Paediatric interventional ultrasound

('Safety first')

By Professor György Harmat MD, Director General of the Budapest Municipal Council Pal Heim Children's Hospital, Hungary

With the rapid development of new instrumentation it is now possible to carry out interventional procedures on ever younger children and even neonates.
Ultrasound guided therapeutic interventional procedures may also be carried out in certain clinical circumstances where the alternative would be operative intervention e.g. the drainage of intra-abdominal abscesses or accumulated peritoneal fluid. In many cases this will result in a definitive cure.

The most frequent intervention is the parenchymal biopsy.
In childhood the pain sensitivity is always individual. Sudden artificial movements are possible. We perform biopsies in the operating theatre, with US guidance attachment.
During our 17-year experience, we have undertaken 366 procedures on 125 children.
Biopsy samples should be taken from children between two breaths with suspended ventilation. The anaesthetist is able to manually ventilate the child allowing the procedure to be performed in the 20 to 45 second pause between ventilations. Using this technique we have not observed any damage to the solid abdominal organs.

During sampling with a special True-cut needle of 18G, the accurate place and dimension of the invasion can be chosen. Control examinations have been performed after 1, 12 and 24 hours of the first intervention. Other interventional procedures, such as drainage, peritoneal lavage, pleuritis punction, abscess or pseudocyst drainage or antibiotic treatments are also performed under general anaesthesia.

In our series, the clinical indications for interventional procedures have been for biopsy intrahepatic cholestasis with portal fibrosis, hepatic tumours such as hepato-blastoma, some at a very early age, chronic persistent hepatitis, Niemann-Pick storage disease, giant cell hepatitis, nephrosis, nephritis, ovarian tumours, neuroblastoma and different other tumours, as well as varying intra-abdominal abscesses requiring drainage, peritonitis, pancreatic pseudocyst.
Taking ’safety first’ as our most important consideration, we have found a very low frequency of minor complications in our cases. We have detected some capsular, subcapsular or perirenal haemorrhages, however these disappeared within 24 hours and could not be observed at follow up. Once, after biopsy, a temporal blood clot was detected within the gall bladder. We have had no major complications.

Conclusions
In children, general anaesthesia should usually be used to avoid involuntary movements.
An early diagnosis of serious illnesses is possible by this very successful combination of ultrasound and biopsy. It does not cause any complications, and due to general anaesthesia during the procedure, children have not suffered. By applying instrumental breathing, damage of the parenchymal tissues can be avoided.

It should be emphasised again that ultrasound guided interventional procedures in children should always be performed with great care. The use of general anaesthesia minimises complications and this is a significant difference in practice between adults and children.

14.11.2007

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