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Technique for Fluoroscopic Air Enema

Once the presence of an intussusception has been confirmed by ultrasound, the child is taken to the flu oroscopy room. Some centers administer pain relief and/or sedation in anticipation of the procedure, but this is by no means universal and there is some evidence that the use of sedation (or the use of smooth muscle relaxants) may prevent the patient from performing the Valsalva manoeuvre which might otherwise enhance the chance of reduction and possibly reduce the chance of perforation. Children should be well resuscitated before attempted reduction, and should be monitored whilst the attempted reduction is in progress. This is particularly important in children who have received sedation as signs of clinical deterioration may not be so apparent.

A balloon catheter is placed per rectum (10 F-18 F). Many operators inflate the balloon on the Foley catheter but this is not universal practice and caution should be used when inflating a balloon catheter in the rectum because of the reported risk of mucosal ischaemia. The buttocks are subsequently taped or gripped firmly to complete a good seal at the anus. Air is then introduced into the distal colon, with a manometer or other monitoring device present on the system to ensure safe and constant pressures of air. The progress of the air (and the reduction of the intussusceptum) is closely observed under fluoroscopic guidance (Fig. 6.8a). It is usual practice to include the whole abdomen within the field of view so as not to miss a perfora

Fig. 6.8a,b. Appearance of intussusception during reduction by air enema. a The soft tissue mass of the intussusception can be seen in the right flank and the remainder of the large bowel is distended by air. Air has not yet flooded back into the small bowel, which would indicate successful reduction. b Air enema in a different patient: the intussusception is shown as a soft tissue mass but perforation of the bowel has occurred

Fig. 6.8a,b. Appearance of intussusception during reduction by air enema. a The soft tissue mass of the intussusception can be seen in the right flank and the remainder of the large bowel is distended by air. Air has not yet flooded back into the small bowel, which would indicate successful reduction. b Air enema in a different patient: the intussusception is shown as a soft tissue mass but perforation of the bowel has occurred tion, which would necessitate the immediate termination of the procedure (Fig. 6.8b). In the case of a tension pneumoperitoneum an 18-G needle should immediately be positioned in the midline to relieve the abdominal distension, thereby preventing respiratory collapse. Typically the pressure is raised to 80 mm of mercury equivalent and sustained at this level for approximately 3 min. This may then be repeated either at the same pressure, or at 100 mm of mercury or 120 mm of mercury until reduction is complete. Typically three attempts of 3 min each are made at each pressure. The whole procedure may be performed with the infant supine or prone at the operator's discretion and preference. Advantages for the supine position include being able to observe the child more closely and for a normally orientated radiographic view. Advantages for the prone position include it being easier to obtain a complete seal on the child's buttocks if these are uppermost.

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