Common Procedures in Paediatric Icu

COMMON
PROCEDURES IN
PAEDIATRIC ICU
MUKESH RAM
COMMON PROCEDURES
1. Obtaining Blood Specimens
2. Nasogastric Tube Insertion
3. Venous Catheterization
4. Capillary Blood (Heel prick)
5. Thoracentesis or Pleural Tap
6. Abdominal Paracentesis or Ascitic Tap
7. Catheterization of Bladder
8. Peritoneal Dialysis
9. Bone Marrow Aspiration and Biopsy
10. Liver Biopsy
OBTAINING BLOOD
SAMPLE
 The vein is palpated and a tourniquet
applied if the vein is not palpated.
 The site for venipuncture is cleaned with an
alcohol wipe and left to dry for a minute.
Povidone-iodine is applied in concentric
circles outwards, allowed to dry for at least
60 seconds.
 The vein is punctured at an acute angle to
the skin with the bleb of the needle pointing
upwards and directed cephalad.
NASOGASTRIC TUBE
INSERTION
 Appropriate size NG/OG tube Age Preterm Term 6 month 12 2-3 year 4-6 year 7-10 year 11-15 > 16 year

month year
Water soluble lubricating gel
 Tongue depressor
 Flashlight Tube size
(Fr) 5 5-8 8 10 10-12 12-14 12-14 14-18 14-18
 Emesis basin
 Catheter tipped syringe 60 mL
 Functioning Suction equipment
 Surgical and Instrument tape
 Skin barrier wipes
Indications NG/OG tube insertion
 To remove fluid and gas from the gastrointestinal tract
 To obtain a specimen of gastric contents
 To treat gastric immobility and bowel obstructions
 To allow for drainage and/or lavage in drug overdoses or poisonings
 For short term medication administration and feeding
Contraindications of NG/OG insertion
 A child with a basal skull fracture or cribriform plate fracture recent
oesophageal surgery / repair, oesophageal varices, oesophageal strictures,
esophagectomy, recent gastric surgery, gastrectomy, recent throat surgery
etc.
 Facial fractures or recent surgery to ear, nose, throat, or jaw.
 Severe coagulopathies. It is recommended to check INR/PTT, haemoglobin
and platelets prior to procedure
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VENOUS
CATHETERISATION
PERIPHERAL VENOUS CATHETERISATION
 Dressing pack
 Skin preparation: alcohol 70% and betadine swabs
 IV cannula
 Sterile disposable syringe and vials (if blood samples are required)
 Syringe, with normal saline for flushing the line
 Saline primed connector
 Sterile IV dressing (eg. Tegaderm™)
 Taping
 Splint of appropriate size
Step 1: Explain procedure and take verbal consent (where ever appropriate). Consider
distraction techniques/analgesia
Step 2: Look carefully for the most suitable vein

 In children, the most suitable vein may not necessarily be palpable
 Dorsum of the non-dominant hand is preferred - the vein running between the 4th and 5th
metacarpals is most frequently used
 In addition to the usual sites in adults, commonly used sites in children include the volar
aspect of the forearm, dorsum of the foot and the great saphenous vein at the ankle
 Transillumination: Application of a cold- light directly to the skin in a darkened room can
be helpful in finding veins in neonates
Step 3: Wash hands and don sterile gloves

Step 4:Holding: Ask assistant to stabilise limb, by holding joints above and below if
necessary
Step 5: Inserting the cannula
 Decontaminate skin with alcohol 70% / chlorhexidine 2% swabs and leave to dry for at
least 30 seconds. Use 'no-touch' technique for insertion after decontamination
 Insert just distal to and along the line of the vein at 10-15° angle
 Advance needle and the cannula slowly
 A 'flash back' of blood may not occur for small veins and 24G cannula
 Once in vein, advance the needle and cannula slowly a further 2-3mm along the line of
the vein before advancing cannula off needle
 Secure the hub of the cannula at the skin entry point either by holding it down or asking
the assistant to place tape across
 Dispose of sharps appropriately
Step 6: Collect blood samples if required, to avoid extra pricks

Step 7: Securing intravenous line
Step 8: Post-insertion care
CENTRAL VENOUS CANNULATION
INDICATIONS
(i) inability to establish venous access in the peripheral circulation
(ii) access for drugs and fluids that require central administration ( e.g. vasopressors, fluids, contrast
medications)
(iii) to monitor central venous pressure
(iv) as an access for performing hemodialysis, plasmapheresis or continuous renal replacement therapies
PREFERRED CHOICES OF SITES FOR CENTRL LINE PLACEMENT
Indication First choice Second choice
Emergency airway management or cardiopulmonary resuscitation Femoral vein Subclavian vein
Long term parenteral nutrition Subclavian vein Internal jugular vein

Acute hemodialysis or plasmapheresis Internal jugular vein Femoral vein
Coagulopathy Femoral vein External jugular vein
Other purposes, e.g. access for surgery or medications Internal jugular vein Femoral or subclavian vein
CAPILLARY BLOOD (HEEL
PRICK)
Indications
useful technique to obtain arterialized capillary blood for blood gas analysis, bilirubin, glucose,
hematocrit and other parameters in newborns.
After ensuring asepsis, a sterile blood lancet or a needle is punctured at the side of the heel in
the appropriate regions
The central portion of the heel should be avoided as it might injure the underlying bone, which
is close to the skin
With the foot dorsiflexed, prick the heel with a disposable lancet to a depth of not more than
1mm in the plantar surface of the heel .
Blood sample is obtained by alternate squeezing and releasing of calf muscles.
ARTERIAL CATHETERIZATION
Indications
i) to monitor blood pressure continuously, especially in hemodynamically unstable patients;
ii) to monitor frequently the arterial blood gas.
Sites: radial artery and femoral artery
procedure
Right radial artery cannulation is performed when preductal arterial oxygen tension is required
for evaluating and treating infants with congenital heart disease. It is often helpful to stabilize
the hand and wrist on an arm board, placing the wrist in approximately 30-45 degrees extension
over several gauze pads. Importantly, if the radial artery is selected for puncture or
catheterization, adequacy of the palmar arterial arch should be assessed by the Allen test
Lumbar Puncture
Site: interspaces between the posterior elements of L3 and L4 or L4 and LS.
Positioning: The patient is restrained in the lateral decubitus position. The spine is maximally
flexed without compromising the upper airway.
Post procedure care:
maintain patient in supine position
Check for headache or backpain
Encourage to have plenty of fluids
THORACENTESIS OR PLEURAL TAP
Indications
(i) diagnostic purpose, e.g. pleural effusion or empyema
(ii) therapeutic purpose, e.g. when large collections of pleural fluid compromise ventilatory function.
PROCEDURE
The procedure is carried out with the patient appropriately positioned upright and leaning forward.
The site of entry is anesthetized with local anesthetic.
The landmark for evacuation of the fluid is the angle of the scapula that corresponds approximately to the
eighth rib interspace. An appropriate catheter is used over a needle.
The needle is introduced immediately above the superior edge of the rib to avoid puncturing the intercostal
artery and vein. Once the pleural space is entered and fluid is aspirated, the Common Medical catheter is
advanced Procedures as the needle - is withdrawn.
The catheter is connected to a three-way stopcock and syringe (10-20 ml). It is important to control the
aspiration of fluid such that air is not allowed to enter the pleural space from the outside.
Peritoneal Dialysis
The modality is used in patients with AKI in whom dialysis is indicated and hemodialysis and continuous renal
replacement therapies are not available, or if hemodialysis is contraindicated due to hemodynamic compromise or
severe coagulation abnormalities.
ARTICLES:PD cathter, PD fluid, 3 way stopcock, paediatric dripset, urobag with urinometer, iv set, iv canula
PROCEDURE
Access for peritoneal dialysis can be achieved by inserting a rigid catheter or a single cuff soft Tenckhoff catheter. e
high, particularly if used for more than 48 hr.
The abdomen is cleansed with chlorhexidine and betadine and draped.
Following administration of sedation and local anesthesia, an 18-22 gauge cannula is inserted below the umbilicus in
the midline or lateral to the rectus abdominus muscle at two-thirds the distance between the umbilicus and the
anterior superior iliac spine
About 20-30 ml/kg of peritoneal dialysis fluid is infused till the flanks appear full.
The cannula is removed and the stiff catheter is inserted using the trocar. Once a' give away' sensation is felt, dialysis
fluid flows freely back into the catheter lumen.
The catheter is inserted carefully avoiding injury to viscus by the trocar and guiding the tip of the catheter into the left
iliac fossa. The trocar is removed and the catheter attached to a three-way connection to the peritoneal dialysis fluid
and the drain bag.
Acute PD can be performed intermittently or continuously depending upon the desired amount
of fluid and solute removal, and either manually by nurses or via an automated device.About 20-
30 ml/kg is infused over 5 min, kept in the abdomen for 20-40 min, and then drained out.

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COMMON

Step 2: Look carefully for the most suitable vein

Step 3: Wash hands and don sterile gloves

Step 6: Collect blood samples if required, to avoid extra pricks

Emergency airway management or cardiopulmonary resuscitation Femoral vein Subclavian vein

Long term parenteral nutrition Subclavian vein Internal jugular vein

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