Guidelines:

GUIDELINES FOR INTUSSUSCEPTION REDUCTION

British Society of Paediatric Radiology draft guidelines for suggested safe practice.
These guidelines are draft and are for consultation only. They are meant to do exactly what they say - ie to act as a guide only. We would really like any comments, thoughts or amendments, email Dr Mchugh at Great Ormond Street Hosp, London. Download a copy in Word Format by clicking here.
  • Patient must be fully resuscitated with i.v. line in-situ [1].
  • Informed consent must be obtained from the parents or guardian (written consent is not necessary).
  • Ultrasound (US) is sensitive in diagnosis [2-6].
  • Local surgeon (and anaesthesia) should be aware of the procedure, and on stand-by. ‘Paediatric anaesthetic equipment must be available where children are treated and a person trained in paediatric resuscitation should be in attendance in the room during the procedure’ [7].‘When a consultant (anaesthetist) with adequate training and continuing experience is not available, arrangements will be made for the transfer of children to another hospital with the necessary staff and facilities’ [7].
  • Radiological reduction must only be attempted in a hospital where the involved radiologist has the appropriate continuing experience and where a surgeon and an anaesthetist competent to deal with the complications are available. [27]
  • Antibiotics and antispasmodics are not routinely indicated [3,8-10].
  • Sedation is of questionable value - consider analgesia as alternative [3,11]. Practices vary but local policies should be defined.
  • Repeated attempts at reduction 2-8 hours later are justifiable, depending on local and clinical circumstances [12].
  • Cautious reduction should be undertaken (maximum 3 attempts)
    - in children <3 months of age [13]
    - if no blood flow is seen in the intussusception on good quality doppler
    evaluation [14,15].
    - if US reveals trapped intraluminal fluid in the intussusception mass [16,17]
  • Lead points can be difficult to diagnose with fluoroscopy, but US is more sensitive [18]. Despite identifying a lead point on US, at least partial reduction of the intussusception may facilitate subsequent surgery in these cases - less handling of bowel at surgery and a smaller abdominal incision and scar may result [Alan Daneman, Hospital for Sick Children, Toronto and David Drake, Great Ormond Street Hospital - personal communication].
  • The goal or target of treatment should be a >65-70% successful reduction rate in each institution [3].
  • Centres with successful reduction rates in <50% of cases should consider re-training or transferring patients to another hospital. A minimum target of 50% successful reductions is recommended.
  • Total fluoroscopy times should be in the region of 3-15 minutes or less, approximately. Over 90% of successful reductions are performed with screening times of less than 10 minutes. Prolonged screening should be avoided.
  • Regular audits of intussusception figures should be undertaken [3].
  • These guidelines also apply to reductions performed solely with US monitoring.

Contra-indications [1,19-22].

  • Peritonitis
  • Shock

HYDROSTATIC REDUCTION

  • Barium should be at 1m above the table top [22,23].
  • Larger bore tube or catheter (>18F approx.) to be used [24].
  • 3 attempts x 3 minutes generally sufficient and safe [3,4,20,22,23].
  • Success defined as reflux of barium (“flooding”) into the distal ileum.
  • The catheter type used (balloon or other) is a local decision [3,12,20,25,26].

PNEUMATIC REDUCTION

  • A maximum pressure of 120mmHg is recommended [3,4,10,19,20,26]
  • Intraluminal pressure should be monitored - a pressure monitoring device is highly desirable [1,3,21]
  • Pressure release valve with a cut-off at 120mmHg is an alternative and is recommended in the absence of a pressure manometer [3]
  • A successful reduction is usually defined as free flow of air into the distal ileum. If an intussusception is reduced to the caecum but no retrograde flow of air can be seen in the distal ileum, the patient may be observed (for a few hours) and management decisions delayed dependent on the child’s condition [12].
  • Initial attempt should be at a pressure of 60-80mmHg [25]
  • 3 attempts x3 minutes are generally sufficient and safe [3,4,20,22]
  • The catheter used (balloon or other) is a local decision [3,12,20,25,26]
  • Although at the discretion of an individual radiologist, it is generally recommended that each sustained attempt at reduction should be for a maximum of 3 minutes [1,3,12,20]
  • A combined maximum of 15 minutes attempted pneumatic reduction should be sufficient [3,25]
  • In the event of bowel perforation, a large pneumoperitoneum can be relieved quickly by needle puncture of the abdomen [1,21]
  • Pneumatic reduction is generally considered the optimal technique, but a well performed hydrostatic reduction is a satisfactory and safe alternative [3,4,19,20,23]

References.

  1. American College of Radiology. Standard for the performance of paediatric contrast enema examinations. 1997 (res. 36) pg3-4.
  2. Verschelden P, Filiatrault D, Garel L et al. Intussusception in children: reliability of ultrasound in diagnosis - a prospective study. Radiology 1992; 184: 741-744.
  3. Rosenfeld K, McHugh K. Survey of intussusception reduction in England, Scotland and Wales: how and why we could do better. Clin Radiol 1999; 54: 452-458.
  4. Daneman A, Alton D J. Intussusception: issues and controversies related to diagnosis and reduction. Radiol Clin N Am 1996;34:743-756
  5. Stanley A, Logan H, Bate T W, Nicholson A J. Ultrasound in the diagnosis and exclusion of intussusception. Irish Med J 1997;90:64-65
  6. Lim H K, Sang H B, Lee K H, et al. Assessment of reducibility of ileocolic intussusception in children: usefulness of colour Doppler sonography. Radiology 1994;191:781-785
  7. The Royal College of Anaesthetists. Guidelines for the Provision of Anaesthetic Services. Guidance on the Provision of Paediatric Anaesthesia. 1999, pg 24-26.
  8. Somekh E, Serour F, Goncalves D, Gorenstein A. Air enema for reduction of intussusception in children: risk of bacteraemia. Radiology 1996;200:217-218
  9. Mortenson W, Eklof O, Laurin S. Hydrostatic reduction of childhood intussusception: the role of adjuvant glucagon medication. Acta Radiol Diagn 1984;25:261-264
  10. Franken EA Jr, Smith W L, Chernish SM et al. The use of glucagon in hydrostatic reduction of intussusception: a double-blind study of 30 patients. Radiology 1983;146:687-689
  11. Shiels W E, Kirk D R, Keller G L, et al. Colonic Perforation by Air and Liquid Enemas: Comparison Study in young pigs. AJR 1993;160:931-935
  12. Gorenstein A, Raucher A, Serour F, et al. Intussusception in children: reduction with repeated, delayed air enema. Radiology 1998;206:721-724
  13. Stein M, Alton DJ, Daneman A. Pneumatic Reduction of Intussusception: 5 year Experience. Radiology 1992;183:681-684
  14. Lam AH, Firman K. Value of sonography including colour Doppler in the diagnosis and management of long standing intussusception. Pediatric Radiology 1992;22:112-114
  15. Lim HK, Bae SH, Lee KH, et al. Assessment of reducibility of ileocolic intussusception in children: usefulness of color Doppler sonography. Radiology 1994;191:781-785
  16. del Pozo G, Gonzalez-Spinola J, Gomez-Anson B, et al. Intussusception: Trapped Peritoneal fluid Detected with US - Relationship to Reducibility and Ischemia. Radiology 1996;201:379-383
  17. Britton I, Wilkinson AG. Ultrasound features of intussusception predicting outcome of air enema. Pediatr Radiol 1999;29:705-710
  18. Miller SF, Landes AB, Dautenhahn LW et al. Intussusception: ability of fluoroscopic images obtained during air enemas to depict lead points and other abnormalities. Radiology 1995; 197: 493-496.
  19. Daneman A, Alton D J, Ein S, et al. Perforation during attempted intussusception reduction in children - a comparison of perforation with barium and air. Pediatr Radiol 1995;25:81-88
  20. Phelan E, de Campo JF, Malecky G. Comparison of oxygen and barium reduction of ileocolic intussusception. AJR 1988;150:1349-1352
  21. Berlin L. Malpractice Issues in Radiology - Reducing the Intussuscepted Colon. AJR 1998;170:1161-1163
  22. Bramson R T, Blickman J G. Perforation during hydrostatic reduction of intussusception: proposed mechanism and review of the literature. J Pediatr Surg 1992;27:589-591
  23. Poznanski A K, Why I still use barium for intussusception. Pediatr Radiol 1995;25:92-93
  24. Schmitz-Rode T, Muller-Leisse C, Alzen G. Comparative examination of various rectal tubes and contrast media for the reduction of intussusceptions. Pediatr Radiol 1991;21:341-345
  25. McAlister W H. Intussusception: Even Hippocrates did not standardise his technique of enema reduction Radiology 1998;206:595-598
  26. Katz ME, Kolm P. Intussusception reduction 1991: an international survey of pediatric radiologists. Pediatr Radiol 1991; 22:318-322
  27. The British Association of Paediatric Surgeons. A Guide for Purchasers and Providers of Paediatric Surgeons. August 1994 (revised March 1995)
Footnote. Please note a recent Royal College of Radiology publication. Antibiotic prophylaxis prior to barium enema in patients at high risk of endocarditis. RFCR(99)7. July 1999.

Dated, April 2003.
Author: Dr. Kieran McHugh, FRCR, FRCPI, DCH,
Radiology Department, Great Ormond Street Hospital for Children,
London WC1N 3JH.
Email: kmchugh@lineone.net


©1999 I.J.Kenney/BSPR