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Oversedation can cause serious adverse events like respiratory insufficiency and cardiovascular depression besides the risk of aspiration [5]. As per the 2016 update of American Academy of Pediatrics guidelines on monitoring pediatric patients under sedation [6], sedation is known to cause serious adverse events especially in children less than 6 years old. Because the intended level of sedation may be exceeded, the person monitoring needs to be well trained in managing pediatric apnea, laryngospasm, and airway obstruction. Hence also the role of a pediatric anesthesiologist is highlighted. With advancement in pediatric anesthesia, administration of GA to a child has become extremely safe. GA even without muscle relaxants owing to its inherent analgesic and muscle relaxant property relaxes the abdominal muscle tone and voluntary pressure exerted by a crying child. In case of an unsuccessful reduction or complication, precious time is saved as the patient is already in the OR. Thus, in addition to a higher rate of success, GA is safer than sedation [7]. The “RIGHT” technique we describe here, involves three elements: general anesthesia, hydrostatic reduction, and USG guidance, which entails an anesthesiologist, pediatric surgeon, and radiologist working in tandem. Reduction of intussusception under GA has been reported in a few studies, but has not been used as a protocol in management. Chatterejee et al. described a technique of hydrostatic reduction assisted manually after performing a laparotomy which can be used by surgeons in resource challenged situations where USG or fluoroscopy is unavailable [8]. Purenne et al. [7] showed that the success rate of reduction by air enema increased when the procedure was done under GA when compared to sedation. However, they performed the procedure in the radiology suite and in cases where surgery was required, the anesthesia was maintained, and the patient was shifted to the OR. Collins et al. [9] in their study achieved successful reduction under GA in those cases which had one failed attempt under sedation. They proposed that GA reduces abdominal wall muscle tone and relaxes a struggling child with abdominal pain, allowing for better conditions for hydrostatic reduction. They also proposed that anestheticinduced reductions in splanchnic blood flow may result in less edema of the bowel wall, which could prevent obstruction and further compromise. Chandrashekharam et al. [2] in their technique done under GA monitored the reduction of intussusception under direct vision after introducing a laparoscope. Digant et al. [10] evaluated the role of USG guidance for hydrostatic reduction using normal saline and concluded that it was an optimal and safe procedure. In our study, the success rate of 44 out of 48 (91.6%) is closer to the success rate with hydrostatic reduction Table 3 Correlation among age in months, duration, volume of fluid, and time for reduction Age in months Symptom duration Volume of fluids Time for reduction Age in months 1 Duration − 0.07 (0.6) 1 Volume of fluids − 0.04(0.8) 0.5 (0.0001) 1 Time for reduction − 0.01 (0.9) 0.5 (0.0002) 0.9 (< 0.0001) 1 Chand et al. Annals of Pediatric Surgery (2021) 17:9 Page 6 of 7 under ultrasound guidance of 95.5% as reported by Bai et al. [11] and Wang and Liu [12]. In all the four patients who underwent surgical exploration, there was no time lag as surgical team was scrubbed and ready and the child was already under GA. Surgery MD: Johns Hopkins University School of Medicine General surgery residency: The Johns Hopkins Hospital Plastic surgery residency: Massachusetts General Hospital Hand surgery fellowship: Indiana Hand Center Expertise: hand transplant; immune modulation; hand and upper extremity surgery Accomplishments: Distinguished Alumnus Award by Johns Hopkins University (2015); Research Achievement Award for Basic Research from the American Association of Plastic Surgeons (2014); the Andrew J. Weiland Medal for Outstanding Research from the American Society for Surgery of the Hand (2014); led the surgical team that performed the nation’s first double-hand transplant in 2009 and the first trans-humeral transplant in 2010; chair of Plastic Surgery Research Council (2001-2); president of the American Society for Surgery of the Hand (2011–12); chair of the American Board of Plastic Surgery (2012–13); president of American Society of Reconstructive Transplantation (2014-16) Gerald Brandacher, M.D. Scientific Director, Vascularized Composite Allotransplantation Program Associate Professor of Plastic and Reconstructive Surgery MD: School of Medicine, Leopold Franzens University, Innsbruck, Austria General and transplant surgery residency: Innsbruck Medical University, Austria Expertise: vascularized composite allotransplantation (VCA); solid organ transplantation; transplant immunology Accomplishments: helped design a novel, cell-based immunomodulatory treatment protocol for VCA; member of the team performing the first bilateral hand transplant and first forearm transplant in the U.S.; research on donor-specific immune tolerance and immunomonitoring strategies for hand and face transplant; chair of the American Society of Transplantation VCA Advisory Council, chair of VCA Committee of the European Society of Organ Transplantation, treasurer of American Society of Reconstructive Transplantation; co-founder and Editor-in-Chief Vascularized Composite Allotransplantation (VCA) journal; selected as a “Fellow of the American Society of Transplantation (FAST)” (2015) Kristen Parker Broderick, M.D. Assistant Professor of Plastic and Reconstructive Surgery MD: Texas A&M University General surgery residency: University of North Carolina Hospital Plastic surgery residency: New York Presbyterian Hospital Weill Cornell/Columbia Breast reconstruction fellowship: Washington University St. Louis Expertise: breast reconstruction, cosmetic breast surgery, microvascular reconstruction, body contouring Accomplishments: numerous clinical and leadership awards and recognitions Julie Caffrey, D.O., M.S. Assistant Professor of Plastic and Reconstructive Surgery DO: Philadelphia College of Osteopathic Medicine MS: Philadelphia College of Osteopathic Medicine General surgery residency: Flushing Hospital Medical Center Burn Fellowships: Westchester Medical Center and The Johns Hopkins University Expertise: adult and pediatric acute burn injury, burn reconstruction, laser therapy forpost-burn scar contractures and hypertrophic scarring, surgical management of hidradentitis suppurativa Accomplishments: researching laser therapy for hypertrophic scarring after burn injury, establishing educational curriculum in burn Carisa Cooney, M.P.H., C.C.R.P. Assistant Professor of Plastic and Reconstructive Surgery and Clinical Research Manager BA: Kenyon College; Gambier, OH MPH: University of Illinois; Springfield, IL Expertise: clinical research on abdominal surgery wound therapy, vascularized composite allo-transplantation (VCA), and breast reconstruction outcomes; enhancement of resident physician education Accomplishments: original publications and ongoing research grants on improving patient outcomes after plastic and reconstructive surgery and on enhancing residency training Damon S. Cooney, M.D., Ph.D. Assistant Professor of Plastic and Reconstructive Surgery MD: University of Oklahoma Health Sciences Center PhD: Ohio State University Plastic surgery residency: Southern Illinois University School of Medicine Microsurgery fellowship: University of Pittsburgh Medical Center Expertise: general plastic surgery; microvascular reconstruction after breast cancer, head and neck cancer and trauma; hand surgery; reconstructive transplantation Accomplishments: research on vascularized composite allo-transplantaion (VCA); engineering human tissues for reconstructive purposes and nerve regeneration; microsurgical education; hand, face, and penile transplantation clinical trials Amir H. Dorafshar, M.B.Ch.B. Associate Professor of Plastic and Reconstructive Surgery Clinical Co-Director, Face Transplant Program MBChB: University of Manchester, United Kingdom General surgery residency: University of Chicago Medical Center Plastic surgery residency: University of Chicago Medical Center Vascular surgery research fellowship: University of California Los Angeles Craniofacial surgery and microsurgery fellowship: The Johns Hopkins Hospital and R Adams Cowley Shock Trauma Center Expertise: microvascular reconstruction; adult and pediatric craniofacial surgery for congenital, oncological and traumatic conditions; facial reanimation; orthognathic surgery; aesthetic facial plastic surgery Accomplishments: House of D Outcomes Research in Facial Plastic Surgery: A Review and New Directions Ramsey
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