Anesthesiology

Intussusception

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What the Anesthesiologist Should Know before the Operative Procedure

Infants and children scheduled for intussusception reduction may have been ill for several days, since presenting signs are variable and somewhat nonspecific. Only a minority of infants demonstrate the classic triad of abdominal pain, vomiting, and blood per rectum, so the diagnosis may be missed until the child is quite ill with dehydration, shock, bowel obstruction, and/or perforation. Other presenting signs may include fever and a notable alteration in mental status, suggesting other diagnoses, such as sepsis or meningitis.

1. What is the urgency of the surgery?

What is the risk of delay in order to obtain additional preoperative information?

Most cases of intussusception present as urgent or emergent procedures. Urgent, in the case of a distended abdomen and bowel obstruction; emergent in the case of bowel perforation, either spontaneously, or as a result of failed radiologic reduction of the intussusception. The presence of hypovolemic shock creates a medical emergency that must be addressed before surgery.

Delaying surgery longer than necessary to obtain additional information prolongs the time of obstruction of the intussuscepted bowel and may further increase edema, venous congestion, and the likelihood of gangrene or perforation.

Emergent: Bowel perforation following a barium enema is an emergency procedure, further complicated by the spillage of barium into the abdomen. Spontaneous bowel perforation may also create an emergency situation, particularly if the abdomen is distended enough to cause respiratory embarrassment. All infants and children with bowel perforation, regardless of NPO status, should be considered to have a full stomach.

Urgent: Failed reduction of the intussusception by a barium enema or a distended abdomen with acute peritoneal signs or the presence of an abdominal mass constitute an urgent procedure, and surgery should proceed as soon as euvolemia is ensured and the OR is properly prepared. The longer a piece of bowel is telescoped into the adjacent bowel, the greater is the edema and venous congestion, raising the tissue pressure and leading to ischemia and gangrene of the bowel.

Elective: Reduction of an intussusception would only be considered an elective procedure if the clinical picture suggests intermittent or repeated self-resolving bowel obstruction, and only in the absence of acute obstruction. This is not a common clinical picture and is more likely to be seen in older children in whom a specific intra-abdominal condition, such as lymphoma or cystic fibrosis, has caused the intermittent intussusception.

2. Preoperative evaluation

A routine preoperative history and physical examination will uncover underlying coexisting diseases that might affect anesthetic management, such as congenital heart disease, asthma, upper respiratory infection, cystic fibrosis, congenital syndromes or inborn errors of metabolism, coagulopathy, or sickle cell disease. A focused physical exam should be performed, with particular attention to mental status, airway anatomy, signs of volume depletion, respiratory distress from the distended abdomen, and presence of, or ease of establishing intravenous access.

Specific to intussusception, the most important focus of the preoperative evaluation is to assess the patient's volume status, since vomiting, refusal to feed, and even diarrhea at the onset of the intussusception may lead to hypovolemia or shock. Secondarily, an assessment of hemoglobin status and the possibility of blood loss necessitating transfusion should be considered. Transfusion is not likely to be required in the absence of a significant preexisting anemia or the need to resect a long segment of bowel.

Medically unstable conditions warranting further evaluation include: hypoxemia of uncertain etiology, hypotension and shock, or an underlying coagulopathy requiring replacement of clotting factors.

Delaying surgery may be indicated if the infant has a severe or palliated congenital heart lesion for which specific expert intervention or consultation might improve the outcome, such as a child with tetralogy of Fallot who presents in a hypercyanotic state.

The vast majority of other coexisting conditions should not delay surgery once intravascular volume has been restored.

3. What are the implications of co-existing disease on perioperative care?

N/A

b. Cardiovascular system

Children with congenital heart disease may present for surgical reduction of intussusception. It is vitally important that the anesthesiologist understand the patient's anatomy and cardiac function prior to planning an anesthetic. Shunting lesions, mixing lesions, obstructive lesions, and regurgitant lesions, as well as partially corrected or palliated lesions, may all be seen in young infants, and each has significant implications for planning an anesthetic. The practitioner must review all recent diagnostic studies, ascertain the patient's current cardiac function, and reconcile the patient's medications. New studies are unlikely to be performed in the instance of an urgent or emergent procedure. The reader is encouraged to read an excellent review of this topic as cited in the references.

c. Pulmonary

Reactive airway disease (Asthma)

The infant or child who presents with active wheezing at the time of surgery may be quickly treated so that the surgery can proceed. Administration of inhaled bronchodilators may be done in the immediate perioperative period, and steroid administration should be considered as an adjunct to managing the acute situation. At the time of induction of anesthesia, the practitioner should take steps to assure that the airway is adequately anesthetized prior to instrumentation; intravenous lidocaine, 1-2 mg/kg prior to laryngoscopy, as well as fentanyl 3-5 mcg/kg may protect the patient from worsening of the bronchospasm. Additional beta-agonist may be administered through the breathing circuit as needed. The goals for ventilation in this setting are to minimize peak airway pressure, and to provide adequate expiratory time for exhalation.

Upper respiratory infection

Like the child with asthma, the child with an acute upper respiratory tract infection is likely to demonstrate a hyper-reactive airway, with increased secretions, and a propensity for coughing, bronchospasm, laryngospasm, and increased airway pressures. Management will be similar to that for the child with asthma.

Cystic fibrosis

For children presenting with intussusception over the age of 1 year, cystic fibrosis is one of the more common predisposing conditions. These children may demonstrate, even at an early age, significant pulmonary disease with thick, inspissated secretions, frequent pulmonary infections, and bronchospastic disease. Previously prescribed pulmonary treatments should be continued up to the time of anesthesia, and additional beta-agonist therapy may be required. Similar precautions regarding adequate anesthesia for the airway should be observed. Adding a humidifier to the breathing circuit will help keep the secretions mobilized.

d. Renal-GI:

A basic metabolic panel including electrolytes, glucose, blood urea nitrogen, and creatinine should be obtained, regardless of whether there is a history of renal disease, which may be silent in infancy.

e. Neurologic:

The history of neurologic conditions may complicate the diagnosis of intussusception, since one of the characteristic findings in intussusception is lethargy. Without the classic history or physical signs of intussusception, lethargy is a nonspecific finding that may signal a postictal state in the child with a seizure disorder or sepsis in the young infant vulnerable by virtue of neuromuscular disease and difficulty protecting the airway, or a reaction to medication or evidence of hypoglycemia or electrolyte disturbance. Other neurologic findings in intussusception are apnea, seizures, hypotonia, and opisthotonus, which may also be seen in other infants and children with neurologic conditions.

In evaluating these children prior to surgery, the history of the child's usual pattern of behavior or neurologic symptoms is important. Chronic medications, particularly anticonvulsant agents, should be administered if possible, on the child's usual schedule. Medications for increased muscular tone should probably be held in the perioperative period, since hypotonia may present with the intussusception.

f. Endocrine:

N/A

g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)

One special population is the formerly premature infant, who may have ongoing issues, including bronchopulmonary dysplasia with oxygen requirement and/or pulmonary hypertension, apnea and bradycardia, developmental delay and muscular weakness, seizure disorder, or a history of prior abdominal surgery from necrotizing enterocolitis.

4. What are the patient's medications and how should they be managed in the perioperative period?

The practitioner should take the history of medications being administered on a chronic basis, as well as those given in response to the infant's symptoms at home. If there are chronic meds that the infant requires, such as anticonvulsants, asthma, or cardiac medications, those agents should be administered as usual, with the exception of diuretics. Routes other than oral should be utilized, since the gastrointestinal tract is nonfunctional in the preoperative period. Prophylactic aspirin prescribed for congenital heart patients does not need to be held and should not impact surgical bleeding in this procedure.

h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?

N/A

i. What should be recommended with regard to continuation of medications taken chronically?

Cardiac:Continue cardiac medications, particularly those for pulmonary hypertension, with the exception of diuretics, which should be held in the perioperative period.

Pulmonary: Bronchodilators may be administered as usual.

Renal: Oral medications should be held. Diuretics should not be given.

Neurologic: Anticonvulsant medications may be administered in the perioperative period, provided that there is a parenteral route for the agent. Agents administered for spasticity or increased tone should probably be held in the perioperative period, since lethargy and/or weakness may be seen in the perioperative period in infants with intussusception, and may persist into the postoperative period.

Antiplatelet: Aspirin administered for congenital heart patients does not need to be held in the perioperative period; like most anti-platelet agents, it has a prolonged duration of action which will persist in the perioperative period whether it is continued or not.

Psychiatric: Agents of this class are unlikely to be administered to patients in the age group most likely to develop intussusception.

j. How To modify care for patients with known allergies -

For patients with known allergies, alternative agents should be administered. For induction agents, there are at least three agents commonly available: propofol, etomidate, or ketamine.

Even though neuromuscular blocking agents are among the most common causes of anaphylactic reactions in the OR, most infants presenting with intussusception will not have had prior exposure, so the likelihood of allergic reaction is quite low.

Similarly, true allergic reactions to opiates would be most unusual at this age.

The infant might have had an adverse reaction to one or more antibiotics administered for common pediatric infections. Although these reactions generally fall into the category of side effects rather than true allergic reactions, giving a different class of agent in the OR will avoid the issue altogether.

k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.

If the OR suite is not a latex-free environment, then careful examination of all products that will touch the infant's skin or be injected must be carried out prior to bringing the patient into the room.

l. Does the patient have any antibiotic allergies- - Common antibiotic allergies and alternative antibiotics]

For patients with penicillin allergy, there is a 15% cross-reactivity with cephalosporins. Either a small test dose may be administered, or an agent of a different class may be selected. For surgical prophylaxis of skin incision sites, either clindamycin or vancomycin may be administered instead of cephalosporins. For infants with bowel perforation, the surgeon may request an aminoglycoside for coverage of gram negative bacteria as well.

m. Does the patient have a history of allergy to anesthesia?

Malignant hyperthermia (MH)

Documented- avoid all triggering agents such as succinylcholine and inhalational agents

  1. Proposed general anesthetic plan: For young children with a prior history of MH or a DNA diagnosis of one of the known mutations in the ryanodine receptor, a total intravenous anesthetic technique should be administered, using a propofol infusion at 100-200 mcg/kg/min, a nondepolarizing muscle relaxant, and an opiate of the practitioner's choice, in combination with an air/oxygen mixture. Nitrous oxide is not contraindicated for patients at risk for MH, but would not be appropriate in the setting of bowel obstruction. Regional techniques may be used to provide intraoperative anesthesia and postoperative analgesia.

  2. Ensure that the MH cart is available, and review the MH protocol prior to initiating anesthesia.

  3. Family history or risk factors for MH: Infants with a first-degree relative with known MH should be considered at risk for MH, whether or not the infant has had a prior MH reaction to triggering anesthetics. Although a number of coexisting conditions have, at one time or another, been implicated as risk factors for MH, the current list of diseases thought to be associated with MH is quite limited: central core myopathy, multi-minicore disease with the RYR1 mutation, and the King-Denborough syndrome. The practitioner should check the excellent resources on the Malignant Hyperthermia Association of the US website for the latest information: www.mhaus.org

Local anesthetics/ muscle relaxants

A history of allergy to muscle relaxants and local anesthetics would be very unusual in the age group of children presenting with intussusception; however, if such an allergy exists, then those agents should be avoided. Infants allergic to agents in the amide class of local anesthetics could receive ester-class agents, and those allergic to one nondepolarizing agent should be administered a different drug.

5. What laboratory tests should be obtained and has everything been reviewed?

For the healthy infant presenting with intussusception, routine preoperative laboratory tests should include a complete blood count with differential, electrolytes, glucose, blood urea nitrogen, and creatinine level. Unless there is a history suggesting coagulopathy, bleeding studies are not warranted.

For the infant presenting with hypovolemia or frank shock, the practitioner should consider drawing an arterial blood gas and a lactate level to help in the assessment and management of metabolic acidosis.

If the infant's course has been prolonged, and or the surgeon suspects that bowel resection will be necessary, a type and screen, or type and crossmatch for packed cells should be considered. It is important to request "fresh" blood for infants to minimize the risk of administering stored blood with a high potassium content.

Hemoglobin levels: Will vary by age for infants at the greatest risk for developing intussusception. The infant will demonstrate the physiologic nadir of Hgb of about 10 g/dL, which occurs at 3-4 months of age. Between then and 1 year of age, the Hgb will increase to approximately 13 g/dL.

Electrolytes: Common findings in intussusception will vary, depending on the clinical picture; normal values would not be surprising in the infant who has been ill for only several hours. Infants who have had prolonged vomiting may demonstrate the hypochloremic metabolic alkalosis, much like those with pyloric stenosis, while infants who are hypovolemic or in shock will demonstrate metabolic acidosis

Coagulation panel: Most patients with intussusception will have normal coagulation studies, unless there is a preexisting disease or anticoagulant medications have been administered.

Imaging: The diagnosis of intussusception, if not suspected or established by history and physical exam, may be made by abdominal ultrasound, by barium enema, or by CT scan of the abdomen. Plain films of the abdomen should demonstrate air-fluid levels suggesting intestinal obstruction, and there may be scant bowel contents on the right side of the abdomen; but these findings may not be specific for intussusception. The barium enema has the advantage of being both diagnostic and therapeutic in the vast majority of cases, since the hydrostatic pressure of the column of barium frequently reduces the intussusception. More recently, a hydrostatic reduction of intussusception may be performed with air instead of with barium. A preoperative chest radiograph is not indicated, unless respiratory signs and physical exam suggest coexisting pulmonary conditions or aspiration related to vomiting.

Other tests: NA

Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?

General anesthesia is the most appropriate anesthetic technique for infants undergoing reduction of intussusception. There are no data to show that one specific technique is preferable over another, but most commonly, a balanced anesthetic technique is selected. Airway control, muscle relaxation, and analgesia are necessary throughout the procedure. Secure intravenous access is necessary since fluid requirements may be considerable; a Foley catheter is recommended as a guide for fluid replacement.

a. Regional anesthesia

Although regional techniques might be included in the perioperative plan for analgesia, a regional technique by itself is not recommended in the awake child with bowel obstruction.

Neuraxial

Benefits

The benefits of a neuraxial blockade include profound analgesia and muscle relaxation of the abdominal muscles. A single-shot caudal epidural injection is the simplest and most practical regional option in this setting for supplementing the general anesthetic and providing postoperative analgesia without unduly delaying the onset of surgery. Alternatively, an epidural catheter could be placed in the caudal, lumbar, or low thoracic epidural space after the induction of general anesthesia, depending on the expected level of the incision. Caudal epidural catheters can be threaded into the thoracic epidural space in infants; either fluroscopy or injection of radiopaque dye should be used to confirm the location of the catheter tip at the desired dermatomal level. Less commonly utilized in most centers, a subarachnoid block could be performed for this procedure once the airway has been secured.

Drawbacks

The major drawback of epidural analgesia in this setting is the time involved for placement of the catheter in an infant with bowel obstruction or perforation. Neuraxial techniques should not be performed in patients with hypovolemia or sepsis, even though infants do not demonstrate a marked fall in blood pressure with epidural blockade. Additionally, the hospital must have the capability to monitor and care for infants with epidural catheters postoperatively. The main drawback to the subarachnoid block is the short duration of action--generally just over an hour--in the event that the procedure took longer than an hour, or required bowel resection unexpectedly.

Peripheral nerve block

Benefits

The most practical peripheral nerve block for this procedure would be bilateral ultrasound-guided blocks of the transverse abdominis process (TAP block), which would reduce anesthetic and opiate requirements while contributing to postoperative analgesia. The space is quite superficial and narrow in young infants, so this block should be reserved for use by those practitioners skilled in the use of ultrasound in small children. One to 2 ml of local anesthetic per side prior to incision should be sufficient.

Drawbacks

The main drawback for this technique would be the potential for inadvertent injection into the peritoneal cavity.

b. General Anesthesia

Benefits

The benefit of general anesthesia in this clinical setting is the opportunity for control of the airway and the cardiovascular and respiratory systems throughout the operative period.

Airway concerns

The child with a bowel obstruction is considered to have a full stomach, regardless of the timing of the last oral intake. For this reason, most practitioners would perform either a rapid sequence induction or a modified rapid sequence induction, being careful not to inflate the stomach until the airway is secured. A cuffed endotracheal tube can be used in this setting without concern for airway damage. At the end of the procedure, the infant should be awakened from anesthesia before extubation of the trachea, using standard extubation criteria.

c. Monitored Anesthesia Care:

Not applicable for this procedure.

What is the author's preferred method of anesthesia technique and why?

The author''s technique for anesthesia for these procedures begins with placement of routine monitors, checking the IV line for patency, and providing preoxygenation. A rapid sequence induction follows, generally with propofol or ketamine, rocuronium or succinylcholine, and fentanyl, 3-5 mcg/kg initially. Once the trachea has been intubated with a cuffed endotracheal tube, a mixture of sevoflurane and air/oxygen would be administered to maintain oxygen saturation >95%. A nasogastric tube is inserted to empty the stomach, if not placed in the preoperative period.

The decision to use sucinylcholine rather than rocuronium might be made because the surgeon reported that the intussusception "almost" reduced with the barium enema, so that the induction of general anesthesia alone may be sufficient for relaxation and reduction--in that case, the procedure might be very quick, shorter than the duration of neuromuscular blockade from an intubating dose of rocuronium.

The decision to use sevoflurane rather than isoflurane or desflurane is a personal choice, not reflecting data. Fluid administration would consist of a balanced salt solution; for the youngest infants, or for formerly premature infants, glucose could be added to assure normoglycemia. The author would place an arterial catheter in any infant who required vigorous fluid resuscitation (especially if vasoactive substances were required), or in infants for whom a bowel resection is planned, or in infants with bowel perforation. Having said that, the surgery should not be delayed if arterial access is not promptly secured.

Time permitting, a single shot caudal block with ropivacaine 0.2% at 1 mL/kg would be performed for postoperative analgesia. If it had not been administered earlier, the author would also administer either rectal or (more likely) intravenous acetaminophen as part of the analgesic plan; similarly, ketorolac would be given at the time of abdominal closure, provided that urine output is appropriate.

At the end of the procedure, the neuromuscular blockade would be reversed, the infant awakened, and the trachea extubated once airway reflexes have returned. As with surgery in any infant, this patient should be placed on a forced air warming device, and should receive other active warming measures, including the placement of a heat/moisture exchanger in the anesthesia circuit, wrapping of the extremities and head, and instillation of warmed IV fluids.

What prophylactic antibiotics should be administered?

For skin prophylaxis alone, in the absence of bowel perforation and/or the concern regarding bowel resection, Cefazolin alone, 25 mg/kg should be administered prior to incision. For patient who are expected to require extensive bowel manipulation, resection, or perforation, Cefoxitin 30-40 mg/kg should be administered before surgery. These dosing guidelines reflect SCIP recommendations as of October 2007.

What do I need to know about the surgical technique to optimize my anesthetic care?

Before inducing anesthesia, the practitioner should find out from the surgeon about the specific site of the intussusception, about the attempts to reduce the intussusception, how long the child has been ill, and the anticipated likelihood of bowel resection. In addition, it is helpful to know the level and orientation of the incision, in case a regional technique is planned. In the most common example, the terminal ileum has telescoped into the right colon, so that the right lower quadrant appears sunken or empty, while the right upper quadrant contains the mass of intussuscepted bowel; in this example, the incision will likely be a right horizontal incision at or just above the level of the umbilicus. In some institutions, the procedure may be done as a laparoscopic-assisted procedure, particularly if the intussusception is felt to be easy to reduce. In some reports, 80% of intussusceptions are reduced at the time of the barium enema.

What can I do intraoperatively to assist the surgeon and optimize patient care?

During surgery, the practitioner should maintain neuromuscular blockade to assist the surgeon in opening and closing the abdomen. Fluid management intraoperatively is important: sufficient to maintain an adequate intravascular volume, but not so much as to further bowel edema or to cause pulmonary edema.

What are the most common intraoperative complications and how can they be avoided/treated?

Prioritize them by urgency. The only intraoperative complication specific to this procedure would be the unexpected perforation of the bowel at the time of attempted reduction. In that case, the abdominal cavity becomes contaminated with bowel contents, and a segmental bowel resection might be necessary. The anesthesiologist's role would be to maintain cardiopulmonary function and to provide sufficient intravenous fluid to maintain intravascular volume.

There are no other specific complications related to intussusception reduction.

a. Neurologic: *** Type Here.

N/A

b. If the patient is intubated, are there any special criteria for extubation?

Standard criteria for extubation should be observed, including awakening from anesthesia with recovery of airway reflexes, reversal of neuromuscular blockade, normothermia, and replenishment of the intravascular volume. For infants, one practical sign demonstrating effective recovery of neuromuscular function is the infant's ability to flex the hips and bring the thighs up to the abdomen; this sign may be blunted or absent if epidural or spinal blockade was performed.

c. Postoperative management

What analgesic modalities can I implement?

The most effective analgesic plan is a multimodal plan that combines opiate therapy with nonopiate agents such as acetaminophen or ketorolac. The choice of opiate is most commonly morphine or fentanyl in the perioperative period. Although some hospitals permitted PCA therapy by nurse or parent, there is a greater incidence of adverse events requiring transfer to a higher level of care when surrogates administer the PCA. Intermittent opiates administered by a nurse every 2-3 hours should provide acceptable analgesia when combined with other therapies. Infants with poor urine output or insufficient volume replacement should not receive ketorolac. Recommended dosing schedules should be followed.

What level bed acuity is appropriate?

For most patients recovering from an uncomplicated intussusception procedure, recovery on a general patient care unit is acceptable. Exceptions might include infants with severe or unstable co-existing conditions, particularly if the patient presented in shock, if the intussusception was difficult to reduce, required bowel resection, and/or transfusion. In those cases, recovery in an intermediate care or intensive care unit might be warranted. Obviously, if the infant does not meet extubation criteria at the end of the procedure, ventilation in PACU or the ICU will be necessary until criteria are met.

What are common postoperative complications, and ways to prevent and treat them?

Postoperative complications of intussusception surgery are the same as other intra-abdominal procedures: postoperative fever, atelectasis, urinary tract infection, wound infection, prolonged ileus, and difficulty re-feeding. Infectious complications are prevented with meticulous attention to skin, wound, IV site, and foley catheter care, as well as with the administration of prophylactic antibiotics for the first 24 hours after surgery. Postoperative fever and atelectasis are common, and may be managed/prevented by early mobilization after surgery, as well as by encouraging coughing and deep-breathing (not easy to do in an infant!)

What's the Evidence?

Waseem, M, Rosenberg, HK. "Intussusception". Pediatr Emerg Care. vol. 24. 2008. pp. 793-800.

Hammer, G, Hall, S, Davis, P, David, PJ, Cladis, FP, Motoyama, EK. "Anesthesia for General abdominal, thoracic, urologic, and bariatric surgery". Smith's anesthesia for infants and children. Elsevier. 2011. pp. 745-85.

Kleizen, KJ, Hunck, A, Wijnen, MH, Draaisma, JM. "Neurological symptoms in children with intussusception". Acta Paediatr. vol. 98. 2009. pp. 1822-4.

(Classic findings in intussusception occurs in a minority of patients. Neurologic symptoms can occur and include lethargy, hypotonia, and alterations of consciousness.)

Hryhorczuk, AL, Strouse, PJ. "Validation of US as a first-line diagnostic test for assessment of pediatric ileocolic intussusception". Pediatr Radiol. vol. 39. 2009. pp. 1075-9.

(Ultrasound examination for ileocolic intussusception was shown to have a 97.9% sensitivity and a 97.8% specificity.)

Brenn, BR, Katz, A. "General anaesthesia may improve the success rate of hydrostatic reductions of intussusception". Paediatr Anaesth. vol. 7. 1997. pp. 77-81.

Suzuki, M, Hayakawa, K, Nishimura, K, Koide, M, Tateishi, S, Yamamoto, E, Mukaihara, S, Morikawa, S. "Intussusception: the role of general anesthesia during hydrostatic barium reduction". Radiat Med. vol. 17. 1999. pp. 121-4.

(General anesthesia for first time reduction of intussusception did not offer an advantage to patients who were not anesthetized.)

Collins, DL, Pinckney, LE, Miller, KE, Bastian, JF, Katzman, DO, Canty, TG, Waldman, J. "Hydrostatic reduction of ileocolic intussusception: a second attempt in the operating room with general anesthesia". J Pediatr. vol. 115. 1989. pp. 204-7.

(Second attempts at hydrostatic reductions of ileocolic intussusception while the patient is anesthetized can be successful in almost 90% of patients.)

Diaz, LK, Androoulos, DB. "Anesthesia for noncardiac surgery and magnetic resonance imaging". Anesthesia for congenital heart disease. Wiley-Blackwell. 2010. pp. 546-82.

Tait, AR. "Upper airway infection and pediatric anesthesia: how is the evidence based?". Curr Opin Anaesthesiol. vol. 15. 2002. pp. 317-22.

(A review of the risks of airway infections with anesthesia.)

Benca, J, Hogan, K. "Malignant hyperthermia, coexisting disorders, and enzymopathies: risks and management options". Anesth Analg. vol. 109. 2009. pp. 1049-53.

(Review paper on MH.)

Gurnaney, H, Brown, A, Litman, RS. "Malignant hyperthermia and muscular dystrophies". Anesth Analg. vol. 109. 2009. pp. 1043-8.

(Review paper on MH and muscular dystrophy.)

Fraser, JD, Aguayo, P, Ho, B, Sharp, SW, Ostlie, DJ, Holcomb, GW, St Peter, SD. "Laparoscopic management of intussusception in pediatric patients". J Laparoendosc Adv Surg Tech A. vol. 19. 2009. pp. 563-5.

(Laparoscopic approach to intussusceptions.)

Bonnard, A, Demarche, M, Dimitriu, C, Podevin, G, Varlet, F, Francois, M, Valioulis, I, Allal, H. "Indications for laparoscopy in the management of intussusception: A multicenter retrospective study conducted by the French Study Group for Pediatric Laparoscopy (GECI)". J Pediatr Surg. vol. 43. 2008. pp. 1249-53.

(Retrospective review of small number of people undergoing laparoscopic reduction of intussusception.)

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