento farmacológico , Oligonucleotídeos , Estudos RetrospectivosRESUMO
PURPOSE: To assess the safety and efficacy of percutaneous image-guided sclerotherapy with doxycycline as primary treatment of intraabdominal lymphatic malformations (LMs). MATERIALS AND METHODS: Retrospective review was performed of all cases of abdominal, mesenteric, or retroperitoneal LMs referred to a single center that were subsequently treated with image-guided percutaneous sclerotherapy. RESULTS: Ten patients were included, of whom six were male. The mean age was 13 years (range, 2-28 y). Preprocedural cross-sectional imaging demonstrated a macrocystic malformation in nine patients and a mixed macrocystic/microcystic malformation in one. The malformation was accessed under sonographic guidance, followed by injection of opacified sclerosant agent under fluoroscopic guidance. A drainage catheter was placed in eight cases, in which sclerotherapy was repeated through the catheter for another 1 day (n = 2) or 2 days (n = 6). Doxycycline was reconstituted at 10 mg/mL, with a mean per-session dose of 608 mg (range, 80-1,000 mg) and a mean total dose of 1,230 mg (range, 80-3,000 mg). Peritoneal spill was identified in one case, but the patient remained asymptomatic. No other complications were encountered. Follow-up imaging was available in eight patients: complete resolution was seen in seven, with partial resolution in one. There was no recurrence of clinical symptoms in the follow-up period. CONCLUSIONS: Initial results indicate that percutaneous image-guided sclerotherapy of macrocystic intraabdominal LMs with doxycycline is a safe and effective procedure.
Assuntos
Doxiciclina/administração & dosagem , Anormalidades Linfáticas/terapia , Soluções Esclerosantes/administração & dosagem , Escleroterapia , Adolescente , Adulto , Boston , Criança , Pré-Escolar , Doxiciclina/efeitos adversos , Feminino , Humanos , Anormalidades Linfáticas/diagnóstico por imagem , Masculino , Radiografia Intervencionista , Estudos Retrospectivos , Soluções Esclerosantes/efeitos adversos , Escleroterapia/efeitos adversos , Resultado do Tratamento , Ultrassonografia de Intervenção , Adulto JovemRESUMO
PURPOSE: To review an initial experience studying the lymphatic system using direct injection of ethiodized oil contrast medium into lymph nodes (ie, intranodal lymphangiography) in children with chylous disorders. MATERIALS AND METHODS: Children with chylous disorders who underwent intranodal lymphangiography were included in this retrospective study. Under general anesthesia, ultrasonography was used to guide the placement of a small-bore (22-25-gauge) needle into an inguinal lymph node. Ethiodized oil contrast medium was very slowly injected into the node. Opacification of the lymphatic system was documented with fluoroscopic and digital substraction imaging and videofluoroscopic clips. RESULTS: Five children (age range, 6 wk to 17 y) with chylous vaginorrhea (n = 1), postoperative chylothorax (n = 2), or spontaneous chylothorax (n = 2) underwent intranodal lymphangiography. The amount of ethiodized oil injected was 0.5-4.5 mL. Intranodal lymphangiography was successfully completed in four patients. One procedure was terminated because of patient motion and extravasation of contrast medium. Lymphangiographic findings included a spectrum of lymphatic channel disorders including incompetence, obstruction, collateralization, chylous reflux, and chylous leak. There were no complications. CONCLUSIONS: The simplified technique of injecting contrast medium into a lymph node to opacify the lymphatic system in children can be an alternative to the more elaborate conventional lymphangiography.
Assuntos
Quilotórax/diagnóstico por imagem , Linfonodos/diagnóstico por imagem , Doenças Linfáticas/diagnóstico por imagem , Linfografia/métodos , Adolescente , Anestesia Geral , Boston , Criança , Pré-Escolar , Meios de Contraste , Óleo Etiodado , Estudos de Viabilidade , Feminino , Fluoroscopia , Humanos , Lactente , Masculino , Projetos Piloto , Valor Preditivo dos Testes , Intensificação de Imagem Radiográfica , Radiografia Intervencionista , Estudos RetrospectivosRESUMO
PURPOSE: To describe the use of the internal mammary vein as an alternative access for central venous catheters. METHODS: We performed a retrospective review of patients who underwent placement of central venous catheters via the internal mammary vein. Patient demographics, indication for venous access, technical success, catheter type, dwell time and indication for exchange or removal were recorded. RESULTS: Placement of central venous catheters via the internal mammary vein was attempted in 11 patients including 8 children (4 males, mean age 5.7 years) and 3 adults. The most common indication was parenteral nutrition in patients with intestinal failure (7/11). Initial needle access of the vein was successful in all patients. Catheter placement was successful in 9 and unsuccessful in 2 patients due to occlusion of the superior vena cava. There were no immediate complications. A total of 20 catheters of various sizes (3-14.5 French) and lengths (8-23 cm) were either placed (n = 12) or exchanged (n = 8). The most common indications for catheter exchange were poor function and malposition (7/8). Four catheters were removed for infection and 4 were accidentally removed. The mean dwell time was 141 days (range 0-963 days) per catheter for a total of 2829 catheter days. The total mean dwell time per patient, including primarily placed and exchanged catheters, was 314 days (range 5-963 days). CONCLUSIONS: The internal mammary vein may provide a safe alternative route for patients who have lost their traditional access veins.