Abstract
Objectives
Ileocolic intussusception is a major cause of intestinal obstruction in children under 2 years of age. Diagnosis is typically confirmed using ultrasonography, and treatment often involves an air or hydrostatic enema performed by radiologists or surgeons outside of the pediatric emergency department (PED) without the provision of adequate sedation or analgesia. This study aimed to assess the efficacy and safety of a comprehensive bedside approach for the diagnosis and reduction of ileocolic intussusception within the PED of a tertiary care pediatric hospital.
Methods
A retrospective cohort study conducted between January 2021 and July 2024. Key outcome variables included the reduction success rate, time to reduction, and adverse events.
Results
During the study period, 28 children diagnosed with ileocolic intussusception via point-of-care ultrasound were treated bedside with ultrasound-guided hydrostatic reduction performed by a pediatric radiologist under sedation provided by pediatric emergency medicine physicians. There were 20 (86%) successful bedside reductions with an average time from admission to reduction of 126 minutes and an average length of stay of 407 minutes, respectively. No adverse events were recorded, although early recurrence of intussusception within 48 hours occurred in 2 patients (7%).
Conclusion
This is the first study that detailed a comprehensive bedside approach for the diagnosis and reduction of ileocolic intussusception in the PED. This approach has a high success rate, minimizes the need for interdepartmental transfers, and facilitates the administration of appropriate sedation and analgesia without significant adverse events. Further prospective studies are needed to confirm the safety and efficacy of this bedside approach.
Keywords: pediatrics, emergency medicine, sedation and analgesia, pediatric surgery, point of care ultrasound
The Bottom Line.
Can pediatric intussusception be diagnosed and treated bedside in the emergency department? In this pioneering study, the Bedside Intussusception Diagnosis and Reduction (BIDAR) protocol successfully facilitated bedside diagnosis and treatment in 86% of cases at a tertiary pediatric hospital, with no procedure-related complications. Moreover, all reductions were performed under sedation, addressing the gap in standard care where fewer than 10% of children with intussusception worldwide receive adequate analgesia. Sedation-related adverse events were rare, resolved easily, and the median diagnosis time was 76.5 minutes. If validated through multicenter prospective studies, the BIDAR protocol could redefine pediatric intussusception management, making it faster, safer, and less painful.
1. Introduction
1.1. Background
Ileocolic intussusception occurs when the terminal ileum telescopes through the ileocecal valve into the ascending colon and is a leading cause of intestinal obstruction in children, most commonly affecting infants under 2 years of age.1 Most cases are idiopathic; however, up to 20% are caused by pathological lead points.2,3 Rapid diagnosis and treatment are essential in order to avoid severe complications, such as ischemia and perforation of the bowel. The gold standard for the diagnosis of intussusception includes ultrasonography performed by a radiologist; however, point-of-care ultrasonography (POCUS) enables emergency medicine physicians to quickly and accurately confirm the diagnosis in order to facilitate rapid treatment using either air enema under fluoroscopy or hydrostatic reduction under sonographic guidance.4,5
1.2. Importance
Current management of ileocolic intussusception often requires a multidisciplinary team approach and involves interdepartmental transfers of distressed infants outside of the pediatric emergency department (PED). Furthermore, recent evidence has shown significant practice variability for the diagnosis, treatment, and disposition of these patients, thereby underscoring the need for further research in order to establish uniform standards of care.6,7 Moreover, recent studies have shown that <7% of patients receive adequate analgesia and sedation before or during reduction.8
1.3. Goals of This Investigation
Given the high accuracy of POCUS for the diagnosis of intussusception and its ability to guide bedside hydrostatic reduction, this study aimed to investigate the feasibility of Bedside Intussusception Diagnosis and Reduction (BIDAR) in order to eliminate unnecessary patient transfers and to ensure the provision of appropriate monitoring and analgesia in the PED.
2. Methods
2.1. Study Design and Setting
This retrospective cohort study was conducted in a large urban tertiary children’s teaching hospital with an annual PED census of 28,000.
2.2. Selection of Participants
We reviewed the medical records of children up to 2 years of age who received a diagnosis of ileocolic intussusception (International Classification of Diseases-10-CM Diagnosis Code K56.1: Intussusception) between January 2021 and July 2024. Patients were excluded if they did not undergo POCUS prior to reduction or if they experienced spontaneous reductions, operative reduction without prior nonoperative attempts, or reductions conducted outside of the PED. After applying exclusion criteria, 28 out of 39 patients (71.8%) underwent the complete BIDAR process and were included in the final analysis (Fig 1). Of note, approval was granted by the institution’s internal review board, and written informed consent was waived.
Figure 1.
Patient flow. BIDAR, beside intussusception diagnosis and reduction; PED, pediatric emergency department; US, ultrasound.
2.3. Interventions
The BIDAR protocol was jointly developed by the departments of pediatric emergency medicine, pediatric radiology, and pediatric surgery in accordance with recently published national guidelines for the nonoperative management of intussusception.9 All participating physicians completed institutional credentialing in POCUS, which includes specific training in bowel sonography and hands-on instruction under the supervision of a pediatric emergency medicine (PEM) attending certified in POCUS. Of note, pneumatic (air) enema remains common practice in many institutions and is supported by national guidelines; however, our center transitioned to ultrasound-guided hydrostatic reduction as the standard of care 1 year prior to study initiation. The complete workflow of the BIDAR protocol is summarized in Figure 2 and consists of several sequential steps: When intussusception was clinically suspected, patients underwent POCUS performed by a PEM attending or fellow and were prepped for bedside reduction. Prior to the initiation of sedation provided by a PEM physician, ileocolic intussusception was confirmed bedside by ultrasonography performed by a pediatric radiologist in order to rule out spontaneous reduction. Likewise, the reduction was performed by a bedside pediatric radiologist and involved rectal insertion of a Foley catheter with balloon inflation, followed by infusion of up to 1 L of warm saline mixed with contrast material from a height of 120 cm. Using ultrasound guidance, the distal end of the intussusception was monitored until fluid flux into the terminal ileum was observed, with up to 3 attempts permitted. Successful reduction was confirmed by bedside abdominal radiography demonstrating contrast material in the small bowel.
Figure 2.
BIDAR flow scheme. BIDAR, beside intussusception diagnosis and reduction; LOS, length of stay; PED, pediatric emergency department; POCUS, point-of-care ultrasound.
Hydrostatic reduction was performed by a pediatric radiologist alongside a PEM attending or fellow responsible for continuous monitoring of vital signs while providing procedural sedation in accordance with the following departmental protocols: intravenous ketamine (1 mg/kg) with midazolam (0.1 mg/kg), intravenous ketamine with propofol (1 mg/kg) titrated to effect, or intranasal midazolam (up to 0.5 mg/kg, with a maximum dose of 5 mg) with intranasal ketamine (up to 5 mg/kg). All sedation-related events were documented in the electronic medical record using standardized international standards and definitions. Of note, there were 3 children who underwent procedural sedation during reduction; however, documentation of sedative doses utilized was incomplete in the electronic medical record. Following recovery, patients were admitted to the pediatric surgical ward for 24-hour observation.
2.4. Measurements
Data from the electronic health record were extracted and included demographic characteristics, clinical presenting history, physical examinations, medications provided, time to POCUS and reduction, serious adverse events, initial success rate, and recurrence rate.
2.5. Outcomes
The primary outcome was successful bedside reduction of intussusception in the PED. Secondary outcomes included procedure-related complications, sedation-related adverse events, early recurrence rates within 48 hours, need for surgical intervention, and temporal metrics, including time to diagnosis and reduction attempt.
2.6. Analysis
Statistical analysis used descriptive methods, with continuous variables expressed as medians with interquartile ranges (IQRs) and categoric variables as frequencies and percentages.
3. Results
3.1. Characteristics of Study Subjects
Out of 39 cases of patients diagnosed in the PED with ileocolic intussusception, 28 (71.8%) met the inclusion criteria. The study population had a median age of 8 months (IQR [6.0-17.5]). Patient characteristics are detailed in Table 1.
Table 1.
Patient characteristics.
| Demographic characteristic, N =28 | No. (%) |
|---|---|
| Mean age (mo) | 8 (IQR, 6-17.5) |
| Male | 13 (46.4) |
| Female | 15 (53.6) |
| Duration of symptoms prior to PED arrival | |
| <24 h | 20 (71.4) |
| 24-48 h | 6 (21.4) |
| >48 h | 2 (7.1) |
| Previous intussusception | |
| Yes | 5 (17.9) |
| No | 23 (82.1) |
| Clinical presentation | |
| Abdominal pain | 7 (25.0) |
| Bloody stools (current jelly/melena) | 4 (14.3) |
| Fever | 6 (21.4) |
| Irritability | 20 (71.4) |
| Lethargy | 11 (39.3) |
| Pallor | 9 (32.1) |
| Vomiting | 20 (71.4) |
| No symptoms documented | 0 (0) |
| General appearance | |
| Well | 26 (92.9) |
| Unwell | 2 (7.1) |
| Abnormal vital signs | |
| Tachycardia relative to age, y | 18 (64.3) |
| Capillary refill time >2 s | 2 (7.1) |
QR, median interquartile range; PED, pediatric emergency department.
3.2. Main Results
Twenty-eight children with intussusception were treated using the BIDAR protocol (Fig 1). Twenty-four (85.7%) of patients were successfully reduced in the PED and did not experience bowel perforation or other procedure-related complications. Early recurrence within 48 hours occurred in 2 patients (7.1%), who were successfully managed with subsequent hydrostatic enemas. Four patients (14.3%) required surgical reduction, and lead points were identified in 3 cases, including 2 patients with enlarged mesenteric lymph nodes and 1 patient with a Meckel’s diverticulum.
Sedation-related adverse events were infrequent and are detailed in Table 2. Of note, 2 patients experienced brief oxygen desaturations during sedation, which resolved with repositioning and noninvasive supplemental oxygen administration.
Table 2.
Outcomes.
| Time metric parameters | Median min (IQR) |
|---|---|
| Time from admission to first reduction attempt | 161 (113.5-212) |
| Duration of sedation | 15.5 (9.5-21.0) |
| Time from reduction to hospitalization | 215 (145-274.5) |
| Total PED LOS | 306 (228-394.5) |
| Adverse events throughout BIDAR, N = 28 | N (%) |
| Desaturation below 90% for >30 s | 2 (7.1) |
| None | 26 (92.9) |
| Sedation used, N = 28 | |
| Ketamine IV and midazolam IV/PO | 19 (67.9) |
| Ketamine IV and propofol IV | 5 (17.9) |
| Ketamine INH and midazolam INH | 1 (3.6) |
| Medication provided unknown | 3 (10.7) |
| BIDAR result, N = 28 | |
| Success | 24 (85.7) |
| Failure | 4 (14.3) |
| Recurrence of intussusception, N = 28 | |
| Early recurrence (<48 h) | 2 (7.1) |
| Nonearly recurrence | 26 (92.9) |
BIDAR, beside intussusception diagnosis and reduction; INH, intranasal; IQR, median interquartile range; IV, intravenous; LOS, length of stay; PED, pediatric emergency department. PO, per os.
The median time from admission to POCUS diagnosis was 76.5 minutes (IQR, 43-170). Notably, there was a modest reduction in the median ultrasound to reduction interval over time from 82.0 minutes (IQR, 38-185) in the first half of the cohort to 76.5 minutes (IQR, 48-157) in the latter half; however, this trend did not achieve statistical significance (Mann-Whitney U = 93; critical U = 61 at P < .05).
4. Limitations
This was a nonrandomized, nonblinded retrospective cohort study consisting of 39 patients who underwent POCUS based on the availability and discretion of POCUS-trained PEM physicians and lacks a comparison group. Furthermore, all patients were derived from a single tertiary care children’s hospital with an established pediatric surgery and pediatric radiology department, which can limit generalizability. In addition to the small sample size, this study may not be applicable to institutions with physicians not trained in POCUS in the pediatric population, in facilities where POCUS is not commonly implemented as a clinical decision-making tool, or in institutions where intussusception is not routinely treated by hydrostatic reduction. Additionally, there was incomplete documentation of medication doses in 3 of the children who underwent procedural sedation for intussusception reduction, and this information could not be ascertained retrospectively.
5. Discussion
Our study is the first to describe a comprehensive process for which intussusception is both diagnosed and treated at the bedside in the PED with a high success rate. As detailed in the Methods section, this multidisciplinary approach was developed collaboratively across PEM, radiology, and surgery departments in accordance with published national guidelines.9 Although pneumatic (air) enema remains common practice in many institutions, our center transitioned to ultrasound–guided hydrostatic reduction as the standard approach, aligning with recently published national guidelines; however, reduction practice variability exists across institutions.
This is the first study to describe a comprehensive bedside protocol for the diagnosis and treatment of intussusception and has the potential to reduce unnecessary and cumbersome interdepartmental transfers during diagnosis and initial treatment. The ability of PEM physicians to monitor and treat this critical condition within the confines of the PED not only has the potential to improve patient safety and parental satisfaction but also has the potential to shorten the time from diagnosis to reduction and promote the administration of appropriate analgesia and sedation for infants suffering from bowel obstruction.10 The ramifications of the former are profound, as a recent large multicenter study cited that >90% of infants with intussusception do not receive procedural sedation and analgesia for reduction.6
Patients were included in this study after having undergone POCUS in the PED; however, 2 patients (5.1%) were excluded because of the lack of availability of a PEM physician at the time of diagnosis. Given that the accuracy of POCUS for the diagnosis of intussusception has been validated in previous works, metrics regarding the precision of POCUS diagnoses were not included in this study.11
After bedside confirmation of diagnosis by a pediatric radiologist, ultrasound-guided hydrostatic reduction was performed, which is a method that has supplanted the use of air enema in our institution, as it can be performed within the confines of the PED. Further research is required to determine if this bedside procedure can also be safely and effectively performed by a PEM physician.
Overall success rate for bedside ultrasound-guided hydrostatic reduction in our study was 86%, which is comparable to reported rates in the literature for fluoroscopic-guided and pneumatic (air enema) reduction, which range from 76% to 95%.12 Likewise, a recent systematic review showed an average success rate of 86.9% for the reduction of intussusception under sedation, while the risk of bowel perforation was reported to be 0.43% for hydrostatic enema and 0.4% for air enema under fluoroscopy, respectively.6,13 Of note, there were no cases of bowel perforation or any other procedure-related complication in our study; however, there were 2 cases of early recurrence within 48 hours (7.1%), which is consistent with reported recurrence rates for ultrasound-guided hydrostatic enema, which range from 3.7% to 20.0%.3
In summary, the BIDAR protocol demonstrated that bedside diagnosis and reduction of intussusception in the PED are feasible, with success rates comparable to traditional methods. These findings are most applicable to tertiary care pediatric emergency departments with established pediatric radiology departments and PEM physicians trained in POCUS. Our findings suggest this approach may optimize patient care by reducing transfer-related delays, enabling appropriate sedation and analgesia, and maintaining continuous monitoring in a controlled environment. Although our single-center experience shows promising results, multicenter prospective studies are needed in order to validate this protocol's safety and efficacy across diverse clinical settings and to establish standardized guidelines for widespread implementation. Such research could potentially transform and unify the standard of care for pediatric intussusception management worldwide.
Author Contributions
OF conceived and designed the study. NA supervised the data collection, undertook the data collection, and drafted the manuscript. JK revised the manuscript and, together with MS, provided advice on the study design and content. TBB provided assistance with institutional review board (IRB) approval and protocol writing. NA takes responsibility for the paper as a whole.
Funding and Support
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Conflict of Interest
All authors have affirmed they have no conflicts of interest to declare.
Footnotes
Supervising Editor: Mike Wells, MBBCh, PhD
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