Distress and radiological investigations of the urinary tract in children

10 Years of Antenatal Hydronephrosis Experience: Comparing Two Different Guidelines

BACKGROUND

Antenatal hydronephrosis refers to the dilation of the renal pelvis and/or calyces in the developing fetus. The challenge lies in distinguishing between cases that warrant long-term follow-up or surgical intervention and those with transient hydronephrosis that require minimal invasive investigations.

MATERIALS AND METHODS

Our study aimed to assess and contrast the efficacy of the 2015 Congenital Anomalies of Kidney and Urinary Tract Guideline from the Turkish Society of Pediatric Nephrology with the Tepecik Antenatal Hydronephrosis Guideline, which was previously employed in our hospital. We conducted a comparative analysis of demographic data, outcome conditions, additional imaging requirements and quantities, radiation exposures, and rates of surgical interventions between two groups.

RESULTS

Group 2 had a significantly higher detection rate of Vesicoureteral Reflux via voiding cystourethrogram at 38.5% compared to Group 1's 13.4% (p<0.01). The incidence of abnormal findings with dimercaptosuccinic acid was similar between Group 1 (28.5%) and Group 2 (26.4%) (p>0.01), but Group 2 had a higher rate of obstruction diagnosis at 68.8% versus Group 1's 29.4% (p<0.01). Group 1 had greater median radiation exposure (500 mrem vs. 200 mrem, p<0.01), and a higher proportion of patients underwent surgery (34.2% vs. 21.9%, p<0.01).

CONCLUSION

This study showed that the new guideline required fewer tests, was less invasive, and exposed patients to less radiation than the old guideline.

Intra-operative Urodynamics: Is the Test an Accurate Representation of the Lower Urinary Tract in Children?

OBJECTIVE

To compare intraoperative UDS results with UDS in the postoperative care unit (PACU) to assess the accuracy and efficacy of intraoperative UDS in children who cannot tolerate ambulatory urodynamic evaluation.

METHODS

Pediatric patients undergoing intraoperative UDS at a single institution were enrolled over a 5-year time period (1/2013-8/2018). Urodynamics were performed in the operating room under general anesthesia, then in the PACU after recovery from anesthesia. Electromyographic (EMG) activity during filling, bladder compliance, cystometric bladder capacity (CBC), detrusor overactivity, presence of urinary leak, leak point pressure (LPP), and pressure specific volumes (PSV) at 10, 20, 30, and 40 cm water were compared between studies.

RESULTS

Nineteen patients underwent urodynamic evaluation under general anesthesia and met inclusion criteria. Ten patients (52.6%) underwent 2 filling cycles while awake in PACU, resulting in a total of 48 urodynamic studies available for subsequent analysis. Intraoperative urodynamic studies were more likely to have decreased EMG activity during filling (P=<.01), normal compliance (P <.01), and a lower detrusor LPP (P = .03) compared to UDS performed after recovery from anesthesia. Detrusor overactivity was less frequently observed intraoperatively (P <.001) and involuntary detrusor contractions were lower in magnitude than those observed in the PACU. Twelve of the 19 (63%) children had detrusor overactivity that was present only on the UDS in PACU and not intra-operatively.

CONCLUSIONS

The results of urodynamic testing performed under general anesthesia should be interpreted with caution, as pediatric patients appear to have improved bladder compliance, lower detrusor LPP and decreased detrusor overactivity when under anesthesia. For this reason, it is preferable to utilize ambulatory urodynamic evaluation to guide patient management and treatment.

The accuracy of cystography under general anesthesia in children with vesicoureteral reflux

PURPOSE

To examine the accuracy of cystography under general anesthesia in children with vesicoureteral reflux (VUR).

MATERIALS AND METHODS

A prospective study of children who had VUR on cystography without general anesthesia (i.e., the gold-standard), and who are candidates for endoscopic VUR repair surgery. All children subsequently underwent a cystography under general anesthesia before injection using standardized method, which was compared to the gold-standard cystography. χ² and Mann-Whitney U tests were used to compare proportions and medians between groups.

RESULTS

Between 2017 and 2021, 126 renal units in 13 boys and 50 girls were included. Median age was 3.4 years (interquartile range [IQR] 1.5-6.5). Median time from cystography without to cystography with general anesthesia was 3.8 months (IQR 2.7-6). Of the 126 renal units, 96 had VUR on cystography without general anesthesia. On dichotomous analysis (no VUR vs. any VUR) sensitivity, specificity, negative and positive predictive values of cystography under general anesthesia were 47% (45/96), 87% (26/30), 34% (26/77) and 92% (45/49), respectively. Accuracy was 56.3%; Cohen's Kappa coefficient was 0.22, indicating poor agreement. In subgroup analysis, the sensitivity of cystography under general anesthesia was significantly lower in primary VUR (20% vs. 55% in secondary VUR, p = 0.01) and active VUR (14% vs. 52% in passive VUR, p = 0.008).

CONCLUSION

Cystography under general anesthesia was poorly correlated to cystography performed while the child was awake or lightly sedated. Clinical decision relying on this cystography is questionable.

Urinary Tract Infection in Children

Symptoms of urinary tract infection (UTI) in young children are nonspecific and urine sampling is challenging. A safe and rapid diagnosis of UTI can be achieved with new biomarkers and culture of clean-catch urine, reserving catheterization or suprapubic aspiration for severely ill infants. Most guidelines recommend ultrasound assessment and use of risk factors to direct further management of children at risk of kidney deterioration. The increasing knowledge of the innate immune system will add new predictors and treatment strategies to the management of UTI in children. Long-term outcome is good for the majority, but individuals with severe scarring can develop hypertension and decline in kidney function.

Sedation Rate Reduction in Paediatric Renal Nuclear Medicine Examinations: Consequences of a Targeted Audit

Background: Nuclear medicine investigations are essential diagnostic tools in paediatric urology. Child-orientated examination techniques and the avoidance of sedation or anaesthesia vary in different institutions. We aimed at evaluating child friendly measures in our department to identify the potential for improvement. Based on these data, we changed the standards regarding the sedation policy and consequently re-evaluated sedation rates. Methods: Four-hundred thirty-five consecutive investigations were evaluated regarding the need for sedation, outcome and patient satisfaction at our department. After the revision of our department standards, we re-evaluated 159 examinations. Statistical analysis was performed with JUMBO (Java-supported Münsterian biometrical platform). Results: Eighty-six percent (60/70) would agree to perform an investigation under identical conditions again. Seventy-seven percent (17/22) of eligible patients >5 years of age felt good during the investigation. By changing our sedation policy, we could reduce the sedation rate from 27.1% to 7.5% (p < 0.0001; OR 0.219 95% CI 0.111–0.423). Conclusion: The evaluation of child friendly examination protocols demonstrated high reliability and patient satisfaction using situational sedation with a relatively high proportion of patients being sedated. Through protocol adaption with clear age limits, individual indication and education of staff, as well as the use of optimized sedatives, the need for sedation could be further reduced whilst maintaining a high patient satisfaction.

Urinary Imaging Findings in Young Infants With Bacteremic Urinary Tract Infection

OBJECTIVES

To describe renal ultrasound (RUS) and voiding cystourethrogram (VCUG) findings and determine predictors of abnormal imaging in young infants with bacteremic urinary tract infection (UTI).

METHODS

We used retrospective data from a multicenter sample of infants younger than 3 months with bacteremic UTI, defined as the same pathogenic organism in blood and urine. Infants were excluded if they had any major comorbidities, known urologic abnormalities at time of presentation, required intensive unit care, or had no imaging performed. Imaging results as stated in the radiology reports were categorized by a pediatric urologist.

RESULTS

Of the 276 infants, 19 were excluded. Of the remaining 257 infants, 254 underwent a RUS and 224 underwent a VCUG. Fifty-five percent had ≥1 RUS abnormalities. Thirty-four percent had ≥1 VCUG abnormalities, including vesicoureteral reflux (VUR, 27%), duplication (1.3%), and infravesicular abnormality (0.9%). Age <1 month, male sex, and non-Escherichia coli organism predicted an abnormal RUS, but only non-E coli organism predicted an abnormal VCUG. Seventeen of 96 infants (17.7%) with a normal RUS had an abnormal VCUG: 15 with VUR (Grade I-III = 13, Grade IV = 2), 2 with elevated postvoid residual, and 1 with infravesical abnormality.

CONCLUSIONS

Although RUS and VCUG abnormalities were common in this cohort, the frequency and severity were similar to previous studies of infants with UTIs in general. Our findings do not support special consideration of bacteremia in imaging decisions for otherwise well-appearing young infants with UTI.

Evaluation of the effects of sedation administered via three different routes on the procedure, child and parent satisfaction during cystometry

Purpose

In this study, we retrospectively investigated case reports with and without midazolam administration via oral, intranasal and rectal before cystometry procedure. We aimed to compare the data to evaluate the effects of sedation before cystometry on the pediatric patients and parents’ satisfaction.

Methods

A total of 124 ASA I-II pediatric cases aged 5–14 years were retrospectively investigated from the hospital records. One of the three administration routes was chosen; oral midazolam at a dose of 0.5 mg/kg and nasal or rectal midazolam at a dose of 0.3 mg/kg (maximum 15 mg). Heart rate, blood pressure, oxygen saturation, the Wisconsin Hospital of Children Sedation Scale (CHWSS) score and the Groningen Distress Rating Scale (GDRS) score were recorded. Cystometry measurement values, diagnoses of the cases and procedure durations were recorded from the urodynamic laboratory records.

Results

80 female, 44 male cases were evaluated. The CHWSS score at the 10th and 20th minutes after the drug administeration was higher in the oral group than the others (p = 0.001). The duration between the administration of the drug and the start of the procedure was shorter in the nasal group (p = 0.01). Parents satisfaction for sedation was 77 % when comparison of the cystometry with and without sedation. Comparison of the cystometry results with or without sedation no significant difference was found between all parameters (p > 0.01).

Conclusion

We believe that sedation with midazolam administered through all three routes is a safe, effective and convenient option during cystometry, especially in the young age group.

Children’s anxious reactions to an invasive medical procedure: The role of medical and non-medical fears

This study investigated the relationship of medical and non-medical fears to children’s anxiety, pain, and distress during an invasive medical procedure, the voiding cystourethrogram. Parents of 34 children completed the Fear Survey Schedule-II prior to their child’s procedure. Child distress behaviors during the procedure were audiotaped and coded using the Child–Adult Medical Procedure Interaction Scale-Revised. Ratings of child procedural anxiety and pain were obtained from children, parents, and examining technologists within minutes following the procedure. Associations were observed between medical fears, procedural anxiety (parent and staff reports), and coded distress behaviors. Findings may inform preparation efforts to reduce anxiety around invasive medical procedures.

Distress experienced during pediatric VCUGs - a granular, prospective assessment using the brief behavioral distress scale

BACKGROUND

In spite of decades of experience with the procedure, controversy persists as to the overall distress experienced by children and the routine need for sedation in children undergoing voiding cystourethrograms (VCUG). Many studies have attempted to address these issues, often divided into one camp that champions routine sedation while another group believes that pretest preparation is often all that is needed. At the root of these issues are some of the limitations of previous studies as most incorporate inherently subjective parental questionnaires to determine distress levels rather than using an objective, unbiased observer.

OBJECTIVE

The objective of this study is to use a validated and reliable tool (the brief behavioral distress scale) to objectively evaluate the distress experienced during VCUGs.

MATERIALS AND METHODS

A prospective study of 26 children (ages 3-7 years old) was performed by the pediatric radiology department at a large urban academic medical center. Patients were evaluated for distress during 12 separate VCUG steps beginning with the patient entering the room and ending with the clothing being replaced at study completion.

RESULTS

Using a general linear model (repeated measures analysis of variance (ANOVA)), significant distress was identified during two phases of the examination, catheter insertion (P-values ranging <0.001-0.19) and the full bladder phase (P-values ranging 0.005-0.043). The mean distress score for catheter insertion (mean: 1.38, standard deviation [SD]: 1.098) was nearly three times higher than the next most distressful step, i.e. full bladder (mean: 0.65, SD: 0.745). Additionally, entering the room was perceived as significantly more distressing than the catheter out (P = 0.016) and clothing replacement phase (P = 0.006).

CONCLUSION

We find that despite there being significantly increased distress during the catheter insertion and full bladder phases, the distress levels during VCUGs are markedly less than in previous reports. Even the most distressful stage, catheterization, was less stressful than previously reported with levels closer to that of minor distress evinced by comfort-seeking behavior from a parent rather than more significant distress resulting in screaming. Our findings corroborate and expand on the conclusion of the effectiveness of pretest preparation and child life specialist involvement.

Vesicoureteric reflux in children

Vesicoureteric reflux is defined as the retrograde passage of urine from the bladder into one or both ureters and often up to the kidneys, and mainly affects babies and infants. In severe cases dilatation of the ureter, renal pelvis, and calyces might be seen. Traditionally it was thought that only a low percentage of children have vesicoureteric reflux, but studies have suggested as many as 25-40% are affected. Guidelines recommend that the number of investigations for vesicoureteric reflux in children who have had a febrile urinary tract infection be reduced, but this approach is controversial. The recommendations also suggest that prophylactic antibiotics and surgery should be avoided in children with non-severe vesicoureteric reflux. In this Seminar I present data on the management of children with vesicoureteric reflux and give suggestions on how to navigate this difficult area.

Efficacy of a cartoon and photograph montage storybook in preparing children for voiding cystourethrogram

BACKGROUND

Undergoing voiding cystourethrogram (VCUG) can be distressing for children.

OBJECTIVE

To assess the efficacy of a cartoon and photograph montage storybook in preparing children for VCUG.

MATERIALS AND METHODS

Outpatient children (ages 2-14 years) who had VCUGs between December 2011 and June 2012 were randomly assigned to two groups; one group received the storybook a week before the procedure. Parents and guardians were asked to complete an anonymous survey rating their child's tolerance of the exam from 1 to 5, worst to best, immediately after VCUG. The VCUG technologist also rated the child's tolerance.

RESULTS

Children prepared for VCUG with the storybook had less distress than those without. Results were analyzed by Cochran-Mantel-Haenszel and Cochran-Armitage Trend exact tests, a P value of both tests of 0.0092 indicating a statistically significant difference between the tolerance scores of children prepared with the storybook and those without. Effects of gender and history of VCUG were not statistically significant. Two-thirds of all children had no other source of information.

CONCLUSION

The cartoon and photograph montage storybook format of preparing children for VCUG was effective in increasing their tolerance for the procedure. The storybook should be mailed out in advance because the majority of families did not pursue information on preparing their children for VCUG.

Comparison of low-dose ketamine to midazolam for sedation during pediatric urodynamic study

INTRODUCTION

Aim of sedation during pediatric urodynamic studies (UDS) is a calm and cooperative child while not affecting measurements. We compared the effectiveness of midazolam to low-dose ketamine infusion for sedation and their impact on urodynamics.

MATERIALS AND METHODS

ASA-I children undergoing UDS were randomly assigned to group K (ketamine) loading dose (0.25 mg·kg(-1)) followed by infusion of 10-20 μg·kg(-1) ·min(-1) or group M (midazolam) loading dose of (0.02 mg·kg(-1)) followed by 1-2 μg·kg(-1) ·min(-1). The sedation scores and reactivity to catheterization were monitored by Children Hospital of Wisconsin Sedation Scale and Frankl Behavior Rating Scale, respectively. The UDS included two-channel filling cystometry in supine position followed by a free uroflowmetry in sitting position. The UDS was performed and interpreted in accordance with good urodynamic practice guidelines of International Continence Society (2002).

RESULTS

A total of 34 children were enrolled. Group K children (n = 17) attained sedation earlier 6.80 (±3.36) min vs. 9.40 (±2.82) min; (P = 0.03) than group M (n = 17) and also recovered earlier 11.60 (±3.13) min vs. 19.67 (±5.49) min (P = 0.01). Reactivity scores during urinary and rectal catheterization were lower in group K (P = 0.03 and 0.01), respectively. Historical UDS data of 21 participants were available for comparison with effect of medication. None of the study drugs affected UDS parameters significantly.

CONCLUSIONS

Midazolam or low-dose ketamine provide satisfactory sedation during pediatric UDS without impacting urodynamic values.

A systematic review of interventions for reducing pain and distress in children undergoing voiding cystourethrography

Voiding cystourethrography (VCUG) is commonly performed to screen for vesicoureteric reflux or other urological anomalies but has a potential to provoke distress in infants and children. We performed a systematic review of randomized controlled trials of interventions to reduce distress, pain or anxiety during VCUG. Eight trials (591 participants) met the inclusion criteria.

CONCLUSION

Conscious sedation with midazolam effectively alleviates the distress of VCUG in children older than 1 year of age. Psychological preparation and warmed contrast medium may also be effective. Nitrous oxide 50% may be an alternative to midazolam, but further evidence is needed.

Evaluation of sevoflurane as an anesthetic agent for voiding cystourethrography in pediatric patients

BACKGROUND

Sevoflurane anesthetic has recently been administered by anesthesiologists during voiding cystourethrograms in a centre where radiologists are not permitted to deliver pediatric sedation.

OBJECTIVE

To determine whether sevoflurane is a satisfactory anesthetic agent for voiding cystourethrography in children.

METHODS

Records of children undergoing voiding cystourethrogram while they were under sevoflurane were reviewed for anesthetic adverse effects and diagnostic quality of the cystourethrogram. The occurrence of on-table voiding and post-void residual bladder volume were documented and compared with an age- and sex-matched control group of children undergoing unsedated voiding cystourethrography. The caregivers were surveyed regarding the anesthetic experience.

RESULTS

A total of 91 children underwent sevoflurane voiding cystourethrography; there were no adverse cardiorespiratory events. Voiding was observed in 96%, with residual bladder volumes minimal in 38%, moderate in 32%, and large in 28% of anesthetized children, not significantly different from the control group. Vesicoureteral reflux was observed in 53% of examinations under sevoflurane. When children with a previous history of reflux or voiding cystourethrography were excluded in a comparison with age- and sex-matched controls, vesicoureteral reflux was observed in 38% of studies under sevoflurane and in 44% of studies in the control group, P = .69; 85% of caregivers of children with prior unsedated voiding cystourethrography found voiding cystourethrography with sevoflurane easier than without sevoflurane; 89% thought the anesthetic experience reduced their child's anxiety towards medical procedures.

CONCLUSION

No adverse events or effects on diagnostic quality of the pediatric voiding cystourethrogram were encountered when using sevoflurane. The majority of surveyed caregivers thought that anesthesia made voiding cystourethrography an easier experience for their child.

Technical report—Diagnosis and management of an initial UTI in febrile infants and young children

OBJECTIVES

The diagnosis and management of urinary tract infections (UTIs) in young children are clinically challenging. This report was developed to inform the revised, evidence-based, clinical guideline regarding the diagnosis and management of initial UTIs in febrile infants and young children, 2 to 24 months of age, from the American Academy of Pediatrics Subcommittee on Urinary Tract Infection.

METHODS

The conceptual model presented in the 1999 technical report was updated after a comprehensive review of published literature. Studies with potentially new information or with evidence that reinforced the 1999 technical report were retained. Meta-analyses on the effectiveness of antimicrobial prophylaxis to prevent recurrent UTI were performed.

RESULTS

Review of recent literature revealed new evidence in the following areas. Certain clinical findings and new urinalysis methods can help clinicians identify febrile children at very low risk of UTI. Oral antimicrobial therapy is as effective as parenteral therapy in treating UTI. Data from published, randomized controlled trials do not support antimicrobial prophylaxis to prevent febrile UTI when vesicoureteral reflux is found through voiding cystourethrography. Ultrasonography of the urinary tract after the first UTI has poor sensitivity. Early antimicrobial treatment may decrease the risk of renal damage from UTI.

CONCLUSIONS

Recent literature agrees with most of the evidence presented in the 1999 technical report, but meta-analyses of data from recent, randomized controlled trials do not support antimicrobial prophylaxis to prevent febrile UTI. This finding argues against voiding cystourethrography after the first UTI.

Comparing stress levels in children aged 2-8 years and in their accompanying parents during first-time versus repeated voiding cystourethrograms

OBJECTIVES

Invasive procedures such as voiding cystourethrograms (VCUGs) cause distress in both children and their accompanying parents. The main purpose of this study was to examine whether stress levels in children and their parents differ during first-time and repeated VCUGs. The second objective was to examine the relationship between parental behavior (behavior promoting child coping and behavior promoting child distress), parental stress levels and child distress in first-time versus repeated VCUGs.

METHODS

In a prospective study, the distress behavior of 31 children aged 2-8 years who were undergoing a repeated VCUG was examined. A second group of 31 children who were undergoing a VCUG for the first time served as a control sample. Child and parental behavior during the VCUG was coded by three independent observers using a standardized rating scale (CAMPIS-R, Blount et al.). Children reported on their stress levels using a faces scale; parents and radiologists rated the child's distress on a visual analog scale. Similarly, parents assessed their own stress levels on a visual analog scale.

RESULTS

The stress levels of children undergoing a repeated VCUG do not differ from those of children undergoing a VCUG for the first time, but parental stress levels were significantly lower during repeated VCUGs. In both VCUG groups there was significant positive correlation between parental distress-promoting behavior and child distress, and between parental stress levels and child distress. Parental coping-promoting behavior showed no significant correlation with child distress or parental stress levels in either VCUG group. Parental stress levels and parental distress-promoting behavior correlated positively only for repeated VCUGs. Neither parental coping- nor distress-promoting behavior differed between first-time versus repeated VCUG groups.

CONCLUSIONS

Repeated VCUGs and first-time VCUGs are both highly distressing procedures for children. Even though parental stress levels are lower during repeated VCUGs, spontaneous parental behavior proves to be ineffective or even counterproductive in reducing the child's distress. Further research into efficient counseling and training methods for parents and children undergoing VCUGs is required.

Antenatally detected urinary tract abnormalities: more detection but less action

We present the findings of a prospective cohort study of babies born with antenatally detected urinary tract abnormalities (AUTAs) between 1999-2003 and compare the outcomes with those of an earlier cohort born between 1989 and 1993. All infants with a fetal anteroposterior renal pelvic diameter (APRPD) > or =7 mm in the third trimester or other urinary tract abnormality underwent a detailed postnatal ultrasound scan and other investigations as indicated. The incidence of AUTAs was significantly greater in the more recent cohort (7.6/1000 vs. 3/1000 live births; p<0.05). Of the 350 infants on which we had data, 48.6% (170/350) were in the non-specific dilatation (NSD) category, and vesicoureteric reflux (VUR) was detected in 12%. Restricting investigations to those who had an APRPD > or =10 mm at >30 weeks of gestation could have reduced the number with NSD in the more recent cohort (26/115; 25%), but 25% of those with pelviureteric junction hold-up and 50% with VUR would have been missed. Significantly fewer patients in the more recent cohort underwent surgery (7 vs. 21%; p<0.001). There is a trend towards larger APRPDs on third trimester scans being associated with more significant pathology, but there is a lot of clinical overlap. The study highlights the need for cautious antenatal counselling combined with an assurance to prospective parents that postnatal investigations will be performed in a stepwise manner based on the initial postnatal ultrasound scan and clinical findings.

Anxiety in children undergoing VCUG: sedation or no sedation?

BACKGROUND

Voiding cystourethrograms are distressing for children and parents. Nonpharmacological methods reduce distress. Pharmacological interventions for VCUG focus on sedation as well as analgesia, anxiolysis, and amnesia. Sedation has cost, time, and safety issues. Which agents and route should we use? Are we sure that sedation does not influence the ability to diagnose vesicoureteric reflux?

METHODS

Literature search of Medline, EMBASE, and the Cochrane Database. Review of comparative studies found.

RESULTS

Seven comparative studies including two randomised controlled trials were reviewed. Midazolam given orally (0.5-0.6 mg/kg) or intranasally (0.2 mg/kg) is effective with no apparent effect on voiding dynamics. Insufficient evidence to recommend other sedating agents was found. Deeper sedating agents may interfere with voiding dynamics.

CONCLUSION

Midazolam reduces the VCUG distress, causes amnesia, and does not appear to interfere with voiding dynamics. Midazolam combined with simple analgesia is an effective method to reduce distress to children undergoing VCUG.

Sedation with nitrous oxide compared with no sedation during catheterization for urologic imaging in children

BACKGROUND

Various strategies to mitigate children's distress during voiding cystourethrography (VCUG) have been described. Sedation with nitrous oxide is comparable to that with oral midazolam for VCUG, but a side-by-side comparison of nitrous oxide sedation and routine care is lacking.

OBJECTIVE

The effects of sedation/analgesia using 70% nitrous oxide and routine care for VCUG and radionuclide cystography (RNC) were compared.

MATERIALS AND METHODS

A sample of 204 children 4-18 years of age scheduled for VCUG or RNC with sedation or routine care were enrolled in this prospective study. Nitrous oxide/oxygen (70%/30%) was administered during urethral catheterization to children in the sedated group. The outcomes recorded included observed distress using the Brief Behavioral Distress Score, self-reported pain, and time in department.

RESULTS

The study included 204 patients (99 nonsedated, 105 sedated) with a median age of 6.3 years (range 4.0-15.2 years). Distress and pain scores were greater in nonsedated than in sedated patients (P < 0.001). Time in department was longer in the sedated group (90 min vs. 30 min); however, time from entry to catheterization in a non-imaging area accounted for most of the difference. There was no difference in radiologic imaging time.

CONCLUSION

Sedation with nitrous oxide is effective in reducing distress and pain during catheterization for VCUG or RNC in children.

Case-series of nurse-administered nitrous oxide for urinary catheterization in children

BACKGROUND

Children undergoing urologic imaging studies requiring urethral catheterization experience considerable discomfort and psychological distress. Nitrous oxide sedation may mitigate these detriments but the requirement for physician administration has limited the applicability of this technique.

METHODS

Registered nurses underwent the nitrous oxide training requirements prescribed for state licensure of dentists and dental hygienists, with special emphasis on pediatric sedation principles. To evaluate the safety of nurse-administered nitrous oxide, we consecutively enrolled all children (ASA PS I-II) sedated for urethral catheterization for urologic imaging in an observational trial designed to identify sedation-related adverse events.

RESULTS

Nitrous oxide was administered on 1018 occasions. There were no major adverse events (apnea, oxygen saturation <92%). Minor adverse events (diaphoresis, nausea, vomiting) occurred in 4% of patients. Eight patients (1%) were described as over-sedated. In 11 (1%) patients, nitrous oxide provided insufficient sedation for completion of urologic imaging.

CONCLUSIONS

Nitrous oxide sedation can be provided by a nurse-administered program in pediatric radiology. Administration of nitrous oxide for pediatric procedures by adequately trained nursing staff with appropriate multidisciplinary oversight may increase children's access to this sedative/analgesic drug.

Magnetic resonance voiding cystourethrography for vesicoureteral reflux

PURPOSE

To assess the feasibility of magnetic resonance voiding cystourethrography (MRVCUG) using MR fluoroscopy for evaluation of vesicoureteral reflux (VUR), and its use as a noninvasive alternative to standard VCUG.

MATERIALS AND METHODS

A total of 22 MR studies of 16 patients (five months to 41 years old) with primary VUR diagnosed by standard VCUG were evaluated. Six patients underwent MR studies and standard VCUG pre- and postoperatively. MR fluoroscopy was executed with a non-enhanced heavily T2-weighted single-shot fast spin-echo (FSE) sequence. The MR findings were correlated with those obtained by the gold standard, standard VCUG.

RESULTS

Of the 44 kidney-ureter units, 20 were refluxing on MRVCUG and 21 were refluxing on standard VCUG. There were one false-positive and two false-negative units. MRVCUG was 90% sensitive with a specificity of 96% for detecting VURs that were calculated based on kidney-ureter units. Two false-negative units were found in mild cases (grade I and II). For the units of grade III, IV, and V (high-grade reflux), MRVCUG detected all of the refluxing renal collecting systems.

CONCLUSION

MRVCUG can demonstrate high-grade reflux without ionizing radiation or catheterization.

Conscious Sedation Reduces Distress in Children Undergoing Voiding Cystourethrography and Does Not Interfere with the Diagnosis of Vesicoureteric Reflux: A Randomized Controlled Study

OBJECTIVE

Voiding cystourethrography (VCU) is a distressing procedure for children. Conscious sedation using oral midazolam may reduce this distress, but its use may also alter the ability of the VCU to show vesicoureteric reflux (VUR). The objectives of our study were to assess the effectiveness of conscious sedation using oral midazolam when administered routinely in children undergoing VCU and to ensure that conscious sedation using oral midazolam does not alter the ability of VCU to show VUR.

SUBJECTS AND METHODS

Our study was a randomized double-blind controlled trial performed at a university teaching hospital; our study group consisted of children over the age of 1 year who been referred for their first VCU examination from July 2001 to July 2003. Participants were randomized to receive a placebo or midazolam syrup (0.5 mg/kg) before the examination. The primary outcome measures were the Groningen Distress Rating Scale (GDRS) and grading of VUR, as defined by the international grading system established by the International Reflux Study Group.

RESULTS

There were no serious adverse events. One hundred thirty-nine children were randomized in the study, and 117 underwent complete assessment. Eight who underwent VCU after the study day were included in a "complete case" intention-to-treat analysis. In the placebo group, 34 children (61%) experienced serious distress or severe distress (GDRS score, 3 or 4). In the midazolam group, 16 children (26%) experienced the same degree of distress. There was a significant difference between the GDRS scores (nonlinear mixed-model analysis, p < 0.001) of the two study groups. The number needed to treat to reduce serious or severe distress in one child was 2.9 (95% CI, 1.9-5.5). VUR was identified in 16% of all children. There was no difference in VUR grading between the groups (nonlinear mixed-model analysis, p = 0.31).

CONCLUSION

Routine use of oral midazolam (0.5 mg/kg) for conscious sedation of children undergoing VCU reduces distress and does not alter the ability of VCU to show VUR well enough to allow diagnosis.

Unilateral multicystic dysplastic kidney: long term outcomes

AIMS

To report the long term follow up of children with antenatally detected unilateral multicystic dysplastic kidney (MCDK) with documentation of complications, involution rate with time, and renal function at 10 years.

METHODS

Data were retrieved from a prospective regional registry of patients with MCDK between 1985 and 2004. Children were followed using a common protocol of investigation with follow up ultrasound scans (USS) at 2 (165 patients), 5 (117 patients), and 10 years (43 patients).

RESULTS

Serial USS showed that 33% of the MCDK kidneys had completely involuted at 2 years of age, 47% at 5 years, and 59% at 10 years. No patients developed hypertension, significant proteinuria, or malignancy, but two developed pelviureteric junction obstruction in the contralateral kidney. Twenty seven of 143 children (19%) had vesicoureteric reflux (VUR) (96% mild to moderate VUR) into the contralateral kidney with no difference in the incidence of urinary tract infections or renal scarring between those with or without VUR. The mean estimated glomerular filtration rate (GFR) was 86.4 ml/min/1.73 m2 (range 48-125) in 31 of 43 patients followed to 10 years.

CONCLUSIONS

Conservative management of unilateral MCDK is justified with clinical review and infrequent USS but longer term follow up continues in the 41% still with renal remnants at 10 years and those with impaired GFR. It is suggested that the initial micturating cystogram is deferred unless abnormal USS features are present in the contralateral kidney or ureter.

Voiding Ability Using Propofol Sedation in Children Undergoing Voiding Cystourethrograms: A Retrospective Analysis

PURPOSE

The ability of a child to void during cystourethrography is important in detecting vesicoureteral reflux. The potential effect of sedation on the capacity to void may impair our ability to detect vesicoureteral reflux. Since 2001, most voiding cystourethrograms at our institution have been performed with moderate sedation using propofol. To assess the impact of sedation on the ability of children to void, we retrospectively evaluated a group of patients who underwent sedated voiding cystourethrograms and compared them to a group undergoing nonsedated voiding cystourethrograms.

MATERIALS AND METHODS

The nonsedated group consisted of children 2 to 8 years old who underwent voiding cystourethrography between 1996 and 2001. The sedated group consisted of children the same age who underwent voiding cystourethrography between 2002 and 2004. Patient characteristics, presenting symptoms, bladder capacity, emptying ability and diagnoses were recorded. Children were categorized as receiving sedation vs not receiving sedation. All sedated children received propofol deep sedation. Statistical analyses were performed using the 2-sided t test and Fisher's exact test.

RESULTS

Of 544 charts reviewed 287 were within the age range defined. Of these children 85% were female. Sex was evenly matched between the sedated and nonsedated groups. Urinary tract infections (65%) and previous vesicoureteral reflux (25%) were the most common factors prompting voiding cystourethrography. Sedation was administered in 146 patients, of whom 80 (55%) were able to void to completion. Of the 141 patients who did not receive sedation 125 (89%) were able to void to completion (p <0.001).

CONCLUSIONS

Children who underwent voiding cystourethrography with sedation were less likely to void to completion. This finding may impair our ability to detect vesicoureteral reflux in children accurately. Large prospective studies are needed for better assessment of bladder emptying and sedation when performing voiding cystourethrography.

Preparing children for day case nuclear medicine procedures

OBJECTIVES

To audit standards developed for children undergoing nuclear medicine procedures involving day case attendance on the renal unit.

METHODS

A prospective audit was undertaken of 210 children (113 males) undergoing day case nuclear medicine procedures in a teaching hospital department catering for adult and paediatric patients. An audit sheet was completed by both ward and nuclear medicine staff at the time of the procedure over an 18-month period.

RESULTS

The majority of families were given relevant information about the procedures and adequate notice before the scan date. Most patients were offered surface analgesia for the venepuncture and play preparation before the procedure. Fifty-eight per cent of patients were successfully cannulated at the first attempt and 88% after three attempts. Only 4% of children were sedated. The median delay between the scheduled and actual scan time was 15 min, with 71% of children being scanned within the standard of a 0-20-min delay. Most delays were due to logistic problems within the department (43%). Cannulation problems (35%) and patient-related factors (22%) accounted for further delays.

CONCLUSIONS

The audit of these locally agreed standards has resulted in changes in practice, including nurse training for cannulation and better scheduling within the nuclear medicine department. We believe that play preparation is an essential component for all potentially painful procedures, with few patients requiring sedation. The standards could be used for comparative audits between units.

Premedication during micturating cystourethrogram to achieve sedation and anxiolysis

Micturating cystourethrogram (MCUG) is an imaging technique indicated in the diagnosis and follow-up of many diseases. We investigated the reliability and the efficacy of midazolam and chloral hydrate in sedation and anxiolysis during micturating cystourethrogram. Fifty-three children of similar ages (39 girls, 14 boys, mean age of 5.8+/-3.5 years) were randomized to midazolam (n=17), chloral hydrate (n=18) and control groups (n=18). Oral midazolam 0.6 mg/kg or chloral hydrate 25 mg/kg or saline were administered to the study groups 15-30 min prior to the urinary catheterization. Brietkopf and Buttner, Frankl and Houpt scales and Spielberger's State Anxiety Inventory and parent's impressions were used to assess the level of sedation and anxiety. The Brietkopf and Buttner classification of emotional status and Houpt behavior rating scale demonstrated a significantly better emotional status and sedation in the midazolam group when compared to controls (P=0.01 and P=0.018, respectively). The catheterization was described as a more unpleasant and distressing event by the parents of the control and the chloral hydrate groups when compared to the parents of the midazolam group (P<0.05). Bladder capacity and frequency of detection of residual urine were not statistically different between the three study groups (P>0.05). Vital signs did not change significantly in any child. Sedation with midazolam does not have adverse effects on the results of micturating cystourethrogram, while it reduces the discomfort in children undergoing this radiological technique.

Sedation with midazolam for voiding cystourethrography in children: a randomised double-blind study

BACKGROUND

Sedation with midazolam facilitates the performance of diagnostic procedures in children, including voiding cystourethrography (VCUG). However, the influence of sedation on voiding and imaging results have not been adequately evaluated.

OBJECTIVE

Midazolam and placebo were compared to assess discomfort during VCUG and to evaluate if sedation influenced the outcome of the examination.

MATERIALS AND METHODS

The study was prospective, randomised and double-blind, and included 95 children, 48 in the midazolam group (median age 2.2 years) and 47 in the placebo group (median age 3.2 years). The evaluation included the child's/parent's experience of the VCUG, as well as the examination results.

RESULTS

The children/parents in the midazolam group experienced the VCUG as less distressing compared to those in the placebo group ( P<0.001). Forty-six of 48 children sedated with midazolam could void during the imaging procedure compared to 38 of 47 children given placebo ( NS). There was no difference in frequency or grade of vesicoureteric reflux or bladder emptying between the groups.

CONCLUSIONS

When sedation is required to perform VCUG in children, midazolam can be used without negative effect on the outcome of the examination.

Effect of thoughtful preparation on the catheterization of children undergoing investigative studies

AIMS

To evaluate an anesthetic sedation free method of transurethral catheterization in children.

METHODS

The child and his or her parents are thoroughly prepared for the procedure by means of written and oral child-adapted information and practical instructions. To evaluate this routine, a simple questionnaire was given to 115 consecutive children undergoing transurethral catheterization.

RESULTS

The questionnaire was returned by 99 children (86%). Most children and parents (95) found the preparation"good"or"very good"and tolerated the catheterization procedure well. Only six children reported the catheterization to be"very painful"(without requiring that the procedure was terminated). Complications, such as urgency, smarting pain during voidings, or both, after withdrawal of the catheter, occurred in 12 children and urinary tract infections in 3. Unexpectedly, girls were affected more often than boys.

CONCLUSIONS

Careful preparation of children and their parents allows the great majority of diagnostic studies that require urethral catheterization to be accomplished without anesthesia.

An audit of RCP guidelines on DMSA scanning after urinary tract infection

AIM

To assess the outcome of imaging investigations carried out in children with urinary tract infection (UTI), to compare the investigations with national guidelines, and to assess the impact on management.

METHODS

Retrospective review of inpatients and outpatients, aged 0-12 years, referred to the University Hospital of Wales Healthcare Trust between February 1997 and January 1998 with UTI. All children without bacterial evidence of UTI and children previously investigated for antenatal urological anomalies, major congenital anomalies, or UTI were excluded.

RESULTS

A total of 164 children (51 boys, 113 girls) were included. Thirteen of 56 infants (23%) and 82/108 older children (76%) were diagnosed at home over one year. The prevalence of dilatation on ultrasound was 8%, renal scarring on dimercaptosuccinic acid (DMSA) scan was 11%, and vesicoureteric reflux (VUR) was 34% when investigations were carried out following guidelines published by the Royal College of Physicians. In children aged 1-6 years, the prevalence of scarring was 1/54 (2%) in those treated at home and 6/18 (33%) in inpatients.

CONCLUSION

The low yield of positive results and lack of evidence of impact on management indicate that DMSA scanning, with all the implications of isotope exposure, intravenous injection, staff time, psychological trauma, and expense, could be omitted in children over 1 year with first simple UTI not sufficiently ill to be admitted to hospital. The low rate of detection of UTI in primary care in infants may represent under diagnosis.