Interventional Radiology for Improved Outcomes in the Neonatal Period

Interventional Radiology for Improved Outcomes in the Neonatal Period Mark J. Hogan, MD Nationwide Children s Hospital The Ohio State University mark.hogan@nationwidechildrens.org

No financial disclosures Lots of FDA off-label uses

Interventional Radiology Basically, using imaging to do a diagnostic or therapeutic procedure. Fluoroscopy Ultrasound CT, MR, and others less common

Interventional Radiology Improved outcomes and IR It was the driving factor for IR to be created! Continuous innovation Fewer complications Better or equivalent results

Interventional Radiology and Neonatal Care Vascular Access GI Access Other GI issues Drainage procedures Lumbar puncture Biliary disease Biopsy Chest interventions Angiography and treatments GU

Vascular Access Types of devices PICC s Tunneled catheters Totally implanted port devices

Vascular Access When is IR needed? Failed attempt at placement Higher risk patients Specific indications (Dialysis, etc)

Vascular Access How does IR help? Ultrasound guidance: The vein gets punctured Fluoroscopic guidance: The catheter gets into the right spot Can make a diagnosis if a problem is encountered

Vascular Access

Shortcomings Equipment limitations Small introducers are too short to easily see with ultrasound Larger introducers are too long

Shortcomings Equipment limitations Ultrasound probes are large WRT premmies

Infection Prevention CDC Guidelines To reduce catheter related infections August 2002 CCH Vascular Access Task Force, 2003-present Evaluate all aspects of vascular access

NCH Actions Related to CVL Insertion All CVL s will be placed with OR protocol Hand Hygiene: Surgical scrub Barriers Skin antisepsis: Chlorhexidine 2% Dressing: Transparent, semipermeable Biopatch Insertion Bundles

GI Access Percutaneous gastrostomy Feeding tube maintenance

GI Access Primary gastrostomy Open surgical placement Endoscopic placement (PEG) Image guided placement Uses ultrasound to identify solid organs Barium allows visualization of the colon Immediate conversion to GJ Easier conversion to GJ

GI Access

G and GJ tube Replacement GJ replacement Tubes can be sticky May need lubricant (Water soluble or Pam)

GI Dilation Stenoses of esophagus after repair for TEF Colonic stenoses from NEC or post op

GI Dilation

Drainage Procedures Basically in any organ system or body area Abdominal Chest/pleural Extremities Head and neck May be definitive care (Avoids surgery)

Drainage Procedures

Lumbar Puncture Show if fluid is present Guides and confirms needle placement Infants with incomplete ossification

Lumbar Puncture: Gravity Effect

Biliary Interventions Neonatal Jaundice DDX Biliary atresia Neonatal hepatitis Bile plug syndrome Conventional treatment Watch and hope it goes away If it persists, NM to see if there is bile excretion If no definite bile excretion, surgery with open cholangiogram and biopsy

Biliary Interventions Alternative Percutaneous cholecystogram Percutaneous biopsy

Biliary Interventions

Biopsy Liver biopsies Tumor biopsies Alternative is surgical biopsy

Biopsy

Angiography Rarely indicated Roles Make diagnosis Open up a blood vessel (Lysis or plasty) Close a blood vessel (Embolization)

Angiography

Genitourinary Urinary diversions for obstruction Nephrostomy/stents UPJ UVJ PUV Suprapubic drainage catheters PUV Urethral injury

Genitourinary

Summary IR techniques can be used to improve outcomes in neonates Almost any organ system can be treated Innovation still needed