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Common PediatricProcedures
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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
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Common Procedures
Airway AccessBlood SamplingPeripheral Vascular AccessCentral Vascular AccessIntraosseous Infusion AccessUmbilical Artery and Vein CannulationLumbar PunctureOthers
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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
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Airway Access
Types of Respiratory Support:Positioning Sniffing PositionO2 via Nasal Cannula/ Funnel/ Face MaskBag-Valve-Mask VentilationOropharyngeal AirwayNasopharyngeal AirwayCricothyrotomyTracheostomy
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Endotracheal Intubation
Complications:Vocal Cord Stenosis/ Rupture
Subcutaneous EmphysemaPneumothorax
Atelectasis
InfectionBleeding
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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)
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Endotracheal Intubation
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
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Endotracheal Intubation
Procedure:iv. Do not attempt for more than 30 seconds
or heart rate decreases to
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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
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Blood Sampling
A. Heel stick / Finger stickIndications: Blood sampling unaffected by
hemolysisComplications:
Infection
BleedingOsteolmyelitis
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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
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Puncture heel.
Wipe away first drop of blood
that may contain tissue fluidwith sterile gauze pad. Allowanother LARGE blood drop to
form.
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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.
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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
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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
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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
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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
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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
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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
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Central Vascular Access
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
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Central Vascular Access
Procedure:Seldinger technique
Modified Seldinger techniqueCut down
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Intraosseous Infusion
Indications:Emergency access in child less than 8years oldVery useful during circulatory collapse/shockShould be removed once vascular accesshas been established (usually
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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
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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
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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
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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
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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
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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)
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Procedure:
Position: lateral recumbent with hips,knees and neck flexed
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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.
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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.
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Drape the child beneath their flank and over the backwith the spine accessible to view.
A l L l A h i
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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
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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.
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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 .
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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
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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.
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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
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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
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Correct size Adequate restrain Determine level Lubricate tube Check placement
Secure with tape
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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
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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)
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Insert needle into site, aspirate, give injection
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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
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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.
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Thank You !!!
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