Fluoroscopic Contrast Studies
(Newborn
through 18 years of age)
Table of Contents
Page
No.
Pediatric
Gastrointestinal Studies
A. Infant UGI 4
B. Upper
GI 5
C. Double
Contrast Upper GI 6
D. Small
Bowel Follow Through 7
E. Upper
GI for Pyloric Stenosis 8
Pediatric Barium
Enemas
A. Materials 9
Tips 9
B. Single
Column Barium Enema 10
C. Barium
Enema for Intussusception 12
D. Double
Contrast Barium Enema 14
E. Enema
Through Ileostomy or Colostomy 16
F. Hirschprung's Barium Enema 17
G. Small
Bowel Enema - Double Contrast Study 18
H. Suspicion
of Meconium Plug Syndrome 18
I. Suspicion
of Meconium Ileus: Aqueous Contrast Enema 19
Pediatric
Urinary Tract Studies
A. Nephrostogram 21
B. Retrograde
Urethrogram 21
C. Excretory
Urogram (EU) / Intravenous Pyelogram (IVP) 22
Guidelines for Use of Non-Ionic
Contrast Material 23
Attached: Contrast Agent Data Form (between p. 25
& p. 26)
Alphabetical
Drug List
ABCD
Approach for Patient Evaluation & Treatment
Categories of
Reactions
D. Emergency
IVP Protocol for Trauma Patients Through ER 26
Page
No.
Miscellaneous
Pediatric Fluoroscopic Procedures
A. Fistulagram 28
B. Pharyngeal Airway
Study 29
C. Vaginogram 29
D. Arthrogram (Hip) 30
VCUG: Voiding Cystourethrogram
A. Cyclic Voiding Cystourethrogram (VCUG) 32
B. Catheterization 32
C. Procedure 32
Pediatric Gastrointestinal
Studies
A. Infant UGI
1. Preparation: NPO for 3-4 hours
2. Materials:
a. Chux layered
under patient’s buttocks
b. 4 oz bottle and nipple, or patient's
regular bottle
c. Routine barium
3. Shield
table
4. Infant
restraining device - only when necessary
5. Film
sequence
a. Preliminary AP supine chest and abdomen
on one film.
b. To evaluate the esophagus:
i. Place infant into straight left
lateral decubitus position.
ii. Observe and image first swallow in the
left lateral projection.
1. Evaluate the swallowing mechanism.
2. Look for evidence of tracheal
aspiration and nasopharyngeal reflux
iii. Evaluate esophageal peristalsis.
iv. Look for position of esophagus,
vascular rings, mucosal abnormalities, hiatal hernia.
v. Turn infant into supine position and
evaluate esophagus for vascular rings, mucosal abnormalities, abnormal
peristalsis, hiatal hernia.
c. To evaluate for malrotation:
i. Turn the baby RPO or, if necessary,
prone oblique with right side down, in relationship to the table.
ii. As soon as the first and second parts
of the duodenum are visualized, turn the infant into a supine AP position and
obtain an image of the entire C-loop including the region of the ligament of
Treitz. The D-J junction should be to
the left of the spine at the level of the duodenal bulb.
d. To further evaluate for hiatal
hernia:
Obtain images of the esophagus either supine or LPO to the table with the
infant crying (induce Valsalva maneuver by removing bottle as infant is
drinking).
e. To evaluate the stomach and duodenum:
Obtain prone barium/air contrast spots of the fundus, prone obliques of
the barium filled duodenum, supine and oblique air filled gastric antrum and
duodenal bulb and loop.
f. To evaluate for gastroesophageal
reflux:
Allow the infant to drink (without fluoroscopic observation) the
equivalent of his/her usual feeding.
Burp the infant. Observe for GER
with the infant in various positions and document reflux, if present.
g. Overhead films:
i. Supine chest/abdomen
h. When
infant has NG tube and cannot drink by mouth:
i. Use 50-60 cc syringe
that is compatible with NG tube and use routine liquid barium.
ii. Begin with the infant in a prone
oblique position with the right side down and obtain images of the gastric
antrum and descending duodenum, a supine view of C-loop, contrast and
air-filled views of the stomach and duodenum.
iii. Check for GER when the stomach is
filled to the amount of the infant's usual feeding.
iv. Overhead films: Supine chest/abdomen
B. Upper GI
1. Preparation:
a. Newborn to 6 months: NPO 3 hours prior to exam
b. 6 - 12
months: NPO 4 hours prior
to exam
c. One year and
older: NPO 6 hours prior to exam
2. Materials:
a. Chux layered
under patient’s buttocks
b. Regular barium
c. Cup and straw and/or baby bottle
d. May need: feeding tube (check size with
radiologist), K-Y jelly, extension tubes and syringe if child is uncooperative
e. Chocolate or strawberry flavoring as
per child's preference
3. Shield table
4. Procedure:
a. Prepare immobilization if needed
b. Take AP scout of abdomen - check with
radiologist regarding including chest
c. Show scout and request to radiologist
doing fluoro
d. Overhead films will be requested by
radiologist after fluoro
Note: Make every effort to establish a good rapport
with the patient so he/she will cooperate with drinking the barium
C. Double Contrast Upper GI (performed only on patients able to
swallow Fizzies,
over 5 years of age)
1. Preparation: NPO 6 hours prior to exam
2. Materials:
a. Cup of E-Z HD (heavy density barium)
Note: To mix heavy density barium: mix powder with
1 measuring cup of water
and shake well
b. Fizzies
c. 30 cc medicine cup filled 2/3 with
water
d. Straw
e. Chocolate or strawberry flavoring as
per child's preference
3. Shield table
4. Procedure:
a. Immobilization as needed
b. Take AP scout film of abdomen
c. Show scout and request to radiologist
doing flouro
d. The radiologist will have the patient
swallow the fizzies right after mixing them with
water
e. Examine esophagus in upright position
unless the child is unable to cooperate in the erect position
f. Spot films are taken by the
radiologist
g. Overhead films requested by radiologist
after fluoro
Note: Have regular barium on hand in case
radiologist requests
D. Small Bowel Follow Through
1. Preparation:
a. Newborn to 6 months: NPO 3 hours prior to exam
b. 6 - 12
months: NPO 4 hours prior
to exam
c. One year and
older: NPO 6 hours prior to exam
2. Materials:
a. Same materials used in "Upper GI" with additional routine liquid barium, amount
to be determined by radiologist
3. Shield table
4. Procedure:
a. Same procedure as "Upper GI"
b. After upper GI is completed the
radiologist will request overhead films
c. The radiologist will instruct you to
have the patient drink additional barium
d. When the radiologist is reviewing the
overhead films he/she will then instruct you to take follow-up films as the
barium is progressing through the small bowel.
Additional spot films at discretion of radiologist.
e. Most often you will receive instructions
to take films at half hour intervals; however, after each follow-up film is
taken it must be shown to the radiologist and he/she will decide the time frame
to follow. Indicate time interval on
each follow-up film.
f. Once the radiologist has determined
that the barium has reached the terminal ileum, he/she will then fluoro and
obtain spot films of this area; have compression paddle available
E. Upper
GI for Pyloric Stenosis (rarely performed)
Note: Babies with clinical and physical findings consistent with pyloric
stenosis should be referred to ultrasound
1. Preparation:
NPO 3 hours prior to exam
2. Materials:
a. One 50 cc syringe filled with regular
barium
b. One EMPTY 20
cc syringe - use to aspirate the stomach
c. Extension tubing
d. Feeding tube (5 or 8 F)
e. K-Y jelly
f. Tape
3. Shield table
4. Procedure:
a. Immobilize as needed
b. Scout film of abdomen
c. Feeding tube is inserted by radiologist
who will aspirate the baby's stomach
d. Barium is hand-injected during
fluoroscopic observation
Note: Be cautious not to overfill the stomach !!!
Note: If hypertrophic pyloric stenosis is
demonstrated, aspirate the stomach at the conclusion of the examination.
Pediatric Barium Enemas
A. Materials
1. Barium
a. For older
infants, children and adolescents: pre-filled bags of barium: fill with warm
water to 2000 cc and shake
b. For infants:
i. Syringes - for small infants, check
with radiologist for size, type and # of syringes
ii. Connecting tubing
2. Gastrografin: dilute half Gastrografin
and half water; may use with syringes or empty BE bags - check with radiologist
before preparing
or Liquid Polibar
Plus (heavy density barium): use two cups of Liquid Polibar
Plus to one cup of water
or Cystografin
Dilute
3. Tips
a. Aged newborn to 2 years old - use Foley
catheters and 60 cc syringes filled with requested contrast medium - check
Foley size with radiologist
b. 5 cc empty syringe on hand if needed to
inflate balloon
c. Aged 2 years and older - use E-Z-EM
Flexi-Tip connected to regular BE bags or Foley catheter (size determined by
radiologist)
d. Air contrast tips used for air contrast
BE's connected to air contrast BE bags used for older
children
e. Special air contrast tips used for
smaller children are located in the barium kitchen. These tips are green and much smaller than
regular air contrast and include a device for inserting air and balloon in
rectum.
f. Foley catheters are used for colostomy
studies.
4. Appropriate
connectors – as needed
5. Chux layered
under patient’s buttocks
B. Single Column Barium Enema
1. Preparation:
a. All children should have clear liquids only for 24 hours before exam time
b. Increase fluid intake for all children
c. Evening before exam, initiate the
following schedule of Milk of Magnesia:
i. Under 2
years: none
ii. 2 – 5
years: 2 teaspoons
iii. 6-11
years: 2 tablespoons
iv. 12 years
and older: 4 tablespoons
d. Children 2
years and older have Fleets enema before bedtime the evening before exam and
another Fleets enema before coming to the hospital for exam
e. If diagnosis is for Hirschsprung’s or
chronic constipation:
i. DO NOT
PREP
ii. For 2 days
prior to BE:
-
no rectal exams
-
no rectal stimulation
-
no rectal thermometers
- no
suppositories
-
no enemas
2. Materials:
a. Barium
1. For older
infants, children and adolescents: pre-filled bags of barium: fill with warm
water to 2000 cc and shake
2. For infants:
i. Syringes - for small infants, check
with radiologist for size, type and # of syringes
ii. Connecting tubing
b. Gastrografin: dilute half Gastrografin
and half water; may use with syringes or empty BE bags - check with radiologist
before preparing
or Liquid Polibar
Plus (heavy density barium): use two cups of Liquid Polibar
Plus to one cup of water
or Cystografin
Dilute
c. Tips
1. Aged newborn to 2 years old - use Foley
catheters and 60 cc syringes filled with requested contrast medium - check
Foley size with radiologist
2. 5 cc empty syringe on hand if needed to
inflate balloon
3. Aged 2 years and older - use E-Z-EM
Flexi-Tip connected to regular BE bags or Foley catheter (size determined by
radiologist)
4. Air contrast tips used for air contrast
BE's connected to air contrast BE bags used for older
children
5. Special air contrast tips used for
smaller children are located in the barium kitchen. These tips are green and much smaller than
regular air contrast and include a device for inserting air and balloon in
rectum.
6. Foley catheters are used for colostomy
studies.
d. Chux layered
under patient’s buttocks
3. Shield table
4. Procedure:
a. Gown patient; immobilize if necessary.
b. Chux layered
under patient’s buttocks
c. AP scout film of patient's abdomen
d. Show scout film and request to
radiologist doing fluoro. The
radiologist will determine the exact materials to use for the study.
e. Once the materials are specified,
prepare the contrast material
f. Hang the BE bag not more than 3' above
the patient.
g. Run the barium throughout the entire
tubing.
h. Insert the enema tip into the patient's
rectum and tape buttocks tightly together. The radiologist will insert the
tip into infants and younger children.
i. The radiologist will take spot films
as necessary.
j. After the radiologist is finished
fluoro he/she will request the required overhead films.
k. Do not remove the tip from the patient
until all films are reviewed by the radiologist and he/she gives you the OK
l. After OK is given, remove tip and send
patient to the bathroom or re-apply diaper.
m. Post Evac film
whenever possible
C. Barium Enema for Intussusception
1. No preparation
2. Preliminary scout films:
a. Supine KUB
b. Erect or left lateral decubitus view of
the abdomen
Note: If child has . . .
¨
Profound
shock
¨
Peritonitis
¨
Perforation
. . . the
patient should proceed to Surgery!
Note: Prolonged symptoms, small bowel obstruction, older age, and
recurrent intussusception are not contraindications, given that the systemic
condition is not prohibitive, but proceed with extra caution!
3. Prior to attempting hydrostatic
reduction (either barium or water soluble contrast), clinicians participate as
follows:
a. Obtain surgical consultation (to assess
for signs of peritonitis)
b. Establish IV access
c. Adequate hydration
d. NG tube
e. Analgesia (Note: ask
the accompanying pediatric and/or surgical resident to order and have on hand
morphine sulfate 0.2 mg/kg, to be administered intravenously in the event that
intussusception is diagnosed radiographically.)
4. Materials:
a. Chux layered
under patient’s buttocks
b. Same as "Single
Column Barium Enema," with minimal amount of K-Y jelly (may use
barium or Cystografin Dilute)
c. Foley catheter - check size with
radiologist (largest bore rectum can accommodate)
d. 5 cc empty syringe on hand to inflate
Foley catheter balloon if necessary
5. Shield table
6. Procedure:
a. Use minimal amount lubrication
b. Tape buttocks tightly
c. Use adequate number of chux layered under patient’s buttocks
d. Rule of 3's:
¨
Reservoir 3 feet above the table
¨
3 attempts
¨
3-5 minutes per attempt
Note: Many cases of intussusception require
additional barium to aid in the reduction of the bowel. If the child continually evacuates the
barium, it will be necessary to fill another bag. At times, it may be necessary to inflate
Foley balloon, in order to achieve an adequate seal. Use extreme caution with
the balloon inflated.
e. Fluoro
intermittently to follow column and to rule out perforation
f. Siphon
off and evacuate if necessary
g. Success
is evident when there is free flow of contrast into the terminal ileum
h. Post-evacuation
film to exclude re-intussusception
i. 24 hour delay post-evacuation film
7. Recurrent intussusception:
a. Uncommon (3.5-10%)
b. Repeat diagnostic and therapeutic enema
unless pathologic lead point is suspected or there are prior contraindications.
D. Double Contrast Barium Enema
Note: Please try to keep the patient as relaxed as
possible during the study. The patient
will be very uncomfortable at times and needs your support !!
1. Preparation:
a. All children should have clear liquids only for 24 hours before exam time
b. Increase fluid intake for all children
c. Evening before exam, initiate the
following schedule of Milk of Magnesia:
i. Under 2
years: none
ii. 2 – 5
years: 2 teaspoons
iii. 6-11
years: 2 tablespoons
iv. 12 years
and older: 4 tablespoons
d. Children 2
years and older have Fleets enema before bedtime the evening before exam and another
Fleets enema before coming to the hospital for exam
e. If diagnosis is for Hirschsprung’s or
chronic constipation:
i. DO NOT
PREP
ii. For 2 days
prior to BE:
-
no rectal exams
-
no rectal stimulation
-
no rectal thermometers
- no
suppositories
-
no enemas
2. Materials:
a. Chux layered
under patient's buttocks
b. Liquid Polibar Plus (heavy density barium)
c. EZ-EM Enema
Bags with Air Contrast tip attached, or emptied single contrast bag with 4 inch
tubing connections
d. Tape
e. Puffers (white square for balloon in
rectum and blue bulb for inserting air into colon)
f. K-Y jelly
g. Glucagon 0.5 mg IV or SQ, at discretion
of radiologist
3. Shield table
4. Procedure:
a. Gown patient; immobilize if necessary
b. Chux layered
under patient’s buttocks
c. Take scout AP abdomen
d. Show scout and request to radiologist
doing fluoro
e. Radiologist determines if cleansing
enema is necessary after seeing scout film; if colon is sufficiently clean, the
radiologist will then authorize preparation of contrast material
f. Hang the enema bag not more than 3
feet above the patient
g. Run the barium through the tubing until
it reaches the tip and clamp shut
h. Place the enema tip into the patient's
rectum gently - radiologist will insert tip when the patient is an infant or
young child
i. Summon the radiologist to begin the
case.
j. After coating the entire bowel with
the heavy density barium the radiologist will drain some barium out by dropping
the bag to the floor;
once he/she sees a uniform coating he/she will then start
inserting the air into the colon
j. The radiologist takes spot films as
necessary
l. After fluoro the radiologist will give
instructions regarding overhead films
m. All films are to be OK'd by the radiologist
before removing the tip
n. After getting radiologist's OK, remove
the tip and send the patient to the bathroom or re-apply diaper
o. Post Evac
film whenever possible
E. Enema Through Ileostomy or
Colostomy
1. Materials:
a. Chux layered
under patient's buttocks
b. Contrast material at the request of the
radiologist or specified by referring physician
c. 50 cc syringes with appropriate tip to
fit catheter being used
d. Connecting tubing and adapters
e. Foley catheter - size requested by
radiologist
f. 5 cc empty syringe to inflate balloon
g. Topper sponges
h. Tape
2. Shield table
3. Procedure:
a. Gown patient; immobilize if necessary.
b. Take AP scout film of abdomen
c. Show scout film and request to
radiologist doing fluoro
d. Radiologist will determine the contrast
material to be used and the size of Foley cath
e. Prepare contrast material as specified
f. Place all the necessary materials on
the table readily available for the radiologist
g. Radiologist will insert catheter into ostomy
opening and gently inflate the balloon.
h. Radiologist will then place topper
sponges over stoma and tube and tape firmly to abdomen
i. Spot films will be taken by the
radiologist
j. Overheads will be requested by
radiologist after fluoro
k. Post Evac
film as per radiologist
F. Hirschprung's Barium Enema
Note: No preparation for patient.
Question parents! For 2 days
prior to BE, no rectal exams, no rectal stimulation, no rectal thermometers,
suppositories or enemas
1. Materials:
a. Chux layered
under patient's buttocks
b. Routine liquid barium
c. Foley catheter or feeding tube - check
type and size with radiologist
d. Extension tubing and connector
e. Syringes with barium or BE bag
depending on instructions from radiologist
3. Shield table
4. Procedure:
a. Gown patient; immobilize if necessary
b. Take AP and lateral scout films (to
include rectum)
c. Show scouts and request to radiologist
d. Radiologist will insert Foley catheter
or feeding tube into rectum and tape buttocks firmly together
e. Radiologist will intermittently fluoro
and take spot films as barium is infused
f. Overhead films will be requested by
radiologist
g. Do not remove tip until radiologist's
OK
h. After OK is given let patient evac barium
i. AP and lateral post evac films are required in ALL Hirschprung's
cases
j. The radiologist may put a small amount
of Esophatrast over anal opening in order to assess
length of very short aganglionic segment
Note: Radiologist may request 24-48 hours post evac AP and lateral films also!!
Note: If it is obvious that there is an agnaglionic segment, avoid overfilling more proximal
dilated colon.
G. Small Bowel Enema - Double Contrast Study
1. Preparation:
a. Newborn to 6 months: NPO 3 hours prior to exam
b. 6 - 12 months: NPO 4 hours prior to exam
c. One year and
older: NPO 6 hours prior to exam
2. Materials:
a. Chux layered
under patient's buttocks
b. Methylcellulose enema: take 5
grams (approximately 75 cc) of methylcellulose located in barium kitchen and
mix with 500 cc of hot water (preferably boiling). Shake until all powder is dissolved. Add 500 cc of cold water. Place in refrigerator for one half hour
before the study. Check to see that
mixture is cool prior to utilization for study.
c. Regular barium in syringes
d. Feeding tube extra long length
e. Extension tubing
f. Guide wire may be used for easier
insertion of tube into jejunum
3. Shield table
4. Procedure:
a. Gown patient; immobilize if necessary.
b. Take AP scout film of abdomen
c. Show scout film and request to
radiologist
d. Have all supplies mentioned readily
available at table for radiologist
e. Radiologist will begin by placing a
feeding tube into the proximal jejunum
f. Once the tube is in place he/she will
then insert barium through the tube and then the methylcellulose solution
g. Overheads as requested by the
radiologist
H. Suspicion of Meconium Plug Syndrome
1. No preparation
2. Materials:
a. Chux layered
under patient's buttocks
b. Foley catheter or feeding tube - check
type and size with radiologist
c. Extension tubing and connector
d. Syringes with CystografinDilute
3. Shield table
4. Procedure:
a. Immobilize patient if necessary
b. Take AP and lateral scout films (to
include rectum)
c. Show scouts and request to radiologist
d. Radiologist inserts Foley catheter or
feeding tube into rectum and tapes buttocks firmly together
e. Radiologist will
intermittently fluoro and take spots as contrast is cautiously hand-injected
via the rectum.
f. The entire colon should be filled.
g. In the presence of meconium plug, a
long filling defect will be identified in the relatively more
narrow descending colon and rectum.
h. Evacuation generally results in passage
of the plug. If not, repeat filling of
the colon should be done.
I. Suspicion of Meconium Ileus: Aqueous Contrast Enema
1. No preparation
2. Materials:
a. Chux layered
under patient's buttocks
b. Foley catheter or feeding tube - check
type and size with radiologist
c. Extension tubing and connector
d. Contrast - CystografinDilute
or Gastrografin 1/2 strength. Check with
referring physician regarding infant's electrolyte status.
3. Shield table
4. Procedure:
a. Immobilize patient if necessary
b. Take AP and lateral scout films (to
include rectum)
c. Show scout films and request to
radiologist
d. Radiologist will insert Foley catheter
or feeding tube into rectum and tape buttocks firmly together
e. Radiologist will
intermittently fluoro and take spots as contrast is cautiously hand-injected
retrograde via the rectum.
f. Attempt is made to fill entire colon
and distal small bowel.
g. In the presence of meconium ileus, the
caliber of the colon will be reduced and small filling defects are noted in the
distal small bowel.
h. Cautiously fill the more dilated
proximal small bowel loops in order to enhance evacuation of the inspissated
meconium.
i. Infant may not evacuate contrast
immediately and procedure may be repeated 2 more times during the next 24 hours
if clinically indicated.
Pediatric Urinary Tract
Studies
A. Nephrostogram
1. No preparation
2. Contrast: Cystografin Dilute
3. Materials:
a. Chux layered
under patient’s buttocks
b. Cystografin
Dilute
c. Tru-Flo
IV set
d. Straight connector/Luer
lock female
e. Foot board at table's end
4. Shield table
5. Procedure:
a. Gown patient; immobilize if necessary.
b. Take AP scout film of abdomen
c. Show scout and request to radiologist
doing fluoro
d. Radiologist will connect and run
contrast into patient's nephrostomy tube from a
height no greater than 6 inches above that of the anterior abdomen, and take
spot films as needed
e. Overhead films as requested by
radiologist
B. Retrograde Urethrogram
1. No preparation
2. Contrast: Cystografin
Dilute
3. Materials:
a. Chux layered
under patient's buttocks
b. Cystografin
Dilute
c. Foley catheter size specified by
radiologist
d. 5 cc empty syringe to inflate Foley
balloon
e. Extension tubing
f. 50 cc syringes to fit tubing
g. Sterile gloves
h. Betadine prep solution
i. Sterile gauze
4. Shield table
5. Procedure:
a. Gown patient; immobilize if necessary.
b. Take AP scout film of abdomen
c. Show scout and request to radiologist
d. Radiologist inserts Foley into urethra
and gently partially inflates balloon
e. Radiologist attaches Foley to extension
tubing which is connected to syringe of Cystografin
Dilute (be sure that contrast is flushed through to the end of the tubing
before attaching to Foley)
f. Radiologist injects contrast while
obtaining spot films of urethra
g. Radiologist may request overhead films
C. Excretory Urogram (EU) / Intravenous Pyelogram (IVP)
1. Preparation:
a. Encourage extra clear liquids for all
children for 24 hours before exam
b. No solid food on day of exam
c. Patient can have clear liquids until 2 hours
prior to exam, then NPO 2 hours prior to exam.
d. Evening before exam take Milk of
Magnesia:
Newborn
to 2 years: no prep
2-5
years: 2
teaspoons
5-10
years: 1
tablespoon
10
and up: 2
tablespoons
e. IV placement
2. Contrast:
a. Contrast Agent Data Form is
filled out by the technologist at the time of every study. The radiologist shall review the patient
request, records (if available) and the Data Form, and will also question the
patient or adult accompanying child as to allergic and other pertinent medical
history.
b. Isovue
300: for patients NB to 14 years of age.
c. Renografin
60 or Isovue 300:
for patients aged 14 years and older, according to ACR criteria.
d. Guidelines for Use of Non-Ionic
Contrast Material
i. Policy: The type and amount of intravenous contrast
material will be selected by the responsible radiologist, according to the
Procedure outlined below.
ii. Procedure:
Note: Because of the
lack of an acute care hospital in close proximity to Einstein Elkins Park
Radiology (EPRA) and Einstein Center One
Radiology (CORA), non-ionic intravenous
contrast material will be used exclusively at these out-patient centers and at
Germantown Community Health Services (GCHS).
a. Patients
with a history of a significant reaction to contrast material.
b. Patients
with a history of asthma or allergy.
c. Patients
with known cardiac dysfunction, including:
¨
recent or
potentially imminent cardiac decompensation
¨
severe
arrhythmia
¨
unstable angina
¨
recent myocardial
infarction
¨
pulmonary
hypertension
d. Patients
with generalized severe debilitation.
e. Any
other circumstances where, after due consideration, the radiologist believes
there is a specific indication for the use of non-ionic contrast agents. Examples of this include but are not
restricted to:
¨
sickle cell
disease
¨
patients at
increased risk for aspiration (such as those in body casts or traction devices)
¨
patients who
are manifestly very anxious about the contrast procedure
¨
patients with
whom communication cannot be established in order to determine the presence or
absence of risk factor
¨
patients who
request or demand the use of non-ionic contrast agents
3. Materials:
a. Contrast material as instructed by
radiologist
b. Syringes for Renografin
60 (should use 20 cc - easier on veins when pushing bolus of contrast)
c. Butterfly needles (21g & 23g are
most commonly used; have 25 g available as well; check g with radiologist)
d. Tape
e. Arm board
f. Topper sponges
g. Band-aids
h. Emesis basin on table
i. May use heat packs for hard to find
veins
4. Procedure:
a. Gown the patient and ask patient when
last meal was eaten
b. Instruct the patient to void
c. Record patient's weight on the request
d. Take AP scout film of abdomen (if
patient had VCUG scout film is not necessary, however, consult with
radiographer who performed VCUG for technique factors used)
e. Show request, scout film and/or
post-void film from VCUG to radiologist
f. The radiologist authorizes the type
and amount of contrast material to be drawn up according to the following
dosage schedule:
|
Pediatric Dosage Schedule |
|
|
Isovue 300 |
1 cc per pound 2 cc per kilogram (to a maximum of 100 cc) |
|
Renografin 60 |
1 cc per pound 2 cc per kilogram (to a maximum of 100 cc) |
Note: Record type of contrast and number of cc used on
request.
g. Do
not remove the needle until the examination is completed and the radiologist
approves the removal.
Note: After 3 injection attempts without success,
contact the pediatric resident.
h. Immediately after injection is
completed take a supine one minute film coned to the kidneys - this nephrogram is extremely important
Note: After the injection of contrast there is a
possibility of the patient having a reaction, therefore, it is important that
someone from radiology staff stay with the patient until the 5 minute film is
taken
i. Show the 1 minute film to the
radiologist
j. Radiologist will usually give
instructions to perform another supine coned kidney film at 5 minutes after the
injection time
k. Show the 5 minute film to the
radiologist who will likely instruct you to perform a PA 15 minute KUB film;
the radiologist may also request oblique or other additional films at this time
l. Show the 15 minute film to radiologist
and ask if any additional films are necessary (e.g., may need delayed or
post-void films)
Attached:
¨
Contrast Agent Data Form
¨
Alphabetical Drug List
¨
ABCD Approach for Patient Evaluation and Treatment
¨
Iodinated Contrast Media: Categories of Reactions
D. Emergency IVP Protocol for Trauma Patients Through
ER
1. No preparation
2. Contrast:
a. Isovue 300:
for patients NB to 14 years
b. Renografin
60 or Isovue 300: 14-18 year olds according to ACR
criteria
3. Materials:
a. Contrast material as instructed by
radiologist
b. Syringes for IV contrast (should use 20
cc - easier on veins when pushing through bolus of contrast; use 50 cc syringe when larger volume indicated)
c. Butterfly needles (21g & 23g are
most commonly used; have 25 g available as well; check g
with radiologist)
d. Tape
e. Arm board
f. Topper sponges
g. Band-aids
h. Emesis basin on table
3. Procedure:
a. Call the radiologist on call and give
all clinical information
b. Record patient's weight on request
c. Instruct patient to void, if possible.
d. Take AP scout film of abdomen
e. Show scout and request to radiology
resident on call
f. Draw up contrast material according to
the following dosage schedule:
|
Pediatric Dosage Schedule |
|
|
Isovue 300 |
1 cc per pound 2 cc per kilogram (to a maximum of 100 cc) |
|
Renografin 60 |
1 cc per pound 2 cc per kilogram (to a maximum of 100 cc) |
Note: Record type of contrast and number of cc used on
request.
g. Take the following films after
injection:
¨
1 minute AP of kidneys
¨
2 minute AP of full abdomen
¨
5 minute AP of kidneys
¨
10 minute oblique films of full abdomen
¨
15 minute AP of full abdomen
h. Show all films to radiology resident on
call after each film is completed; he/she will make any recommendations if
needed
Miscellaneous Pediatric
Fluoroscopic Procedures
A. Fistulagram
1. No preparation
2. Materials:
a. Chux layered
under patient’s buttocks; additional chux as needed
to cover patient
b. Water soluble contrast (Cystografin Dilute)
c. Syringes 50 cc
d. Foley catheter or feeding tube
e. 5 cc empty syringe to inflate Foley
balloon
f. Extension tubing
g. Topper sponges
h. Tape
i. Gloves
j. Sterile blade to shorten feeding tube,
if necessary
3. Shield table
4. Procedure:
a. Gown patient; immobilize if necessary.
b. Take AP scout film of area of fistula
c. Show scout film and request to
radiologist doing fluoro
d. Radiologist will select catheter and
insert it into fistula
e. Extension tubing hooked to syringes
after flushing with contrast
f. The catheter will be taped in place
g. Radiologist will inject contrast and
take spot fluoro films
h. After fluoro, radiologist will request
overhead films if needed
B. Pharyngeal
Airway Study
1. Preparation: NPO for 2 hours prior to
exam
2. Materials:
a. 1 cup heavy
density barium
b. Tissues
c. Basin
d. Nose dropper
e. Video Machine
3. Shield table
4. Procedure:
a. Gown patient; immobilize if necessary.
b. Mix one cup of barium
c. Show request to radiologist doing
fluoro and summon speech therapist
d. Ready video machine for taping video
and audio
e. Radiologist will begin study by
dropping one ml of barium into each nostril and having the patient sniff
f. Radiologist will place patient in
erect, lateral position
g. Speech therapist will then give the
patient sentences to repeat while fluoroing and
taping
h. Patient will then be placed in AP
position for the same enunciations
i. Patient will then be placed in base
position for the same enunciations
Note: Be sure to record the patient's information
in the video log book being careful to note the tape ID letter and amount of
tape used. Log book has two portions of
records.
C. Vaginogram
1. Materials:
a. Chux layered
under patient’s buttocks
b. Cystografin
Dilute
c. Syringes (50 cc)
d. Foley catheter or feeding tube; size
determined by radiologist
e. 5 cc empty syringe to inflate Foley
balloon
f. Extension tubing
g. Topper sponges
h. Tape
i. Gloves
j. Sterile blade to shorten feeding tube,
if necessary
2. Shield
table
3. Procedure:
a. Gown patient; immobilize if necessary.
b. Take AP scout film of area of fistula
c. Show scout film and request to
radiologist doing fluoro
d. Radiologist will insert catheter into
fistula and inflate balloon
e. Extension tubing attached to syringes
should be flushed through and then connected to Foley catheter or feeding tube
f. The catheter will be taped in place
g. Radiologist will inject contrast and
take spot fluoro films
h. After fluoro, radiologist will request
overhead films if needed
D. Arthogram (Hip) - Performed in radiology
department by orthopedic surgeon with fluoro assistance by radiology department
1. Preparation: NPO and sedation to be
given by anesthesiologist, when indicated
2. Materials:
a. Arthrogram
tray
b. #20 spinal
needle (two for both hips)
c. Renografin 60
d. Epinephrine
e. Lidocaine
f. Sterile drape with aperture
g. Sterile towels
h. Betadine prep solution
i. 2 10 cc syringes
j. Extension tubing
k. Sterile gloves
l. 3-way Stoplock
m. Tape
n. Bandaids
3. Shield table
4. Procedure will be requested by the
orthopedic surgeon
Note: Anesthesia may
be requested for this study!!
Note: During fluoro of any arthrogram
study, the radiographer may be required to record the name of the views as they
are being filmed. Have a pen and paper
on hand!!
VCUG - Voiding Cystourethrogram
A. Cyclic Voiding Cystourethrogram
(VCUG)
1. No preparation
2. Contrast: Cystografin
Dilute: 300 cc bottle
3. Materials:
a. Chux layered
under patient's buttocks
b. Cystografin Dilute: 300 cc bottle
c. Intravenous Solution Administration Set
d. Urinary catheterization tray (sterile)
e. Catheter: use feeding tube unless Foley
is required, size to be indicated by radiologist
f. KY jelly, preferably xylocaine jelly
g. Tape
4. Shield table
B. Catheterization
1. Use sterile technique to catheterize
the bladder and tape catheter to inner thigh.
Note: Foreskin should be retracted to ensure sterile technique. Foreskin may be impossible to retract in
babies with a tight phimosis. In that
case, cleanse the external genitalia and perform a "blind"
catheterization.
2. Catheter selection based on size of
patient (5-12 F).
3. Attach tubing from bottle of Cystografin Dilute (300 cc, 50% dilution) to catheter.
4. Wrap Chux
around patient as one would a diaper.
C. Procedure:
1. Obtain
KUB
2. Catheterize
bladder as per technique described above (B.1-4)
3. During fluoroscopic observation, check
the position of the catheter by allowing the gravity drip to flow slowly. Then proceed as follows:
4. In females:
a. With the
patient in a straight lateral position with the bladder minimally filled, check
for a filling defect that may indicate a
ureterocele. If present, obtain spot
film.
b. Obtain supine
AP view of filled bladder. Note that the toes begin to curl when the bladder capacity limit is
approaching.
c. Obtain both
obliques (45 degrees) of region of each uretero-vesical
junction and ipsilateral retroperitoneum during maximum bladder capacity.
d. As
micturition begins, obtain images of the urethra with the catheter in place
and, ideally, simultaneous images of each uretero-vesical
junction and ipsilateral retroperitoneum during voiding. If the patient is too large for simultaneous
images of urethra and area of ureters, obtain both obliques of retroperitoneum
during voiding as well as images of urethra.
e. Obtain postvoid AP supine view fluoroscopically in infants and
with KUB in children who are too large for fluoroscopic inclusion of entire
abdomen and pelvis.
f. Remove
catheter. Note the
bladder capacity by observing the amount of contrast left in bottle and
indicate on the requisition the type of contrast and amount used to achieve
bladder capacity.
5. In males:
a. Proceed as in (B) and (C. 3, 4
a-d). Note the
bladder capacity.
b. Refill the bladder to capacity.
c. As the patient begins to void, remove
the catheter and obtain films of the urethra in one or both oblique positions.
d. Obtain postvoid
AP supine films.