SPS Newsletter

An official publication of the Society for Pediatric Sedation

An official publication of the
Society for Pediatric Sedation®

How Do You Do It? Exploring VCUG’s in Two Programs

The Children’s Hospital of Philadelphia
at Virtua Voorhees
Katherine Friend, CCLS

Sedation planning:

Who receives sedation?  Ultimately the decision is collaborative between the parents, NP, RN, and CCLS.

Who doesn’t? Most children under 1 year do not receive sedation. Anyone on the team (or the parents) may advocate for a non-sedate approach if they feel it is in the best interest of the patient. As the team member whose primary role is to assess, protect, and promote psychological health, the CCLS is the professional who is most likely to advocate for a non-sedate approach. Drawing on our background in trauma theory, psychology, and child development, we may assess that the oral versed is likely to inhibit or derail the patient’s coping, and/or endanger their psychological health (in combination with the procedure). In these cases, it would not be used.

Which medications are used?
Oral Versed

Who administers the sedation?
The RN

Pre-procedural education and/or play:

Is scripting utilized?
Our CCLSs tailor the preparation to each individual child.

Which educational tools are typically used?
We have child-friendly pictures of the fluoroscopy room and the renal system that can help in explaining the process. We also have two anatomically correct baby dolls (male and female) that have been adapted to allow children to practice catheterizing them. Some children benefit immensely from this hands-on preparation tool, which allows for exposure to, and manipulation of, the medical equipment, and a more concrete understanding of the steps involved in catheterization.

Imaging:

Which modality is utilized?
We use fluoroscopy to obtain the images.

Catheterization:

Who inserts the catheter?
The RN

Non-pharmacological support:

Preferred approach to support?
Each child is different! I think the biggest danger for adults (medical staff and parents) when trying to support a child through a VCUG is that they will project their own coping preferences on the child (for example, insisting the child not look at what’s happening, when the child needs to see in order to cope). When the adult and the child’s coping strategies are different, and the adult does not accept this difference, it places an added stress on the child.

Favorite resource?
For children that prefer to be distracted during a VCUG, I like active distraction such as an interactive iPad game, or a “Look and Find” book. For infants and toddlers, singing familiar songs (slowly and calmly), and patting with the beat can be very effective.

Parental Presence:

Yes or No?
Yes! Parents are a wonderful source of comfort for the patient, and are always welcome to accompany their child through the entire VCUG process. Our parents stand at the head of the bed, and help provide distraction, coaching, and reassurance. They can also help hold their child in position if the child is struggling with staying still. Having the parent do this is less traumatic for the child than being restrained by unfamiliar adults.

Post Procedural snack: (Just for fun.)

Goldfish are always a favorite!

Nemours/Alfred I duPont Hospital for Children
Laura Mitchell, CCLS

Sedation planning:

Who receives sedation?
When our patients are scheduled for a sedated VCUG, there are different options available (see below.) Stakeholders in this decision making process are Physicians, Nurses, parents, Child Life Specialists, and/or the patient

Who doesn’t?
Typically, children younger than six months are not scheduled with sedation.  Also if catheterization is part of a patient’s daily routine and would not be considered a stressor, they would typically not be scheduled for sedation for their VCUG.

Which medications are used?
Typically patients who receive sedation for this procedure fall into three categories:  versed only, versed and nitrous together or nitrous only.  Versed can be given by mouth or intra-nasal.

Who administers?
Once the Physician enters the order, the RN can give the Versed.  We keep in close communication with our Imaging team about procedure start times to ensure that the medication will be at peak effectiveness when needed. Our current workflow involves our Sedation Physician administering nitrous oxide during catheterization, however Sedation APNs have previously also assumed this role.

Pre-procedural education and/or play:

Is scripting utilized?
Pre-procedural preparation is tailored to meet the unique needs of each patient, though over time, some common themes have emerged.  We focus on the sensory elements of the procedure, sequence of events, staff roles and the patient’s “job.”  As a team, we also try to use consistent terms and phrases to increase understanding and demonstrate team collaboration.

Which educational tools are typically used?
In addition to images of the procedure rooms, we also show children the bedpans/urinals which they may need to use.  If nitrous oxide is part of the sedation plan, we will allow opportunities for role rehearsal to promote rhythmic breathing.  Children can choose their “flavor” and help put the lip balm in their mask.  Opportunities for guided medical play are also provided.

Imaging:

Which modality is utilized?
Fluoroscopy is typically used for our VCUGs.  However we have begun to explore utilizing ultrasound technology for CEVUS (Contrast-enhanced voiding urosonography)

Catheterization:

Who inserts the catheter?
For our VCUGs, the fluoro technologist typically inserts the catheter.  For our CEVUS procedures, the radiologist is responsible for this.

Non-pharmacological support:

Preferred approach to support?
Individualization is key.  Some children benefit from active engagement (conversation & play) while other seems to prefer a quieter environment with music and soothing touch.  Explanation about the procedure can also be valuable.  Whatever the approach, One VoiceTM is critical, especially if nitrous oxide is part of the medication plan.

Favorite resources?
If we assess that a child will benefit from alternate focus, an Ipad can be a great resource because it’s versatile and easy to clean between patients.  If a child prefers not to look, the Ipad serves a dual purpose of blocking site lines. Of course, a child’s favorite comfort item from home can also be incredibly helpful.

Parental Presence:

Yes or No?
Absolutely.  As long as a parent or caregiver feels comfortable, (assuming they pass safety screenings) they are more than welcome to accompany their child during this procedure.  Just as we prepare the patients, our team educates the parents for what they might see and how their child might respond during the procedure.  When a parent knows what to expect, they are better able support their child during a potentially challenging experience.  Kids will often look to their parents for guidance and reassurance so we try to help the parents feel as comfortable as they can be going into the procedure.

Post Procedural snack: (Just for fun.)

Though we offer saltines and graham crackers, Goldfish (and juice) is by far the most popular.