PEDIATRIC PROCEDURES

PEDIATRIC PROCEDURES PART II

Exchange Transfusion
Vascular Procedures
Percutaneous Peripheral Venous Access
Umbilical Vessel Cannulation
Blood Extraction
Capillary Blood Sampling
Arterial 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 aspiration
An assistant should be present to help monitor, tally
the volume of blood exchanged, and perform
emergency procedures.


EXCHANGE TRANSFUSION
PROCEDURE
1. With 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.
2. 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 TRANSFUSION
PROCEDURE
3. The 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 TRANSFUSION
COMPLICATIONS
Acute complications (510% of infants)
Transient bradycardia with or without calcium infusion
Cyanosis
Transient vasospasm
Thrombosis
Apnea 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 4
8 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 RESORT
Metacarpal Vessels
-Located between joints and
metacarpal bones (act as natural splint)
-Formed by union of digital veins



Digital
Veins of the Upper Extremities
Cephalic (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 Extremities
Basilic
- 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 nutrition
To provide avenue for dialysis/apheresis
To transfuse blood products
To provide avenue for hemodynamic monitoring
To provide avenue for diagnostic testing
To 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 Devices
Butterfly (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 phlebotomy
Safety Over the needle catheters (ONC)
Vascular Procedures
EQUIPMENT AND MATERIALS
Vascular Devices
- 2 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 MATERIALS
Antiseptic swabs, inch skin tape and a torniquet
Use 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 IV
TECHNIQUE

1) 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 IV
PROCEDURE

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

4. Topical or local anesthetic may be used especially if a large bore
needle will be inserted
5. The 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 IV
PROCEDURE

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



COMPLICATIONS AND PRECAUTIONS

Hematoma formation
Extravascular infiltration
Local infection or phlebitis

Infiltration/Extravasation
The 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 Cannulation
The 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, Asphyxia
Continuous IV BP monitoring
Additional Vascular access
ANATOMY

Umbilical Vessel Cannulation
INDICATIONS:

For umbilical venous cannulation:
Emergency volume expansion or transfusion of
blood products
Exchange transfusion
Central venous access for reliable infusion of fluids
with high dextrose loads, medications
CVP monitoring
Umbilical Vessel Cannulation
EQUIPMENT AND MATERIALS
Povidone iodine antiseptic solution
Sterile NSS
Sterile umbilical cannulation set
Sterile gloves
Cord tie
Scalpel handle and blade
Iris scissor
Hemostats
Needle holder
Sutures (3.0 or 4.0 silk)
Umbilical catheter (single/double/triple lumen or feding
tubes (5.0 or 8 Fr)
Syringes
3-way stop cock
2x2 gauze pads

Umbilical Vessel Cannulation
PROCEDURE
1) Immobilize the neonate in supine position (arms
and legs are properly restrained)
2) Provide thermoregulation
3) Measure distance from the acromioclavicular
(AC) joint to a line extending laterally from the
umbilicus
4) Don a cap and mask, Perform 3-5 mins surgical
scrub. Put on sterile gown and gloves.
5) 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 Cannulation
PROCEDURE
6) 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 base
8) 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 Cannulation
DIRECT TECHNIQUE
- Grasp 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 Cannulation
SIDE TECHNIQUE
- Visualize the approximate course of one of the
arteries along the side of the cord
- Cut partially through the cord until you
transect one third to halfway through the
artery.
- Dilate and cannulate

Umbilical Artery Cannulation
SIDE TECHNIQUE
- Visualize the approximate course of one of the
arteries along the side of the cord
- Cut 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 Cannulation
Does not require dilatation
The 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 Vein Cannulation
Does not require dilatation
The 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 Cannulation
Xray for placement verification
The cannulae can be taped using goalpost of
H-type
UMBILICAL VESSEL
CANNULATION
VIDEO
http://www.youtube.com/watch?v=UIRy3kaxoKY


BLOOD EXTRACTION
CAPILLARY BLOOD SAMPLING
INDICATIONS
1) Routine laboratory blood tests including serial
glucose determination
2) Capillary blood gas sampling
3) Difficulty obtaining blood from a vein (preterm
infants)
BLOOD EXTRACTION
CAPILLARY BLOOD SAMPLING
CONTRAINDICATIONS
1) Infection at the site
2) Decreased blood flow to the area (extremities with
poor perfusion) in cases of shock
3) Edema of the extremity
4) Polycythemia
5) Bleeding disorders with prolonged bleeding time

BLOOD EXTRACTION
CAPILLARY BLOOD SAMPLING
CONTRAINDICATIONS
1) Infection at the site
2) Decreased blood flow to the area (extremities with
poor perfusion) in cases of shock
3) Edema of the extremity
4) Polycythemia
5) Bleeding disorders with prolonged bleeding time

BLOOD EXTRACTION
CAPILLARY BLOOD SAMPLING
SITE
Medial plantar surface of the heel (lateral area is
also acceptable)
EQUIPMENT
1) Sterile gloves
2) 70& alcohol swab or cotton with alcohol
3) Gauze square Lancet
4) Capillary tubes with sealer caps/wax
5) Microtainers/collecting tubes




BLOOD EXTRACTION
CAPILLARY BLOOD SAMPLING
TECHNIQUE
1) Warm 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 area
2) Clean the area using alcohol swabs. Allow it to dry
3) Position 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 EXTRACTION
CAPILLARY BLOOD SAMPLING
TECHNIQUE
4) 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 1
st
drop of blood is obtained, wipe this
off using a dry gauze




BLOOD EXTRACTION
CAPILLARY BLOOD SAMPLING
TECHNIQUE
6) Slightly relaxed the grip on the heel to allow blood
to accumulate. Gently squeeze or milk the heel again.
This step may be repeated
7) Position the collecting tube (microtainer or the
capillary tube so that it touches the drop of blood)



BLOOD EXTRACTION
CAPILLARY BLOOD SAMPLING
TECHNIQUE
8) 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 EXTRACTION
COMPLICATIONS
1) Maceration of the site from excessive
squeeze or from numerous pricks.
2) Subcutaneous nodules at puncture sites.
3) Osseus spurs from hitting to the talus.
4) Ankle dislocation or even foot fracture
from overzealous milking of the heel



BLOOD EXTRACTION
ARTERIAL BLOOD SAMPLING
INDICATIONS
1) Determination of arterial blood gas
2) Blood sampling when capillary and venous
sites are found inaccessible
3) Specific blood tests (e.g. ammonia levels)


BLOOD EXTRACTION
ARTERIAL BLOOD SAMPLING
CONTRAINDICATIONS
1) Compromised blood supply to the extremity
site
2) Infection in the affected site
3) Site will be used for central or percutaneous
line insertion
4) Clotting disorders


BLOOD EXTRACTION
ARTERIAL BLOOD SAMPLING
SITES
1) Radial artery
2) Dorsalis pedis
3) Posterior tibial arteries
4) Ulnar artery, temporal & brachial arteries
(alternative sites)

BLOOD EXTRACTION
ARTERIAL BLOOD SAMPLING
SITES
AVOID FEMORAL ARTERY!

BLOOD EXTRACTION
ARTERIAL BLOOD SAMPLING
EQUIPMENT
1) Sterile Gloves
2) Gauze 23 or 25 butterfly needle for venipucture
preferred
3) TB syringe (Heparinized syringe for blood gases)
4) Antiseptic solution/spray
5) Sterile gauze/ cotton balls
6) Sterile alcohol


BLOOD EXTRACTION
ARTERIAL BLOOD SAMPLING
TECHNIQUE
1) 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 EXTRACTION
ARTERIAL BLOOD SAMPLING
TECHNIQUE
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 EXTRACTION
ARTERIAL BLOOD SAMPLING
TECHNIQUE
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 EXTRACTION
ARTERIAL BLOOD SAMPLING
TECHNIQUE
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 EXTRACTION
ARTERIAL BLOOD SAMPLING
TECHNIQUE
6) Secure the angiocatheter with Tegaderm
and tape just as with any intravenous line.
7) Send blood specimen immediately for blood
gas analysis or ammonia level


BLOOD EXTRACTION
ARTERIAL BLOOD SAMPLING
COMPLICATIONS
1) Hematoma
2) Arterial embolism, thrombosis and fibrosis of
a vessel
3) Infection (eg abscess formation, septic emboli,
and osteomyelitis)
4) Fibrosis of artery



BLOOD EXTRACTION
ARTERIAL BLOOD SAMPLING
COMPLICATIONS
5) Keloid and hypertrophic scar formation
6) Arterial spasm
7) Extensor tendon sheath injury resulting in false
cortical thumb
8) Nerve injury of the median, posterior tibial or
femoral nerves


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

Intraosseous infusion
INDICATIONS
2) As 1
st
attempt in cases of cardiopulmonary
arrest

Intraosseous infusion
CONTRAINDICATIONS
1) Placement ina recently fractured bone
2) Osteogenesis imperfecta
3) Soft tissue infection or cellulitis in the
area selected for intraosseous infusion
4) Obliterative diseases of marrow as
osteopetrosis

INTRAOSSEUS INFUSION procedure
VIDEO
http://www.youtube.com/watch?v=UIRy3kaxoKY
BLOOD EXTRACTION
ARTERIAL BLOOD SAMPLING
COMPLICATIONS
5) Keloid and hypertrophic scar formation
6) Arterial spasm
7) Extensor tendon sheath injury resulting in false
cortical thumb
8) Nerve injury of the median, posterior tibial or
femoral nerves


BLOOD EXTRACTION
ARTERIAL BLOOD SAMPLING
COMPLICATIONS
5) Keloid and hypertrophic scar formation
6) Arterial spasm
7) Extensor tendon sheath injury resulting in false
cortical thumb
8) Nerve injury of the median, posterior tibial or
femoral nerves


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