Fluoroscopy-guided insertion of nasojejunal tubes in children - setting local diagnostic reference levels

Age-specific and gender-specific radiation risks in paediatric angiography and interventional cardiology: conversion coefficients and risk reference values

OBJECTIVES

To estimate risk for exposure-induced cancer death (REID), organ-specific risks of exposure-induced cancer death (REIDHT) and associated conversion coefficients (CCREID:KAP=REID/kerma-area product (KAP), CCREIDHT:KAP=REIDHT/KAP) in paediatric cardiac catheterizations using data from radiation dose structured reports (RDSR). A novel risk surveillance tool consisting of age-specific and gender-specific risk reference values (RRVs) related to population cancer risk is suggested.

METHODS

The PCXMC v.2.0 code is used together with exposure-related information from RDSR from a cohort of 238 children to assess cancer risks and related conversion coefficients. The KAP corresponding to 1 in 1000 of increased REID is used to define age-specific and gender-specific KAP values to monitor risk in such patient cohorts, here denoted as RRVs.

RESULTS

The REID estimates ranged from below 1 up to 300 in 100,000, and the RRVs for the different age groups and gender ranged from 0.77 Gycm2 and 2.1 Gycm2 for neonates (female, male) to 11 Gycm2 and 25 Gycm2 for 15-year-olds (female, male). The CCREID:KAP and CCREIDHT:KAP decreased biexponentially with increased age, being notably higher for female patients.

CONCLUSIONS

Prominent risk contributing organs were the lungs and the (female) breast. The concept of age-specific and gender-specific RRVs related to population cancer risk is introduced and is intended to be used as a supporting tool for physicians performing such interventions.

ADVANCES IN KNOWLEDGE

Age-related and gender-related conversion coefficients for radiation risk, CCREID:KAP and CCREIDHT:KAP, are introduced and a novel risk surveillance concept, the RRV, is suggested for paediatric cardiac catheterizations.

Nasojejunal tube feeding in children: knowledge and practice

Nasojejunal tubes (NJ) are used in small numbers of children outside of neonatal and paediatric intensive care units. There is limited evidence on which to base practice aside from insertion techniques. Ongoing care and management is largely based on historical practice and extrapolation from nasogastric tube practice. This paper presents the historical caseload data for 36 babies and children over a five year period. The children ranged from 0 to 13 years of age, and 95% were less than 2 years old. They had a median of 4 tubes each (range 1 - 46). The paper presents data from two surveys of health professionals that demonstrate a lack of consistency in practice. There are concerns about ongoing position checks and about the radiation burden in these children. Local practice is described that aims to reduce dependence on x-ray procedures and to stimulate debate. Finally, an argument is made for a better evidence base for future practice.

Effects of Mechanical Complications on Radiation Exposure During Fluoroscopically Guided Gastrojejunostomy Exchange in the Pediatric Population

The purpose of the article is to evaluate the effects of mechanical complications, such as clogging or coiling, of gastrojejunostomy tubes on radiation exposure during exchange in the pediatric population. In this HIPAA-compliant and IRB-approved study, we retrospectively reviewed procedural records for patients undergoing gastrojejunostomy (GJ) tube exchange during a 4-month period in 2014. Success of the procedure, specifications of the tube, age, and sex of the patient as well as radiation exposure during the procedure were included. Radiation exposure was measured in fluoroscopy time and cumulative air kerma. Complications encountered during exchange were also recorded, if available. Patients presenting for gastrostomy to GJ conversions or combined procedures were excluded from the study. Ordinary and mixed effect linear regression models were used to test associations between GJ tube parameters, presence of mechanical complications, and fluoroscopy time and radiation dose. 146 patients undergoing 285 GJ exchanges met inclusion criteria over the 4-month study period (M:F 82:64). All exchanges were successful with 85 demonstrating a form of mechanical complication (44 coiled, 41 clogged). Of the reported GJ tube specifications, only tube length was significantly associated with mechanical complications (p < 0.001). The presence of mechanical complication was significantly associated with increased radiation exposure and fluoroscopy time (p < 0.0001). Mechanical complications of gastrojejunostomy tubes, such as clogging or coiling, are associated with increased radiation exposure during exchange. Strategies to decrease these complications, including re-siting the gastrostomy tract or placement of a surgical jejunostomy in the event of repeated coiling of a tube should be strongly considered.

Retrospective Review of Current Nasojejunal Tube Insertion Practice

Repeated fluoroscopically guided nasojejunal tube (NJT) insertions, particularly in children, can pose health risks through increased radiation exposure. We analyzed frequency of NJT reinsertions and associated radiation exposure through retrospective evaluation of children <18 years at our institution who underwent fluoroscopically guided NJT insertions from 2007 to 2012. Age and weight, reinsertion frequency per patient, radiation dose (dose actual percentage [DAP]), time interval between, and indication for reinsertion were recorded. A total of 252 children (3 days to17 years, 11 months) had 449 NJT insertions. Reinsertions occurred in 105 (41.7%) patients with 14 (5.6%) having ≥5 reinsertions, and 67.6% of reinsertions occurring in patients <1 year. Mean DAP increased with frequency of reinsertion, along with age and weight. Most common indication for reinsertion was a pulled NJT (34.0%). Fluoroscopic NJT reinsertion was most frequent in younger, smaller patients. Self-guided, bedside NJT insertion, and/or earlier instigation of definitive nutritional therapy delivery should be considered.

Frequency and methods of gastrojejunal tube replacement in children

Gastrojejunal (GJ) tubes are increasingly used for enteral feeding in children in whom gastric feeding either is not tolerated or is contraindicated. The most common complications associated with GJ tube use are mechanical failure (clogging, cracking, deterioration) and dislodgement. Less common, but more significant, complications are bowel perforation, aspiration, and feeding intolerance. Some of these complications may be prevented by replacing GJ tubes at regular intervals. Methods to direct a GJ tube include 1) guidewire, 2) gastroduodenoscopy-guidewire, 3) esophagogastroduodenoscopy-forceps, and 4) fluoroscopy-guidewire. Clinical experience to determine the ideal method and optimal timing of GJ tube replacement is evolving. GJ tube replacement using a guidewire through the prior GJ tube, without endoscopy, fluoroscopy, or sedation, is the least risky method, but is also the least likely to be successful.