Pediatric Proceduresii

PEDIATRIC PROCEDURES

PEDIATRIC PROCEDURES PART II

Exchange Transfusion Vascular ProceduresPercutaneous Peripheral Venous AccessUmbilical Vessel Cannulation Blood ExtractionCapillary Blood SamplingArterial Blood Sampling

EXCHANGE TRANSFUSION

Term infants with levels of 20 mg/dL or higher have an increased risk of kernicterus.Blood for exchange transfusion should be as fresh as possible. Heparin or citrate-phosphate-dextrose-adenine solution may be used as an anticoagulant.Blood should be gradually warmed and maintained at a temperature between 35 and 37C throughout the exchange transfusion.

EXCHANGE TRANSFUSION

The infant's stomach should be emptied before transfusion to prevent aspirationAn assistant should be present to help monitor, tally the volume of blood exchanged, and perform emergency procedures.

EXCHANGE TRANSFUSIONPROCEDUREWith strict aseptic technique, the umbilical vein is cannulated with a polyvinyl catheter to a distance no greater than 7 cm in a full-term infant. When free flow of blood is obtained, the catheter is usually in a large hepatic vein or the inferior vena cava. Alternatively, the exchange may be performed through peripheral arterial (drawn out) and venous (infused in) lines

EXCHANGE TRANSFUSIONPROCEDUREThe exchange should be carried out over a 4560 min period, with aspiration of 20 mL of infant blood alternating with infusion of 20 mL of donor blood. *Smaller aliquots (510 mL) may be indicated for sick and premature infants. * The goal should be an isovolumetric exchange of approximately two blood volumes of the infant (2 85 mL/kg).

EXCHANGE TRANSFUSIONCOMPLICATIONSAcute complications (510% of infants)Transient bradycardia with or without calcium infusionCyanosis Transient vasospasmThrombosisApnea with bradycardia requiring resuscitation, and death. Infectious risks include CMV, HIV, and hepatitis. Necrotizing enterocolitis (rare complication of exchange transfusion).

After exchange transfusion, the bilirubin level must be determined at frequent intervals (every 48 hr) because bilirubin may rebound 4050% within hours.

Vascular Procedures

Anatomy Digital Vessels -Along lateral aspects fingers, infiltrate easily, painful, difficult to immobilize and should be your LAST RESORTMetacarpal Vessels -Located between joints and metacarpal bones (act as natural splint) -Formed by union of digital veins

Digital

Veins of the Upper ExtremitiesCephalic (Interns Vein) -Starts at radial aspect of wrist -Access anywhere along entire length (BEWARE of radial artery/nerve)

Medial Cephalic (On ramp to Cephalic Vein) -Joins the Cephalic below the elbow bend -Accepts larger gauge catheters, but may be a difficult angle to hit and maintain

Veins of the Upper ExtremitiesBasilic - Originates from the ulner side of the metacarpal veins and runs along the medial aspect of the arm. It is often overlooked becauses of its location on the back of the arm, but flexing the elbow/bending the arm brings this vein into view

Medial Basilic - Empties into the Basilic vein running parallel to tendons, so it is not always well defined. Accepts larger gauge catheters. - BEWARE of Brachial Artery/Nerve

Purposes of Vascular Access

To provide parenteral nutritionTo provide avenue for dialysis/apheresisTo transfuse blood productsTo provide avenue for hemodynamic monitoringTo provide avenue for diagnostic testingTo administer fluids and medications with the ability to rapidly/accurately change blood concentration levels by either continuous, intermittent or IV push method.

Types of Peripheral Venous Access DevicesButterfly (winged) or Scalp vein needles (SVN) not recommended for non compliant patient as it can easily penetrate the vein wall causing extravasation. We use these frequently for phlebotomySafety Over the needle catheters (ONC)

Vascular ProceduresEQUIPMENT AND MATERIALSVascular Devices2 types of cannulae:1) Metal cannulae (Butterflies) - indicated for very short term use (1-2 days) or for blood sampling - can easily dislodged or cause inadvertent punctures.- common size: G23 or G25. For blood extraction: G21

2)Plastic cannulae are more easily kept in place and may last for several days if properly maintained. (size G24 or smaller for neonates)

OTHER MATERIALSAntiseptic swabs, inch skin tape and a torniquetUse of gloves is encouraged.The fluid and delivery system should be prepared beforehand.Local anesthetic, syringes or vacuum tube and splints may be prepared.

Starting a Peripheral IVTECHNIQUE

Anatomic considerations Iff an IV line is to be established, the most distal available vein should be utilized (eg dorsum of the hand before arm)AVOID SITES:- Angulated- Dependent- Mobile - Contaminated

Starting a Peripheral IVPROCEDURE

Clean the area with antiseptic swabIf a limb is to be used, apply a torniquet about 3-5 cms above the place where the needle will be inserted * Placing the area in a dependent position and local heat application will help distend the vein

Topical or local anesthetic may be used especially if a large bore needle will be insertedThe needle bevel up is inserted into the skin and is directed at an acute angle towards the surface or the side of the vein

Starting a Peripheral IVPROCEDURE

A give may be felt or the butterfly tubing or cannula chamber may fill by blood indicating puncture of the veinThe tornique is removed and the previously filled intravenous tubing is attached to the needle or cannula The needle or cannula is then taped and secured to the skin.Proper application of fixed splints

COMPLICATIONS AND PRECAUTIONS

Hematoma formationExtravascular infiltration Local infection or phlebitis

Infiltration/ExtravasationThe most common cause is damage to the wall during insertion or angle of placement.

Phlebitis/Thrombophlebitis Chemical- Infusate chemically erodes internal layers. Warm compresses may help while the infusate is stopped/changed. Anti-inflammatory and analgesic medications are often used no matter what the cause Mechanical- Caused by irritation to internal lumen of vein during insertion of vascular access device and usually appears shortly after insertion. The device may need to be removed and warm compresses applied Bacterial- Caused by introduction of bacteria into the vein. Remove the device immediately and treat w/antibiotics. The arm will be painful, red and warm; edema may accompany

Cellulitis Inflammation of loose connective tissue around insertion site- Red swollen area spreads from insertion site outwardly in a diffuse circular pattern- Treated w/antibiotics

Umbilical Vessel CannulationThe umbilical vessels are accessible generally up to only 10-14 days of life

INDICATIONS:For umbilical artery cannulation:Frequent ABG determination in extremely low birth weight infants, preterms, PPHN, AsphyxiaContinuous IV BP monitoring Additional Vascular access

ANATOMY

Umbilical Vessel CannulationINDICATIONS:

For umbilical venous cannulation:Emergency volume expansion or transfusion of blood productsExchange transfusionCentral venous access for reliable infusion of fluids with high dextrose loads, medicationsCVP monitoring

Umbilical Vessel CannulationEQUIPMENT AND MATERIALSPovidone iodine antiseptic solutionSterile NSSSterile umbilical cannulation setSterile glovesCord tieScalpel handle and bladeIris scissorHemostatsNeedle holderSutures (3.0 or 4.0 silk)Umbilical catheter (single/double/triple lumen or feding tubes (5.0 or 8 Fr)Syringes3-way stop cock2x2 gauze pads

Umbilical Vessel CannulationPROCEDUREImmobilize the neonate in supine position (arms and legs are properly restrained)Provide thermoregulationMeasure distance from the acromioclavicular (AC) joint to a line extending laterally from the umbilicusDon a cap and mask, Perform 3-5 mins surgical scrub. Put on sterile gown and gloves.Open the cannulation set, check contents, flush catheters w/ NSS, attach to stopcocks, affix needle/suture to needle holder and check all other equipment

Umbilical Vessel CannulationPROCEDURE6) Grasp the cord with mild traction. Paint the cord and its base w/ povidone and iodine solution and allow to dry.7) Apply cord tie to the umbilical base. Cut the cord about 1-1.5 cm from the base8) Identify the umbilical vessels (2 arteries: 1 vein) Arteries have thick muscular walls, vein is thin-walled and bleeds more easily after cutting)

Umbilical Artery CannulationDIRECT TECHNIQUEGrasp the side of the cord with a hemostat. Dilate one of the arteries, initially with iris forceps The tip of the catheter is then introduced into the lumen and advance with a gentle and even pressure

Umbilical Artery CannulationSIDE TECHNIQUEVisualize the approximate course of one of the arteries along the side of the cordCut partially through the cord until you transect one third to halfway through the artery.Dilate and cannulate

Umbilical Artery Cannulation

A low lying arterial catheter is generally advanced about two-thirds the distance from the acromioclavicular joint to the umbilical level previously measured.

Umbilical Vein CannulationDoes not require dilatationThe flushed catheter is slowly advanced, initially to a level 1-2 cm beyond the planned distance.The catheter is slowly withdrawn until a steady backflow of blood is encountered.

Umbilical Vessel CannulationXray for placement verificationThe cannulae can be taped using goalpost of H-type

UMBILICAL VESSEL CANNULATIONVIDEOhttp://www.youtube.com/watch?v=UIRy3kaxoKY

BLOOD EXTRACTIONCAPILLARY BLOOD SAMPLINGINDICATIONSRoutine laboratory blood tests including serial glucose determinationCapillary blood gas sampling Difficulty obtaining blood from a vein (preterm infants)

BLOOD EXTRACTIONCAPILLARY BLOOD SAMPLINGCONTRAINDICATIONSInfection at the siteDecreased blood flow to the area (extremities with poor perfusion) in cases of shockEdema of the extremityPolycythemia Bleeding disorders with prolonged bleeding time

BLOOD EXTRACTIONCAPILLARY BLOOD SAMPLINGSITE Medial plantar surface of the heel (lateral area is also acceptable)EQUIPMENTSterile gloves70& alcohol swab or cotton with alcoholGauze square LancetCapillary tubes with sealer caps/waxMicrotainers/collecting tubes

BLOOD EXTRACTIONCAPILLARY BLOOD SAMPLINGTECHNIQUEWarm the heel using a small wet towel or disposable diaper soaked in warm water. Wring out excess water. This will increase blood flow to the areaClean the area using alcohol swabs. Allow it to dryPosition the heel. Grasp gently using your thumb & second or third finger to assume a dorsiflexed position so that it will be possible to milk the heel.

BLOOD EXTRACTIONCAPILLARY BLOOD SAMPLINGTECHNIQUE4) Use a lancet to pierce the skin using one continuous stroke. Do not go deeper than 2.5mm. If less amount of blood is needed, make a shallower incision.5) Once the 1st drop of blood is obtained, wipe this off using a dry gauze

BLOOD EXTRACTIONCAPILLARY BLOOD SAMPLINGTECHNIQUE6) Slightly relaxed the grip on the heel to allow blood to accumulate. Gently squeeze or milk the heel again. This step may be repeated7) Position the collecting tube (microtainer or the capillary tube so that it touches the drop of blood)

BLOOD EXTRACTIONCAPILLARY BLOOD SAMPLINGTECHNIQUE8) Place the cap onto the containers or seal the capillary tubes using wax 3-5mm

9) Apply pressure on the puncture site for at least 2 minutes until no bleeding at the site occurs.

BLOOD EXTRACTIONCOMPLICATIONS Maceration of the site from excessive squeeze or from numerous pricks.Subcutaneous nodules at puncture sites.Osseus spurs from hitting to the talus.Ankle dislocation or even foot fracture from overzealous milking of the heel

BLOOD EXTRACTIONARTERIAL BLOOD SAMPLINGINDICATIONSDetermination of arterial blood gas Blood sampling when capillary and venous sites are found inaccessibleSpecific blood tests (e.g. ammonia levels)

BLOOD EXTRACTIONARTERIAL BLOOD SAMPLINGCONTRAINDICATIONSCompromised blood supply to the extremity siteInfection in the affected siteSite will be used for central or percutaneous line insertion Clotting disorders

BLOOD EXTRACTIONARTERIAL BLOOD SAMPLINGSITESRadial arteryDorsalis pedisPosterior tibial arteriesUlnar artery, temporal & brachial arteries (alternative sites)

BLOOD EXTRACTIONARTERIAL BLOOD SAMPLINGSITESAVOID FEMORAL ARTERY!

BLOOD EXTRACTIONARTERIAL BLOOD SAMPLINGEQUIPMENTSterile GlovesGauze 23 or 25 butterfly needle for venipucture preferredTB syringe (Heparinized syringe for blood gases)Antiseptic solution/spraySterile gauze/ cotton ballsSterile alcohol

BLOOD EXTRACTIONARTERIAL BLOOD SAMPLINGTECHNIQUE Select and prepare the site. One that has barely been tapped is ideal. Transillumination of the vessel may aid if pulsation from the artery is not palpated. Apply antiseptic solution thrice and allow it to dry

BLOOD EXTRACTIONARTERIAL BLOOD SAMPLINGTECHNIQUE 2) Position the limb. If the radial artery is chosen, extend the wrist. Do nit hyperextend. If the dorsalis pedis artery is selected, slightly extend the foot. If the temporal artery is used, choose the area anterior to the tragus of the ear.

BLOOD EXTRACTIONARTERIAL BLOOD SAMPLINGTECHNIQUE 3) Locate where to puncture and position the needle at 15-25 degree angle for the horizontal plane of the skin. At wrist, choose an area proximal to the wrist crease

BLOOD EXTRACTIONARTERIAL BLOOD SAMPLINGTECHNIQUE 4) Insert the needle to penetrate the skin, bevel down for small premature infants.Advance the needle very slowly to allow the blood to flow into the needle. Avoid advancing and pulling the needle blindly using several strokes as this can injure nerves and other tissues.5) Apply gentle suction by applying traction on the syringe plunger while simultaneously advancing the needle until resistance is not felt & blood from the vessel lumen is drawn

BLOOD EXTRACTIONARTERIAL BLOOD SAMPLINGTECHNIQUE Secure the angiocatheter with Tegaderm and tape just as with any intravenous line.Send blood specimen immediately for blood gas analysis or ammonia level

BLOOD EXTRACTIONARTERIAL BLOOD SAMPLINGCOMPLICATIONSHematomaArterial embolism, thrombosis and fibrosis of a vesselInfection (eg abscess formation, septic emboli, and osteomyelitis)Fibrosis of artery

BLOOD EXTRACTIONARTERIAL BLOOD SAMPLINGCOMPLICATIONS5) Keloid and hypertrophic scar formation6) Arterial spasm7) Extensor tendon sheath injury resulting in false cortical thumb8) Nerve injury of the median, posterior tibial or femoral nerves

Intraosseous infusionINDICATIONS1) Reserved for use when attempts in establishing immediate vascular access are not successful as in shock, status epilepticus and in cardiopulmonary arrest.

Intraosseous infusionINDICATIONS2) As 1st attempt in cases of cardiopulmonary arrest

Intraosseous infusionCONTRAINDICATIONSPlacement ina recently fractured boneOsteogenesis imperfectaSoft tissue infection or cellulitis in the area selected for intraosseous infusion Obliterative diseases of marrow as osteopetrosis

INTRAOSSEUS INFUSION procedure VIDEOhttp://www.youtube.com/watch?v=UIRy3kaxoKY

BLOOD EXTRACTIONARTERIAL BLOOD SAMPLINGCOMPLICATIONS5) Keloid and hypertrophic scar formation6) Arterial spasm7) Extensor tendon sheath injury resulting in false cortical thumb8) Nerve injury of the median, posterior tibial or femoral nerves

]\

*and body temperature should be maintained and vital signs monitored. *SET UP EXCHANGE TRANSFUSION*and body temperature should be maintained and vital signs monitored. *and body temperature should be maintained and vital signs monitored. *and body temperature should be maintained and vital signs monitored. **Show person in classWhy difficult to access elderly patientLaying proneVeins of the lower extremities*Veins of upper extremities****************

Documents

Pediatric Proceduresii