Common Pediatric Procedures

Introduction
See one, Do one, Teach one Always explain the procedure to the
patient/ parents Explain the risk and complications Obtain a written consent if indicated Check the completeness of the materials before starting

Common Procedures
Airway Access Blood Sampling Peripheral Vascular Access Central Vascular Access Intraosseous Infusion Access Umbilical Artery and Vein Cannulation Lumbar Puncture Others

Airway Access
1st Priority in ABCs of Emergency Management
Open the Airway Support the Breathing Assess Circulation Indications for Respiratory Support: Impending Respiratory Failure Neurologic Deterioration Structural Abnormalities

Airway Access
Types of Respiratory Support:
Positioning Sniffing Position O2 via Nasal Cannula/ Funnel/ Face Mask Bag-Valve-Mask Ventilation Oropharyngeal Airway Nasopharyngeal Airway Cricothyrotomy Tracheostomy

Endotracheal Intubation
Complications:
Vocal Cord Stenosis/ Rupture Subcutaneous Emphysema Pneumothorax Atelectasis Infection Bleeding

Endotracheal Intubation
Materials:
Face Mask and Ambubag ET tube of different sizes Laryngoscope O2 tubing and O2 source Suction machine and catheters Tape, Scissor, Tongue Guard Pulse Oximeter, Stethoscope Medications: Atropine(0.02mg/kg) and Epinephrine(0.01mg/kg)

Endotracheal Intubation
Procedure: i. Position, Ventilate with 100% O2 ii. Prepare Materials and Monitoring
devices( O2 saturation and heart rate) iii. Visualize the Vocal Cords
Properly align the mouth, pharynx and trachea Insert the scope at the ride side of the mouth and try to sweep the tongue Look for the epiglottis Lift the epiglottis using the tip of the scope

Endotracheal Intubation
Procedure: iv. Do not attempt for more than 30 seconds or heart rate decreases to <60 seconds v. Insert the ET tube once the vocal cord is open vi. Place the black marker on the ET at the level of vocal cords vii. An assistant may apply cricoid pressure to facilitate visualization

Endotracheal Intubation
Procedure: viii. Assess for the position of ET Observe for symmetrical chest movement Auscultate for equal breath sounds Should have absent breath sounds over the stomach Notation of end-tidal carbon dioxide level viii. WOF: Displacement Obstruction Pneumothorax Equipment failure

Blood Sampling
A. Heel stick / Finger stick
Indications: Blood sampling unaffected by hemolysis Complications: Infection Bleeding Osteolmyelitis

Capillary Blood Extraction

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

puncture : just off center and perpendicular to the fingerprint ridges (A puncture parallel to the ridges tends to make the blood run down the ridges and hamper collection.)

Warm site with soft cloth, moistened with warm water up to 41C, for three to five minutes.

Cleanse site with alcohol prep. Wipe DRY with sterile gauze pad.

Puncture heel. Wipe away first drop of blood that may contain tissue fluid with sterile gauze pad. Allow another LARGE blood drop to form.

The finger is gently massaged from base to tip and the blood drops are collected into the proper collection device.

The blood is mixed in microtainers with an additive.

Blood Sampling
B. Venous Extraction Indications: Blood sampling for laboratory studies Complications: Thrombosis, bleeding, infection Access sites:
Dorsal metacarpal, Median antebrachial, Basilic, Cephalic, Venous arch and plexus, Greater Saphenous, Lesser Saphenous, Scalp veins

Blood Sampling
Procedure: 1. Restrain the patient 2. Prepare the site with 70% alcohol 3. Apply tourniquet and insert the needle, bevel
up at 30 degree angle 4. Extract only the needed amount 5. Apply dry cotton and withdraw the needle 6. Apply pressure to the site

Blood Sampling
C. Arterial Extraction Indications: Need for arterial blood sample Complications: Infection, bleeding, occlusion of artery by hematoma or thromboses, ischemia Access sites:
Radial artery, posterior tibial and dorsalis pedis, Scalp(Temporal) arteries, *Brachial artery

Blood Sampling
Procedure: 1. Locate the artery, usually radial artery 2. Perform Allen test 3. Insert the needle (attached to a syringe) at 30-60
4.
5.
degree angle over the point of maximal impulse Observe for free flow of blood into the syringe in a pulsatile fashion After drawing the blood, apply firm, constant pressure for 5 minutes then place a pressure dressing on the puncture site

Peripheral Vascular Access

Indications: To deliver fluid, medications or blood products Complications: Infection, Thrombosis Procedure:
1. Choose a site and prepare with alcohol 2. Apply tourniquet then insert IV catheter, bevel up, at 3. 4.
angle almost parallel to the skin, advancing until flash of blood is seen in the catheter hub. Advance the plastic catheter only, remove the needle and secure the catheter. Attach T connector/ heplock and flush with normal saline

Venoclysis
Veins : upper and lower
extremity scalp
Antecubital vein in a child
Scalp vein in a neonate Dorsal hand/inner wrist in a toddler Greater saphenous vein in an infant

Central Vascular Access

Indications: to deliver high concentration parenteral solutions, prolonged IV therapy, infusion of large amounts of blood products/ fluids and monitor central venous pressure

Complications: Infection, bleeding, arterial or venous laceration, pneumothorax, hemothorax, thrombosis, catheter fragment in circulation, air embolism, AV fistula and catheter-related sepsis

Central Vascular Access

Access Sites: External jugular vein Internal jugular vein Subclavian vein Femoral vein
Note: Femoral vein catheterization is contraindicated in severe abdominal trauma, and Internal jugular catheterization is contraindicated in patients with severe intracranial pressure elevation

Central Vascular Access

Procedure: Seldinger technique Modified Seldinger technique Cut down

Intraosseous Infusion
Indications: Emergency access in child less than 8 years old Very useful during circulatory collapse/ shock Should be removed once vascular access has been established (usually <6 hours)

Intraosseuos Infusion
Complications: Infection, bleeding, osteomyelitis, compartment syndrome, fat embolism, fracture, epiphyseal injury Sites of Entry:
1. Anteromedial surface of proximal tibia, 2 cm below and 2 cm medial to the tibial tuberosity 2. Distal femur 3 cm above the lateral condyle in the midline 3. Medial surface of the distal tibia 1 to 2 cm above the medial malleolus

Intraosseous Infusion
Procedure:
1. 2. 3. 4.
Prepare the site with iodine solution Wear sterile gloves and lay a drape on the site May opt to anesthetize the site with 1% lidocaine Insert a large-bore gauge IO needle perpendicular to the surface and advance to the periosteum with boring rotary motion 5. 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 tubing Note: Any crystalloid, blood products or drugs can be infused through the IO line

Umbilical Artery and Vein Cannulation

Indications: Vascular access (UV) and for blood gas monitoring (UA) for critically ill neonates Complications: Infection, bleeding, hemorrhage, perforation of vessel, thrombosis with distal embolization, ischemia/infarction of lower extremities, bowel or renal vessels, arrhythmia, air embolus

Caution: Should not be performed if there is omphalitis Line Placement: 1. Arterial line a) High line (cm): [BW(kg) X 3] + 9 between T6-T9 recommended for less than 750gr. b) Low line (cm): BW(kg) + 7 between L3-L5 avoids renal and mesenteric arteries 2. UV line (cm): [high line UA / 2] + 1 placed at inferior vena cava above the level of ductus venosus and below right atrium Note: May not be appropriate for LGAs and SGAs

Procedure:
1. Prepare materials/ catheters/sterile procedure 2. Determine the length of catheter to be inserted and 3. 4. 5.
flush with normal saline Apply umbilical suture/ tape and tighten accordingly to prevent bleeding Cut through the cord horizontally 1-2 cm from the skin and determine the vein and the arteries Grasp the catheter 1 cm from its tip with toothless forceps and insert gently into the lumen up to the desired level Secure the catheter by suturing and tape Confirm the position of the catheter tip radiologically

6. 7.

Lumbar Puncture
Indications: For examination of spinal fluid, instillation of chemotherapy, measurement of opening pressure and to decrease CSF Complications: Infection, bleeding, spinal fluid leak, hematoma, headache, acquired spinal cord tumor, epidural abscess Contraindications: Overlying skin infection, Increased ICP, Bleeding diathesis, unstable patients (hypotensive, in shock)

 Procedure:
Position: lateral recumbent with hips, knees and neck flexed

Locate The Puncture Site

spinal cord ends at the L1 and L2 vertebral bodies desired sites for lumbar puncture : interspaces between the posterior elements of L3 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 by indentation of the skin with a fingernail.

Use Sterile Technique

Cleanse the skin with povidine-iodine solution after donning sterile gloves.

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

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

Apply Local Anesthetic

Local anesthetic should be used in children older than 1 year of age.
Inject 1% lidocaine intradermally to raise wheal, then advance 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 in position 2. Support the needle between your index fingers and stabilize the hub of the needle with your thumbs. 3. Grasp the spinal needle firmly with the bevel facing up toward the ceiling

Puncture
1. With the needle perpendicular to the vertical plane but with the bevel pointed slightly cephalad, advance through the skin.

2. Advance slowly into the deeper structures until you detect a slight resistance on penetration of the spinous ligaments. The resistance continues until the needle penetrates the dura, at which time you will typically feel a "pop" sensation caused by the change in resistance. The pop indicates that you are in the subarachnoid space.

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 fullterm neonate. In older children 3 to 6 mL can be safely removed. 2. Note the character of the CSF and, if bloody fluid flows originally, observe the fluid for clearing with subsequent collection.
3. If the fluid does not clear this may indicate the presence of a subarachnoid hemorrhage.

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 before the LP to determine the CSF serum ratio of glucose.

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, if able, to lie prone for 3-4 hours to prevent leakage.

Others
Needling: - suspected pneumothorax - placed on 2nd ICS, midclavicular line - May cause bleeding, infection, pneumothorax Chest Tube Placement: - confirmed pneumothorax - place of entry is at the 3rd 5th ICS, mid to anterior axillary line, usually at the level of the nipple

Orogastric / Nasogastric Tube Insertion

tube can be used :

initially to remove air

and digestive juices from the stomach

as a feeding tube
tube is uncomfortable, but not painful

Correct size Adequate restrain Determine level Lubricate tube Check placement Secure with tape

Torniquet Test
Test for capillary fragility :
Platelet disorders Vascular disorders

Determine the blood pressure Inflate sphygmomanometer to midway

between systolic and diastolic pressures Release cuff after 5 minutes After 2 minutes, measure a circle with 2.5 cms diameter Normally < 10 petecchiae

Injections
Strict asepsis and adequate restrain

Intramuscular Injections
Site: infants anterolateral aspect of thigh older children deltoid muscle Size of needle : > 4 months - 1 needle < 4 months - 5/8 needle (gauge 23 or 22)

Insert needle into site, aspirate, give injection

 Subcutaneous injections
Site : anterolateral aspect of the thigh or upper arm Size of needle: 5/8 , G25

Insert needle in a pinched up fold of skin and subcutaneous tissue

 Intradermal injection
Site: volar aspect of forearm ; deltoid for BCG Size of needle : 5/8 , G25

Insert needle almost parallel to skin, bevel up. Injection would result to a wheal.

Thank You !!!