Common Pediatric Procedures

8/14/2019 Common Pediatric Procedures

1/59

Common PediatricProcedures


2/59

Introduction

See one, Do one, Teach one Always explain the procedure to thepatient/ parentsExplain the risk and complicationsObtain a written consent if indicated

Check the completeness of the materialsbefore starting


3/59

Common Procedures

Airway AccessBlood SamplingPeripheral Vascular AccessCentral Vascular AccessIntraosseous Infusion AccessUmbilical Artery and Vein CannulationLumbar PunctureOthers


4/59

Airway Access

1 st Priority in ABCs of Emergency Management Open the AirwaySupport the Breathing

Assess CirculationIndications for Respiratory Support:Impending Respiratory FailureNeurologic DeteriorationStructural Abnormalities


5/59

Airway Access

Types of Respiratory Support:Positioning Sniffing PositionO2 via Nasal Cannula/ Funnel/ Face MaskBag-Valve-Mask VentilationOropharyngeal AirwayNasopharyngeal AirwayCricothyrotomyTracheostomy


6/59

Endotracheal Intubation

Complications:Vocal Cord Stenosis/ Rupture

Subcutaneous EmphysemaPneumothorax

Atelectasis

InfectionBleeding


7/59

Endotracheal IntubationMaterials:Face Mask and AmbubagET tube of different sizes

LaryngoscopeO2 tubing and O2 sourceSuction machine and cathetersTape, Scissor, Tongue Guard

Pulse Oximeter, StethoscopeMedications: Atropine(0.02mg/kg) andEpinephrine(0.01mg/kg)


8/59


Procedure:i. Position, Ventilate with 100% O2ii. Prepare Materials and Monitoring

devices( O2 saturation and heart rate)iii. Visualize the Vocal CordsProperly align the mouth, pharynx and tracheaInsert the scope at the ride side of the mouth and try tosweep the tongueLook for the epiglottisLift the epiglottis using the tip of the scope


9/59


Procedure:iv. Do not attempt for more than 30 seconds

or heart rate decreases to


10/59

Endotracheal IntubationProcedure:viii. Assess for the position of ET

Observe for symmetrical chest movement Auscultate for equal breath sounds

Should have absent breath sounds over thestomachNotation of end-tidal carbon dioxide level

viii. WOF:

DisplacementObstructionPneumothoraxEquipment failure


11/59

Blood Sampling

A. Heel stick / Finger stickIndications: Blood sampling unaffected by

hemolysisComplications:

Infection

BleedingOsteolmyelitis


12/59

puncture : just off center and perpendicular to thefingerprint ridges

(A puncture parallel to the ridges tends to make the bloodrun down the ridges and hamper collection.)

proper location on the 3rd or 4th finger of the non-dominant hand

Capillary Blood Extraction


13/59


14/59


15/59

Puncture heel.

Wipe away first drop of blood

that may contain tissue fluidwith sterile gauze pad. Allowanother LARGE blood drop to

form.


16/59

The finger is gently massagedfrom base to tip and the blooddrops are collected into the

proper collection device. The blood is mixed inmicrotainers with anadditive.


17/59

Blood Sampling

B. Venous ExtractionIndications: Blood sampling for laboratory

studiesComplications: Thrombosis, bleeding,

infection Access sites:

Dorsal metacarpal, Median antebrachial, Basilic,Cephalic, Venous arch and plexus, GreaterSaphenous, Lesser Saphenous, Scalp veins


18/59

Blood Sampling

Procedure:1. Restrain the patient2. Prepare the site with 70% alcohol3. Apply tourniquet and insert the needle, bevel

up at 30 degree angle4. Extract only the needed amount

5. Apply dry cotton and withdraw the needle6. Apply pressure to the site


19/59


20/59


21/59

Blood Sampling

C. Arterial ExtractionIndications: Need for arterial blood sample

Complications: Infection, bleeding, occlusionof artery by hematoma or thromboses,ischemia

Access sites:Radial artery, posterior tibial and dorsalis pedis,Scalp(Temporal) arteries, *Brachial artery


22/59

Blood Sampling

Procedure:1. Locate the artery, usually radial artery2. Perform Allen test

3. Insert the needle (attached to a syringe) at 30-60degree angle over the point of maximal impulse4. Observe for free flow of blood into the syringe in a

pulsatile fashion

5. After drawing the blood, apply firm, constant pressurefor 5 minutes then place a pressure dressing on thepuncture site


23/59

Peripheral Vascular Access

Indications: To deliver fluid, medications orblood productsComplications: Infection, Thrombosis

Procedure:1. Choose a site and prepare with alcohol2. Apply tourniquet then insert IV catheter, bevel up, at

angle almost parallel to the skin, advancing until flashof blood is seen in the catheter hub.

3. Advance the plastic catheter only, remove the needleand secure the catheter.

4. Attach T connector/ heplock and flush with normalsaline


24/59


25/59


26/59


27/59


28/59

Central Vascular Access

Indications: to deliver high concentrationparenteral solutions, prolonged IV therapy,infusion of large amounts of blood products/

fluids and monitor central venous pressure

Complications: Infection, bleeding, arterial orvenous laceration, pneumothorax, hemothorax,thrombosis, catheter fragment in circulation, airembolism, AV fistula and catheter-related sepsis


29/59


Access Sites:External jugular vein

Internal jugular veinSubclavian veinFemoral vein

Note: Femoral vein catheterization is contraindicated insevere abdominal trauma, and Internal jugularcatheterization is contraindicated in patients with severeintracranial pressure elevation


30/59


Procedure:Seldinger technique

Modified Seldinger techniqueCut down


31/59

Intraosseous Infusion

Indications:Emergency access in child less than 8years oldVery useful during circulatory collapse/shockShould be removed once vascular accesshas been established (usually


32/59

Intraosseuos Infusion

Complications: Infection, bleeding,osteomyelitis, compartment syndrome, fatembolism, fracture, epiphyseal injury

Sites of Entry:1. Anteromedial surface of proximal tibia, 2 cm below and 2

cm medial to the tibial tuberosity2. Distal femur 3 cm above the lateral condyle in the

midline3. Medial surface of the distal tibia 1 to 2 cm above the

medial malleolus


33/59

Intraosseous Infusion

Procedure:1. Prepare the site with iodine solution2. Wear sterile gloves and lay a drape on the site3. May opt to anesthetize the site with 1% lidocaine4. Insert a large-bore gauge IO needle perpendicular to the surface

and advance to the periosteum with boring rotary motion5. Penetrate through the cortex until there is decrease in resistance,

indicating that you have reached the marrow

6.Remove the stylet and attempt to aspirate marrow

7. Flush with normal saline and attach to IV tubingNote: Any crystalloid, blood products or drugs can be infused through

the IO line


34/59

Umbilical Artery and VeinCannulation

Indications: Vascular access (UV) and forblood gas monitoring (UA) for critically illneonates

Complications: Infection, bleeding,hemorrhage, perforation of vessel,thrombosis with distal embolization,ischemia/infarction of lower extremities,bowel or renal vessels, arrhythmia, airembolus


35/59

Caution: Should not be performed if there isomphalitis

Line Placement:1. Arterial linea) High line (cm): [BW(kg) X 3] + 9

between T6-T9recommended for less than 750gr.

b) Low line (cm): BW(kg) + 7between L3-L5avoids renal and mesenteric arteries

2. UV line (cm): [high line UA / 2] + 1placed at inferior vena cava above the level ofductus venosus and below right atrium

Note: May not be appropriate for LGAs and SGAs


36/59

Procedure:1. Prepare materials/ catheters/sterile procedure

2. Determine the length of catheter to be inserted andflush with normal saline3. Apply umbilical suture/ tape and tighten accordingly to

prevent bleeding

4. Cut through the cord horizontally 1-2 cm from the skinand determine the vein and the arteries5. Grasp the catheter 1 cm from its tip with toothless

forceps and insert gently into the lumen up to the

desired level6. Secure the catheter by suturing and tape7. Confirm the position of the catheter tip radiologically


37/59

Lumbar Puncture

Indications: For examination of spinal fluid,instillation of chemotherapy, measurementof opening pressure and to decrease CSF

Complications: Infection, bleeding, spinalfluid leak, hematoma, headache, acquiredspinal cord tumor, epidural abscess

Contraindications: Overlying skin infection,Increased ICP, Bleeding diathesis,unstable patients (hypotensive, in shock)


38/59

Procedure:

Position: lateral recumbent with hips,knees and neck flexed


39/59

Locate The Puncture Site

spinal cord ends at the L1 and L2 vertebral bodies desired sites for lumbar puncture :interspaces between the posterior elements ofL3 and L4 or L4 and L5

an imaginary line from the iliac crest to the spine= the interspace between L4 and L5

Use it or the interspace cranial to it.

After locating the site of intended puncture, mark it byindentation of the skin with a fingernail.


40/59


41/59

Use Sterile Technique

Cleanse the skin with povidine-iodine solution after donning sterile

gloves.

Using sponges, begin at the intended puncture site and sponge inwidening circles until an area of 10 cm in diameter has beencleansed.


42/59

Drape the child beneath their flank and over the backwith the spine accessible to view.

A l L l A h i


43/59

Apply Local Anesthetic

Local anesthetic should be used in children older than 1 year ofage.

Inject 1% lidocaine intradermally to raise wheal, thenadvance the needle into the desired interspace injecting anesthetic,being careful not to inject it into a blood vessel or the spinal canal.

Prepare The Spinal Needle

1. Check the spinal needle to ensure that the stylet is firmly inposition

2. Support the needle between your index fingers and stabilize thehub of the needle with your thumbs.

3. Grasp the spinal needle firmly with the bevel facing up towardthe ceiling


44/59

Puncture

1. With the needle perpendicular to the vertical plane butwith the bevel pointed slightly cephalad, advancethrough the skin.

2 . Advance slowly into the deeper structures until you detect a slightresistance on penetration of the spinous ligaments. The resistancecontinues until the needle penetrates the dura, at which time you willtypically feel a "pop" sensation caused by the change in resistance. The

pop indicates that you are in the subarachnoid space.


45/59

3. Remove the stylet.

4. Check for flow of spinal fluid.

5. If there is no CSF, rotate the spinal needle a few millimeters forward,then recheck. Repeat.

6. Obtain opening pressure reading.

Obtaining Spinal Fluid Samples

1. Collect a total of 2 mL of CSF in the premature or full-term neonate. In older children 3 to 6 mL can be safelyremoved.

2. Note the character of the CSF and, if bloody fluid flowsoriginally, observe the fluid for clearing with subsequentcollection.

3. If the fluid does not clear this may indicate the presenceof a subarachnoid hemorrhage .


46/59

CSF Analysis

Send CSF for analysis of:

Cell count and differential.Protein and glucose determinations.Gram stain.

Routine culture.

To prevent misinterpretation caused by RBC contamination,send the last tube collected for cell count evaluation.

Obtain a peripheral serum glucose level immediately beforethe LP to determine the CSF serum ratio of glucose.

f ll fl d b l d


47/59

4. After collecting CSF fluid, obtain a closing pressure reading.

5. Replace the stylet and remove the needle.

6. Place a bandage over the site and encourage the patient, ifable, to lie prone for 3-4 hours to prevent leakage.


48/59

Others

Needling:- suspected pneumothorax- placed on 2 nd ICS, midclavicular line

- May cause bleeding, infection, pneumothoraxChest Tube Placement:

- confirmed pneumothorax

- place of entry is at the 3 rd 5 th ICS, mid toanterior axillary line, usually at the level of thenipple
http://images.google.com/imgres?imgurl=www.shieldhealth.com/images/ENTERAL4.gif&imgrefurl=http://www.shieldhealth.com/whatenteral.html&h=288&w=234&prev=/images%3Fq%3D%2522nasogastric%2Btube%2522%26svnum%3D10%26hl%3Den%26lr%3D%26ie%3DUTF-8%26sa%3DG


49/59

Orogastric / Nasogastric

Tube Insertiontube can be used :

initially to remove airand digestive juicesfrom the stomach

as a feeding tube

tube is uncomfortable, but not painful
http://images.google.com/imgres?imgurl=www.shieldhealth.com/images/ENTERAL4.gif&imgrefurl=http://www.shieldhealth.com/whatenteral.html&h=288&w=234&prev=/images%3Fq%3D%2522nasogastric%2Btube%2522%26svnum%3D10%26hl%3Den%26lr%3D%26ie%3DUTF-8%26sa%3DG


50/59

Correct size Adequate restrain Determine level Lubricate tube Check placement

Secure with tape


51/59


52/59

Torniquet Test

Test for capillary fragility :Platelet disordersVascular disorders

Determine the blood pressureInflate sphygmomanometer to midwaybetween systolic and diastolic pressuresRelease cuff after 5 minutes

After 2 minutes, measure a circle with 2.5cms diameterNormally < 10 petecchiae


53/59

Injections

Strict asepsis and adequate restrain

Intramuscular Injections

Site: infants anterolateral aspect ofthigh

older children deltoid muscleSize of needle : > 4 months - 1 needle

< 4 months - 5/8 needle (gauge 23 or 22)


54/59

Insert needle into site, aspirate, give injection
http://www.doh.state.fl.us/disease_ctrl/immune/images/big_nurse_vac.jpg


55/59
http://www.doh.state.fl.us/disease_ctrl/immune/images/big_nurse_vac.jpg


56/59

Subcutaneous injectionsSite : anterolateral aspect of the thigh or upper

armSize of needle: 5/8 , G25

Insert needle in a pinched up fold of

skin and subcutaneous tissue


57/59

Intradermal injectionSite: volar aspect of forearm ; deltoid for

BCGSize of needle : 5/8 , G25

Insert needle almost parallel to skin, bevel up.

Injection would result to a wheal.


58/59


59/59

Thank You !!!

Common Pediatric Procedures

Documents

Transcript of Common Pediatric Procedures