Neonatal Fluoroscopic Imaging at the Bedside
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Children’s hospital pilots bedside fluoroscopy imaging in the neonatal intensive care unit.
By Mark C. Liszewski, MD, Children’s Hospital at Montefiore.
Portable radiography and sonography are mainstays of initial diagnostic assessment in critically ill patients. However, there are many situations in which they cannot provide the information that clinicians need. Advanced imaging options, like fluoroscopy, CT, MRI, and NM, as well as interventional procedures, are often not available at the bedside.
In 2017, the Children’s Hospital at Montefiore (CHAM) and Montefiore Radiology partnered with Carestream Health to pilot a forward-looking technology to enable fluoroscopic exams to be performed with a modified DRX-Revolution system in our neonatal intensive care unit. The portable fluoroscopy unit is capable of providing comparable image quality at equivalent dose levels to an in-room fluoroscopy system for neonates with minimal risks to the staff and other patients in the neonatal intensive care unit (NICU). Read on to learn the details of this innovative pilot on neonatal fluoroscopic imaging.
Bedside imaging reduces the risks of patient transport
There are a multitude of issues associated with transporting critically ill patients. First and foremost is the risk to the patient. Complications encountered during transport can include respiratory compromise, hemodynamic instability, acid-base disturbances, and potential for infection.
For fluoroscopy, patient transport to and from the fluoroscopy room may require prolonged time away from the hospital unit—thus increasing the possibility of adverse events—for an exam that may only require 10 minutes or less to perform. The ability to perform these procedures effectively at the patient bedside has the potential to reduce the risk of adverse events and lead to improved outcomes. A portable radiographic system capable of fluoroscopic imaging in the NICU potentially benefits critically ill neonates by eliminating the need to transport them to a fluoroscopy suite.
Transporting critically ill patients requires considerable staffing. Transporting a neonate from the NICU often requires a dedicated team to travel with the patient, including NICU physicians, nurses, and respiratory therapists. Enabling imaging tests at the bedside reduces the strain on NICU staffing. It may also increase satisfaction for patients and patients’ families who may prefer to stay in their hospital rooms.
Enabling neonatal fluoroscopic imaging with a mobile unit also keeps the fluoroscopy room available for more complex procedures. This helps with imaging volume and revenue for the facility.
Lastly, the arrival of COVID-19 has provided an additional benefit to bedside imaging: infection control. Keeping a patient in their room helps limit their potential exposure to infection and decreases the opportunities for them to infect others – including staff – during transport. Imaging COVID-infected patients at the bedside also reduces the number of times that a healthcare facility needs to clean and disinfect a fluoroscopy suite after a COVID-infected patient has been imaged there.
These are just some of the reasons that many of us in the healthcare industry, including Carestream Health, have a vision of bringing more imaging to the patient bedside.
Study: evaluating portable bedside fluoroscopy system in the NICU
We partnered with Carestream Health to evaluate whether a portable bedside fluoroscopy system in the NICU can deliver comparable image quality at a similar dose rate to a standard system in a fluoroscopy suite. Specifically, we wanted to evaluate the workflow, patient dose and scattered radiation associated with performing upper gastrointestinal series (UGI) and voiding cystourethrograms (VCUG) in the NICU using portable bedside fluoroscopy.
The prototype (not available for sale) for our study was a modified Carestream mobile radiography unit, the DRX-Revolution. Carestream enabled the system to capture fluoroscopic image sequences and deliver real-time image processing and display. The prototype consisted of:
- Modified Carestream mobile radiography unit
- High-frame rate portable digital X-ray detector
- Integrated graphical user interface (GUI) to control X-ray exposure duration, including dose limits and cutoff
- Display console, with foot pedal fluoroscopy controls
The prototype portable fluoroscopy system and display were positioned adjacent to the isolette. The images were initially acquired with the prototype portable fluoroscopy system; and the final image was obtained with the standard portable unit, allowing diagnoses to be determined on an FDA-approved system.
Results
In phase A of the IRB-approved protocol, 20 patients <3 years of age and scheduled to undergo upper GI series or VCUG in the radiology fluoroscopy suite were recruited to evaluate the portable fluoroscopic unit. The modified portable radiographic system with a cassette-sized detector and an in-room fluoroscopy system were sequentially used in the same examination. Four radiologists compared the image quality of 20 images from each system using the Radlex score (1–4) for five image quality attributes. The radiation dose rates for the portable and in-suite systems were collected.
In phase B, fluoroscopy studies were performed in 5 neonates in the NICU and compared to 20 previous neonatal studies performed in the department. Clinical workflow, examination time, fluoroscopy time, scattered radiation dose and patient radiation dose were evaluated.
In phase A, average dose rates for in-room and portable systems were equivalent, (0.322 mGy/min and 0.320 mGy/min, respectively). Reader-averaged Radlex scores for in-room and portable systems were statistically significantly greater (P<0.05) for all attributes on the portable system except for image contrast.
In phase B, scattered radiation from the average fluoroscopy time (26 s) was equivalent to the scattered radiation of 2.6 portable neonatal chest radiographs. Procedure time and diagnostic quality were deemed equivalent. The average dose rate in the NICU with the portable system was 0.21 mGy/min compared to 0.29 mGy/min for the in-room system.
This neonatal fluoroscopic imaging pilot study suggests that the portable fluoroscopy unit utilizes similar dose levels to an in-room system with minimal risk to the staff and other patients in the NICU. I hope that this work will lead to a solution that will allow for diagnostic fluoroscopy imaging at the bedside in the future, so that critically ill patients can get the care they need in the safest possible way.
About the author: Mark C. Liszewski, MD, is Director of the Division of Pediatric Imaging at Children’s Hospital at Montefiore (CHAM), Director of Outpatient Imaging at Montefiore, Associate Director of the Diagnostic Radiology Residency Program at Montefiore, and Associate Professor of Radiology and Pediatrics at Albert Einstein College of Medicine. Dr. Liszewski joined Montefiore in 2015. As a Pediatric Radiologist, Dr. Liszewski works with pediatricians and pediatric specialists to provide family-centered diagnostic imaging services attuned to the needs of children. He also has specialized experience and knowledge of the radiologic diagnosis of medical conditions affecting children.
Other contributors to this study were: Jordana Gross, Alison Schonberger, Terry Levin, Einat Blumfield, Suhas Nafday, and Benjamin Taragin.
Disclosures: Dr. Liszewski and Dr. Taragin are members of Carestream’s Medical Advisory Board. Funding for the study was provided by Carestream Health.
Read the complete study at Springer Link; Liszewski, M.C., Richard, S., Gross, J.N. et al. Feasibility study of a novel portable digital radiography system modified for fluoroscopy in the neonatal intensive care unit. Pediatr Radiol (2021).
Learn more about:
- Balancing Dose with Image Quality in Pediatric Imaging
- The Benefits of Mobile Imaging
- CARESTREAM DRX-Revolution
- CARESTREAM DRX-Excel for General Radiography and Fluoroscopy Exams
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