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Pediatric Fluoro Handbook

UNC Pediatric Imaging 1/1/21

Resident Supplement to Peds Radiographer Handbook

Fluoro Baby & Fluoro Orientation

On your first day on peds, one of the peds fluoro techs will give an orientation and

show you how to use the fluoro equipment. Make sure that you get oriented to both

room 3 and room 4 as they operate differently. After orientation, practice

fluoroscopy technique with the fluoro baby trainer prior to performing any fluoro

procedure. The trainer is an anatomically correct 500mL bag of saline located in a

cabinet nearest the lower level workstation in the peds reading room. It is sized to

simulate a premature infant. Skills to master prior to working with patients include:

moving tower over (Parking and unparking), moving Bucky under table, angling

table up/down, magnification, collimation, obtaining spot images in and out of

series mode, saving clips and screen shots, understanding pulse rate options,

moving patient in Octostop, reviewing videofluoroscopic images from the DVR,

selecting and sending images to PACs etc. Please practice until you feel

comfortable with the equipment. See end of this handbook for pictures of room 4

tower buttons and info on parking tower.

Morning huddle:

First thing in the day, the lower level resident should review the history on all

scheduled fluoro patients and triage add on requests. Important information

includes: reason for exam, findings on prior imaging and surgical history. The

lower level resident will present the daily fluoro cases at the morning huddle with

the fluoro side attending so that an individual plan can be made for each patient.

Early in the rotation, the upper level resident is also included in the huddle.

We always need to know the clinical history. Studies should be tailored to answer

the clinical question. Many times, a request for a barium swallow, esophagram

and/or UGI are the same thing in the infant and young child, meaning the child

should be imaged from the hard palate to the proximal jejunum regardless of the

request. Other times, a dedicated exam of a single area is all that is needed.

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On call, the senior radiology resident should triage requests and then coordinate

with the pediatric radiology attending and with the radiology department

technologist supervisor to get a tech and decide on timing for the case.

Immobilization:

Most children 0-3 years old are placed in the Octostop unless their caretakers

specifically request otherwise. Please see separate fluoro guide for radiographers

for information on how to place a child in a Octostop. We call it our “special

carseat”. I explain to the parents it is less scary for the kids to be in a “special

carseat” than to have strange adults holding them and turning them as disembodied

arms reaching under the fluoro tower. The Octostop also makes it much easier to

control the patient and get the images you need when you need them. To

summarize: To the set up the Octostop, diapers are placed over the head sponges,

a blue chux is folded in thirds and placed over the board and the straps are

positioned. The child is placed into the holder and the arms slowly and gently

raised until they can be tucked into the arm cutouts in the head holder. The child is

then covered with a blanket or towel and then strapped in place with straps at the

head, chest, pelvis and just above the knees. The strap position is variable

depending on the age and size of the child. Below is a doll in the Octostop.

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Upper GI (UGI)

Common indications for emergent UGI:

Bilious vomiting

Non-bilious vomiting

Rule out malrotation

Check g-tube position or eval g-tube track

Common indications for non-emergent studies

Pre-G tube placement

Failure to thrive/ persistent reflux

Contrast:

Water soluble contrast is indicated if there is a risk for perforation

Premature or Newborn : Omnipaque 140

2 weeks old and older Omnipaque 300

Barium suspension is preferred and is used for most outpatients.

Feeding Issues:

Always ask a caregiver or parent how child is fed, amount fed and success with

feeding. Emergent neonatal studies are generally performed through a feeding

tube (usually 8F going down to 5F for very tiny babies). The nurse with the patient

may be willing and able to place a tube for you. Older babies usually drink contrast

from a bottle. We currently stock premature, newborn and NUK type nipples. In

non-cooperative children attempts should be made to give contrast via a cath tip

syringe. If this is unsuccessful, we will discuss options with parent and place tube

if needed. Remind parents (not in front of the kid) that terminating the study is

always an option. Ask returning Crohn’s patients upfront about a tube. Many who

have had barium studies in the past will opt for a tube at the beginning. Don’t

place tubes in immunocompromised patients without consulting the referring

physician.

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NG tube placement: Start with the patient supine. Tell the patient what you are

doing (numbing up nose, putting in a little tube, etc. as appropriate for age) Try to

make as much small talk as possible, as you feel appropriate. To place a tube use

viscous Lidocaine in the nose. Squirt some in the appropriate nare and occlude the

other by gently pinching the nose. Try to have the child sniff in the lidocaine.

Only use the lidocaine spray on teenagers. It’s too scary for the younger kids.

Place the tube with the patient supine with as much chin tuck as possible. If they

can cooperate, have them sip a little water through a straw while you slide the tube

into position. Proceed as below.

Contrast Administration:

Always control your contrast. In the child who is drinking, start the study in left

lateral decubitus position so that if there are a few early problems (need to switch

types of nipples, change flavors, etc) the contrast will be held in the stomach rather

that going in the duodenum before you are ready. In the child with a tube or the

older child who will drink contrast reliably, start right side down, RAO to the table.

Always evaluate for possible malrotation by evaluating the position of the

duodenal C loop and the duodenal-jejunal junction. The two critical views to

evaluate the duodenum are a lateral demonstrating contrast exiting the stomach

into a posteriorly positioned 2nd portion of the duodenum and an AP of the

duodenal jejunal junction (DJJ). Normal on AP is a DJJ at the level of the

duodenal bulb positioned to the left of the left pedicle. These images can be

obtained as screen shots, dedicated exposures or in room 4, cine clips.

An additional manoeuvre can be helpful to access the C loop and the DJJ. After

contrast reaches the second portion of the duodenum, quickly roll the child from

right lateral to LPO to get a “reverse” C-loop. This will usually allow you to see

the level of the DJJ relative to the bulb as contrast moves from the second

duodenum intothe 3rd and 4th portions of the duodenum and proximal jejunum.

Then, when you roll the patient back down supine for the AP view, most of the

contrast will be in the upper region of the stomach and you can see through the air

filled body of the stomach to visualize the C-loop. If the c-loop isn’t quite right

but isn’t definitely abnormal either, you may need to repeat the lateral view to

access the position of the 4th portion of the duodenum (is it posterior like the

second portion or not), do a small bowel follow through, or in emergent cases, an

enema to document position of the cecum to help rule in or rule out malrotation.

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Once you have evaluated the position of the duodenum, you can go back and get

anything else you need… lateral esophagus, AP esophagus, views of the gastric

antrum to rule out webs, views of the duodenum for SMA syndrome, extra view of

the esophagus to r/o vascular rings, fluoro of the airway in a child with possible

tracheomalacia, views of the oropharynx to rule out nasopharyngeal reflux etc.

Additional considerations:

In the non-emergent cases, we occasionally check for reflux. At the conclusion of

the exam, the child should have a moderately full stomach and then sips of water

may be given to clear the esophagus. Then other maneuvers can be performed

(such as rolling the patient, coughing or doing leg lifts) to check briefly for reflux.

If the infant drank contrast, include images of the oropharynx while drinking to

document nasopharyngeal reflux or aspiration.

In children with an NGT in place, obtain views of the duodenum and DJJ. If views

of the esophagus are needed, ask the technologist to pull the tube back, leaving the

tape in place, if possible. Position the tip in the distal esophagus and the

technologist can gently inject to obtain esophagus views. The tube can then be

easily slid back into place. Ask the tech aspirate the contents of the stomach after

at the end of the study. Flush the tube with water if it will be left in place.

Occasionally, an upper GI will be obtained after a G tube has been placed. The

early portion of the exam is obtained via the G tube to look at the stomach and

duodenum. Additional images of the esophagus can be obtained if needed.

Nissen fundoplication: The esophagus should be imaged in patients with a Nissen.

Give contrast p.o. if possible or place a tube and evaluate esophagus for motility,

obstruction, gastroesophageal reflux, location of GE junction relative to the

diaphragm, para esophageal hernia and/or—position and integrity of the Nissen

wrap.

Study documentation:

A scout view is obtained, even if the child just had a portable or ER film. You can

add a decubitus film if indicated. In general, we get a CXR for the barium swallow

kids and a lower chest/KUB for the UGIs but that is the only difference between

the 2 studies. It is essential to r/o malrotation on all these kids. Make sure to check

the scout prior to starting the exam.

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Remember to use the lowest fluoroscopic frame rate possible- usually between 7.5

and 3 frames/second. Use fluoro store/screen shot liberally rather than shooting

additional spot images. Collimate as tightly as possible and only magnify if

needed.

Please see pictures below for UGI images

Figure 1 lateral and AP fluorstore esophagus

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Figure 2 lateral spot film and AP fluoro store of the duodenum

Figure 3 AP esophagus with bottle off to the side and post study overhead

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Figure 4. DJJ initially hidden by contrast in stomach (a) can be seen through body

of stomach after LPO manoeuver (arrow b).

Esophagram (AKA Barium smallow):

Common indications include possible esophageal stricture or esophageal foreign

body or unexplained pneumomediastinum. In non-emergent outpatients, an AP

chest scout and barium are fine. For acute indications, follow the rule out leak

protocol outlined below. Don’t forget to check for gastroesophageal reflux.

Rule out esophageal leak/injury/ GI leak or s/p

esophageal atresia repair

Obtain scouts—AP and lateral chest for esophageal leak, AP and decubitus

abdomen for abdominal studies. Have suction hooked up and available on the

fluoro table to limit any possible aspiration.

Perform exam with water-soluble contrast, typically Omnipaque 300. Obtain

images in at least 2 positions (AP and lateral), with an oblique view if needed.

Evaluate for T-E fistula, leak, aspiration, airway compression, gastroesophageal

reflux, etc as needed. Post procedure, obtain a 2 view overheads like scout views

and check carefully for leak/extravasation. Overheads may demonstrate a leak not

seen on fluoro. If no leak, repeat study with barium (may see leak not seen with

water-soluble contrast) and then repeat 2 view overheads post exam. If performing

first exam after TE fistula/esophageal atresia repair in a neonate also perform UGI

to evaluate gastric emptying and position of duodenum and DJJ.

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G tube or Nissen check

The most common reason for the study is to confirm position after a tube fell out

and was replaced. Occasionally studies are obtained due to tube malfunction or to

confirm position after surgical G tube placement. Bring patient down to

department, do not do as a portable at the bedside. Ask that appropriate G-tube

adaptor be sent down with the patient.

Scouts: combined chest/abdomen

Find out usual feeding volume and route of administration

Contrast: Water soluble if G tube is new or might be malpositioned, otherwise

barium

Instill contrast via G-tube adaptor—Patient should initially be imaged supine. Use

a small volume of contrast to confirm tube tip positioning in or not in the stomach.

An oblique or lateral view should be included to evaluate the G tube balloon

position and the tube track. One should also evaluate gastric emptying and

presence or absence of gastroesophageal reflux.

For G tube malfunction or leak exams, after g tube position is confirmed as above,

we usually fill the stomach to 50% more than routine feeding volume to fully

distend stomach to look for leak around the G Tube, gastric emptying, etc. The

table can be moved into a slight Trendelenburg position to test Nissen integrity.

UGI with Small Bowel Follow Through (SBFT) Usually UGI performed first but occasional just the SBFT. SBFT is mainly

overhead views obtained alternating between prone and supine with spot

compression views (with wooden spoon or paddle) of the terminal ileum and small

bowel to document any abnormality or transition zone. The overhead are obtained

at approximately 0, 15, 30, 60, 90, 120 minutes and then as needed until contrast is

in the cecum. Patient may be given additional contrast to drink during the SBFT to

have a continuous contrast column from the stomach to the cecum. Check the

overheads as they appear in PACs to monitor the progression of the exam.

Contrast Enema

Common indications for contrast enema include neonatal distal bowel obstruction,

evaluation of cecal position in neonate with equivocal upper GI and potential

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malrotation, evaluation for stricture after necrotizing enterocolitis, presurgical

planning and possible Hirschsprung disease in infants or older children.

Contrast Water soluble:

Neonates: Omnipaque 140

Infant/toddler Omnipaque 300

Older child Omnipaque 300

Air

R/o intussusception air contrast enema

Barium suspension

Routine r/o Hirschsprung

Technique:

Obtain a scout KUB. Use an appropriate sized end-hole straight silicone catheter.

An 8F is usually a good choice for a neonate. The technologist will gently hand-

inject contrast material for neonates. Make sure person injecting contrast knows to

stop if meeting resistance. A bag of contrast and gravity assisted contrast

administration are appropriate for toddlers and older children. Document lateral

filled rectosigmoid, AP rectosigmoid, splenic and hepatic flexures, cecum and then

reflux of contrast into terminal ileum if possible. Additional spot films or fluoro

store images can be obtained as needed to document progression of contrast during

filling. Follow contrast column as it progresses proximally. Rolling from left

lateral decubitus to right lateral decubitus and back can help move contrast. If the

patient suddenly seems uncomfortable, roll them in a different position to prevent

over distention of a bowel loop. Reflux contrast into the terminal ileum if possible.

The contrast enema may be terminated before complete colonic filling if a

transition point is definitely identified or if there is significant mucosal irregularity

to suggest Hirschsprung enterocolitis. Obtain an immediate and then post

evacuation overhead films. If there has been no evacuation, you might suggest a

repeat overhead in 1-4 hours followed by a repeat KUB at 24 hours.

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Figure 4 AP scout

Figure 5 Normal lateral rectum fluorostore

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Figure 6 Post-evacuation overhead shows a capacious, redundant colon and retained fecal material consistent

with idiopathic constipation

Ostomy or Mucous fistula injection Ostomy injections are a variation on a contrast enema. The surgical history and

post operative anatomy will help in determining the approach for the exam. Studies

may be performed retrograde or antegrade. Water soluble contrast or barium can

be utilized. A radiopaque ruler may be included in the field of view as a reference

for measurements. A radiopaque marker (Beekley spot) should be placed at the

level of the anus in children with imperforate anus. The ostomy is best accessed

using a Foley threaded through a ring forceps. The Foley balloon is over inflated,

outside the patient and gently placed on the stoma. Contrast should be gently

instilled under fluoro guidance. A mucous fistula may be crusted over and small in

size, mimicking a port site. A wet gauze placed on the site can help remove the

crusting. A small flexible catheter is then placed. It can be held in place and then

advanced during the exam to diminish leaking. Two views of the bowel should be

obtained. All loops should be well distended to exclude stricture. Magnified views

may help identify a fistula to the GU track in children with imperforate anus.

Evacuation should be documented in children who are post op anorectoplasty for

imperforate anus.

Intussusception reduction:

Screen for intussusception with ultrasound. Small bowel intussusceptions are not

reducible via an enema. If ultrasound positive call the referring team to notify and

request order for FL Barium enema intussusception. The patient will need to have

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an iv in place, be on a monitor and be accompanied by a nurse either from the Peds

ER, inpatient floor or Radiology department. Notify the attending pediatric

radiologist on call to plan for the reduction. Make sure pediatric surgery is aware

of the patient prior to the study. A surgeon capable of taking the patient to the OR

for surgery should be immediately available in the hospital. The surgeon does not

need to be present in radiology. Obtain informed consent.

Obtain a supine scout and review. Add a lateral decubitus scout if there is any

question of pneumoperitoneum, a contraindication to reduction. Use Shiels air

enema kit. A rough estimate is to use blue enema tip until 6 months and pink

thereafter. Wrap narrow tape around the appropriate sized catheter in multiple

layers to create tape plug approximately ½ inch thick using ½ inch wide tape

positioned approximately 1 inch from narrowest part of catheter. Add silicon disk,

if using. Make sure the technologist has set up the recording device. Keep the

entire abdomen in view for procedure and fluoro continuously (usually 7.5

frames/second). Use the foot pedal to fluoro and hold the sphygmometer up in

front of the fluoro screen to watch both simultaneously. Know where to obtain

large bore needle if needed to reduce a pneumoperitoneum. Try to get free rush of

air into small bowel. Keep trying reduction until no longer making progress. Take

a break approximately every 3 minutes for about a minute and allow air to release

through side valve. Maintain mean pressure at 120mmHg if possible. If having

difficulty due to air leak, consider extra pieces of 2-inch-wide tape or having an

assistant such as the surgery resident gently compress the child’s bottom around

the tube. The procedure can be performed supine on table, in Octostop or prone.

Review post procedure overheads carefully for evidence or recurrence and repeat

enema immediately if needed. Recurrence rate is approximately 10%. If

symptoms recur after reduction after leaving radiology, repeat ultrasound and

repeat reduction as needed. Patient may return to ER following reduction and

observed in ER, short stay unit or be admitted to the hospital.

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7A.

7 B.

.

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7D Figure 7 A. US exam demonstrates ileocolic intussusception. B. Scout shows nonspecific bowel gas pattern. C.

Fluoro store during intussusception reduction with catheter in rectum and intussusception at level of ileocecal

valve outlined by gas in the cecum. D. Final image shows reflux of air into the small bowel with resolution of

the residual mass.

Voiding cystourethrogram (VCUG)

Common indications for VCUG include prenatal hydronephrosis and urinary tract

infection. Less common indications include pelvis fracture with possible bladder

injury, evaluation of neurogenic bladder, ambiguous genitalia, and fistula

evaluation in boys with high imperforate anus. Know medical, surgical and

imaging history prior to starting exam. Many times the patient will have

ultrasound just prior to VCUG. Try to be completely ready and start case as soon

as catheter is placed.

After explaining the procedure and obtaining a scout, the technologists or nurses

will catheterize patient usually with an 8F feeding tube. A 5F or Coudé may be

used instead if needed. Use Cystografin (18%) or dilute Omnipaque 300 via

gravity to fill the urinary bladder. See pictures below for required images. Use

shot save to decrease radiation and to see tip of penile urethra. A cyclic exam (3 or

more fill and void cycles) should be performed on children 0-12 months old.

Patients over 2 years old are offered low dose p.o. Versed for anxiolysis. If Versed

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is requested, the radiology nurse will record patient weight in EPIC and you can

then place the order for the patient in EPIC. The dose of midazolam is 0.5mg/kg of

the 5mg/mL syrup. Patient does not need to be NPO. The Versed is administered

by the Radiology nurse 30 minutes before catheter placement. The nurse will also

give written post Versed discharge instructions which are available in both English

and Spanish.

Check scout as soon as available in PACs. Be ready to begin exam as soon as the

catheter is in place. Check the catheter position with fluoro just prior to starting

contrast. Potential problems include position too high with tip extending into a

ureter, too low in the posterior urethra, excessive tubing coiled in the bladder

which can tangle and form a knot or a malpositioned catheter in the vagina. If there

is an atypical appearance, administer a small amount of contrast to further evaluate

the catheter location. Stop contrast and reposition using sterile technique if needed.

Obtain the following minimum images:

Early filling bladder (fluoro store)

Full bladder (fluoro store)

Oblique bladder bilateral (center on femoral head, collimate off anterior bladder,

include bladder base with catheter in urethra, show position of ureteral insertion,

ureteroceles, diverticula, etc)

The bladder volume can be estimated as:

For children <1yo: 7 x weight in kg

For children >1 year old: (Age in years +2) 30 =bladder capacity in ml

Voiding image Girls AP- collimate off the upper bladder

Boys: Dynamic technique: Lateral rolling to oblique

Girls voiding: Most are imaged supine. Collimate off top of bladder. Keep

monitor on single shot acquisition mode, ask tech to loosen tape and tell you when

voiding. When told voiding, fluoro quickly to check for large amount contrast in

bladder, if so, tell tech to pull catheter and obtain single image of urethra. A fluoro

store is usually adequate. If the pictures from the first void aren’t adequate, try

again. If the pictures are adequate, fluoro the bladder and up to the level of the

kidneys. If there is new reflux, reshoot obliques to look at ureteral insertions. If

there isn’t any new reflux, shoot image over kidneys and obtain overhead.

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Boys voiding: Imaging the male urethra is more challenging than imaging the

female urethra. It requires coordination between the radiologist, technologist,

patient and caregiver. Describe/demonstrate to parent and child the rolling

maneuver before voiding so that they know to expect when the patient is rolled

during voiding. Either turn the child in the Octostop to demonstrate or place your

hand on the iliac crest and demonstrate the turning to the older child or teen. Use

age appropriate language to describe the change in position while the child voids.

Acquire the cyclic void images is child 12 months old or younger. When the

bladder is nearly full, roll the patient into a left lateral decubitus position, magnify

image, collimate off top of bladder, center over the pelvis with the posterior urethra

in the right hand third of the image, set monitor on series mode, ask tech to loosen

tape and tell you when voiding. When told voiding, fluoro quickly to check for

large amount contrast in bladder, if so tell tech to pull (the catheter) while you will

“pull the trigger on the fluoro tower” to acquire a series of images. This requires a

firm steady compression on the trigger. Once you start series acquisition, the

tower locks. You should roll the Octostop or patient with your right hand while

you fluoro with your left. If the urethra is out of the field of view and you need to

reposition, you will need to move the patient not the tower. As soon as you have a

view of the distended posterior urethra without the catheter, roll the patient slightly

towards a supine position to obtain images to the tip of the penile urethra. Obtain

the smallest number of images possible to document the entire urethra from

bladder base to tip of penis. If the pictures from the first void aren’t adequate, try

again. If the pictures are adequate, take off series mode and fluoro the bladder and

continue up to the level of the kidneys. If there is new reflux, reshoot obliques to

look at ureteral insertions. If there isn’t any new vesicoureteral reflux, simply

shoot image over kidneys and obtain overhead. Review case with faculty prior to

completion of the exam.

Boy or girl, if the bladder is not full when patient starts to void, tell tech “NO” and

let the patient void around the catheter. It is easy to refill the bladder a second and

third time turning it into a cyclic VCUG. It is not as easy to recatheterize the

patient but will likely need to be done if images of the urethra are incomplete. It is

essential to image the entire urethra, particularly in boys. Review images with

fluoro attending prior to discharge.

Ambiguous genitalia: Each case will need to be individualized. Usually the studies

are performed as described above for boys. Insertion of catheters in more than one

perineal opening may be required. Consultation with Pediatric Urology is often

also helpful.

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Urethral injury or stricture may be evaluated with a retrograde urethrogram (RUG).

The catheter is placed in the anterior urethra using sterile technique and water

soluble contrast instilled retrograde. Oblique, lateral and AP views are obtained to

fully evaluate urethra.

An intravenous pyelogram (IVP) is rarely performed but can be useful to evaluate

the ureter course and integrity. Intravenous contrast is instilled at 2cc/kg and

filming individualized to the patient.

Figure 8 Diagram of images for VCUG

Figure 9 Early filling bladder fluoro store

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Figure 10 Oblique view for ureter insertion, collimated and centered over the acetabulum or femoral head

Figure 11 Lateral and obliue views of urethra from these are the 3rd and 6th images from a series of 8 images

Figure 12 Image centered over kidney, near level 11th and 12th ribs

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Figure 13 AP voiding urethra in 8 year old girl with top half bladder collimated off.

Port or Central Line Check

Evaluate lines placed by pediatric care providers—Peds Surgery, ICUs etc

Ordering team accesses catheter and places extension tubing to allow for contrast

injection

Scout: 2 views of catheter (usually AP lateral chest)

Contrast: Omnipaque 180 maximum dose 2cc/kg (confirm contrast is for

intravenous use and check expiration date)

Check scouts. Confirm that heparin has been withdrawn from catheter. Aspirate

blood. Perform rapid sequence imaging (4 frames/sec) using up to half of contrast

with entire catheter course in field of view. If necessary, repeat in orthogonal

plane.

Patient should be discharged back to the ordering team. Communicate the results

and the condition of the catheter (working, flushed, not flushed, etc) with the care

team so that they can finalize catheter care before the patient leaves the facility.

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Room 4

Here is a summary of the buttons on the tower in room 4

Here are specific directions for parking and un-parking the tower. Please do no pull on the

handle.

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