Instruments for paediatric practicals USGS

Instruments

1. INSTRUMENTS Dr. K. Zohara Parveen Father Muller Medical College Mangalore

2. INSTRUMENTS Lumbar Puncture needle Bone Marrow Aspiration & Biopsy needle AMBU bag and mask Face Mask Laryngoscope Endotracheal tubes Liver biopsy needle red rubber catheter Ryle’s tube Foley’s catheter MDI with spacer Tuning fork

3. Description Identify +/- parts Use / Indication Site / method of use / procedure Contraindications Complications

4. 1. Lumbar Puncture Sterile spinal needle with stillet , 22 – gauge (black), length according to age (1.5‐3.5 inch) The line connecting the iliac crests should correspond to approximately the L4 spinous process, one to two interspaces above the optimal space to access the subarachnoid space .

5. L.P INDICATIONS DIAGNOSTIC CNS infections like meningitis , encephalitis Subarachnoid hemorrhage , GBS Instillation of intrathecal dye for imaging procedures ( eg. : myelography) 4. Measurement of CSF pressure .

6. L.P INDICATIONS cont’d THERAPEUTIC : Instillation of intrathecal medication ( e.g.: chemo in CNS leukemia , methotrexate, anaesthesia ) Benign Intracranial HTN Spinal anesthesia

7. L.P CONTRAINDICATIONS Intra Cranial Space Occupying Lesion / Raised intracranial pressure Thrombocytopenia ( Platelet count < 20,000 ) / coagulopathy Local infection at puncture site Severe resp distress/ shock ( may worsen while in flexed position for LP)

8. L.P COMPLICATIONS Postdural puncture headache (relatively common) Local back pain Iatrogenic meningitis Spinal hematoma Cerebral herniation ( in sudden drop of elevated intracranial pressure )

9. GUARDED l.p needle Indications:- Benign intracranial hypertension

10. 2. BM biopsy / aspiration needles BM Aspiration -> Salah’s needle BM biopsy -> Jamshidi needle

11. BM indications Diseases like leukemia , to detect marrow infiltration in disorders like lymphomas and other non hematologic malignancies Staging of Hodgkin’s and Non-Hodgkin’s lymphoma , and small blue round cell tumours of childhood (neuroblastoma, rhabdomyosarcoma and Ewing’s sarcoma Aplastic anemia ITP (r/o malignancy before starting steroids)

12. BM indications Bone marrow culture in enteric fever Inadequate or failed marrow aspiration Suspected bone marrow fibrosis Diagnosis of myelodysplastic syndromes and acute megakaryoblastic leukemia

13. BM BIOPSY NEEDLE JAMSHIDI TREPHINE BIOPSY NEEDLE SITES OF BIOPSY : POSTERIOR SUPERIOR ILIAC CREST ( most common - because it contains the most cellular marrow, no vital organs in close proximity & it’s a non weight-bearing) ANTERIOR ILIAC CREST (in v. obese) ANTEROMEDIAL ASPECT OF UPPER 1/3 OF THE TIBIA (preferred  in kids <18 months of age)

14. BM ASPIRATION NEEDLE SALAH’S NEEDLE PROCEDURE: Palpate iliac crest, Move posteriorly Identify post sup iliac crest Insert needle with twisting motion Till firmly attached to bone 4. Remove stylet, attach syringe Pull with strong suction into the syringe Make smears immediately Confirm if marrow particles are present With a pathologist Withdraw needle, apply pressure bandag

15. Bone marrow biopsy CONTRAINDICATIONS HEMORRHAGING DISORDERS DIC Coagulation def disorders 2. BONE DISORDERS Ostemyelitis Osteogenesis Imperfecta 3. SKIN Infection Recent Radiation therapy to site of sampling COMPLICATIONS Trauma to the soft tissue Pain Infection Hemorrhage – buttocks, thigh, retroperitoneum Breakage of BM needle (rare) {{People at risk – with thrombocytopenia, platelet dysfunction, coagulopathy, von Willebrand’s disease, renal impairment or obesity and those receiving acetylsalicylic acid, warfarin or heparin }}

16. Causes of dry tap Myelofibrosis Aplastic anemia

17. 3. AMBU - ARTIFICIAL MANUAL Breathing Unit - PARTS

18. AMBU – INDICATIONS Failed intubation Resuscitation in apnoeic child Respiratory failure- failed oxygenation or ventilation Elective intubation before procedure or in OT

19. AMBU BAG SIZES 250 ml 500ml 750ml 1600ml – ADULT

20. AMBU inlet A chamber is seen, through which oxygen flows continuously from the o2 inlet to reservoir, without going thru ambu bag WHAT IS THE FUNCTION OF RESERVOIR BAG? To increase the FiO2 of oxygen to 100%. In case reservoir bag is NOT used, patient will receive Oxygen with FiO2 of 40% WHEN AMBU BAG IS PRESSED, WHERE DOES THE O2 GO? TO RESERVOIR BAG /PT? It goes to the pt /outlet, as there s a valve at inlet, which prevents O2 from entering reservoir, when ambu bag is squeezed

21. Ambu outlet There are many small holes below the yellow rim of the ambu outlet through which the pt’s exhaled air goes out. Fish mouth shaped valve at oxygen outlet ( as seen from above), which allows uni directional flow of oxygen, so So, the exhaled air (CO2) doesn’t go back inside ambu bag

22. AMBU CONTRAINDICATIONS Diaphragmatic hernia Severe facial trauma Complete Upper airway obstruction COMPLICATIONS Hypo/Hyperventilation Gastric insufflation Barotrauma Volutrauma

23. 4. FACE MASK

24. FACE MASK – patient POSITIONING

25. Face mask positioning

26. 5. Laryngoscope Handle Detachable blade Fibreoptic light guide Also point out the junction where the blade hinges onto the laryngoscope PARTS :

27. Laryngoscope INDICATION : Intubation (asphyxia, resuscitation, meconium a spiration, RDS, Tra Oeso Fistula ) 2. Surfactant administration in newborn RDS 3. Drugs through ET route 4. To detect and remove foreign body obstructing larynx 5. To pass bronchoscope/oesophagoscope/ throat packing

28. Laryngoscope blades TYPES :- CURVED (Macintosh) – adults STRAIGHT (Miller) – paediatric Age Miller Blade size Very Preterm 00 Preterm Term neonate 1 2-10 yrs 2 > 10 yrs 3 Straight Miller paeds Curved Mackintosh Adults/ older kids

29. Laryngoscopy COMPLICATIONS Injury to local tissues – teeth, tongue, palate Stimulation of post. Pharyngeal wall – vaso vagal syncope- hypoxia, bradycardia. OR vomiting * Method of use

30. 6.Endotracheal tube Identify Mention size (written over the cover) Cuffed / uncuffed Murphy’s eye prevents complete blockage of ET tube in case distal end gets impacted with secretions

31. ET TUBE – CUFFED/ UNCUFFED SIZE :- Uncuffed – age/4 +4 Cuffed – age/4 +3 Cuffed ET tubes used in kids > 8 yrs of age. Function of cuff in ET tube – When inflated, it keeps tube in place & prevents aspiration of gastric contents. Q: Why is uncuffed ET tube used in smaller kids? A: In smaller kids, the narrow subglottic area itself is enough to hold the ET tube in place, hence uncuffed tubes are used. Uncuffed ET tube starts with size 2

32. Et tube depth ET size x 3 (NICU) weight +6 NTG + 1cm Age/2 + 12 **Method of insertion **How to check position of ET tube NTG measured from Nose to Tragus of ear to a point midway between xiphoid & umbilicus

33. Laryngoscopy – ET Why is miller’s blade used in small kid? Why is uncuffed ET TUBE used in smaller kid? Anatomy of throat in child- larynx is funnel shaped, narrower, more vertical, ant & cephalad, as compared to adults. Epiglottis is at C3 in newborn & C5 in adults…. Narrowest portion is Below Glottis. In older kids, curved, stronger blade is required to displace tongue properly.

34. 7. LIVER BIOPSY NEEDLE- VIM SILVERMANN

35. LIVER BIOPSY NEEDLE 3 Types:- Trucut Menghini Needl e Vim Silverman – bifid needle Vim silvermann needle Indication :- liver & kidney biopsy

36. LIVER BIOPSY INDICATIONS Cirrhosis TB Storage disorders – Glycogen storage disorder, Wilson’s Malignancy – leukemia, Lymphoma

37. Pre‐ requisites before doing liver biopsy • Prothrombin Time •Blood group & crossmatching •Vitamin K administration before biopsy

38. LIVER BIOPSY‐ PROCEDURE When using Menghini , after making a track with the track maker, the needle is fitted with a 2 ml syringe containing normal saline and introduced. The needle is first flushed and then applying a suction force it is advanced further and quickly withdrawn. The specimen is then flushed out of the needle

39. 8. SIMPLE Red rubber catheteR

40. Red rubber catheter INDICATION – to drain urine, in case of retention of urine Made of Indian rubber Sterilized by autoclaving, re – usable, temporary use COMPLICATIONS : - Trauma, infection * procedure – with aseptic precautions- clean, apply lignocaine jelly, insert catheter till urine comes

41. 9. Ryle’s tube Also called INFANT FEEDING TUBE Plastic tube with blunt tip (to prevent injuries while inserting) Has a marked line to help with proper placement Has radio opaque marker so that it can be easily seen on x ray

42. Ryle’s tube indications Diagnostic Gastric lavage – AFB (TB) Poisoning – gastric aspirate can be sent for chemical analysis Tracheo - Oesophageal fistula Internal bleeding in stomach / upper GIT To administer oral contrast for CT in neurologically impaired child Therapeutic Enteral nutrition: feeds In poisoning - Gastric lavage Intestinal obstruction or Ileus conservative management Drug administration : Surfactant, ORS, etc Decompression of stomach

43. Ryle’s tube : insertion & sizes Age Tube size preterm 5 Fr Newborn 5 - 8 Fr 6 mo 8 Fr 1 year 10 Fr 2 - 3 yrs 10 -12 Fr 4 - 10 yrs 12 -14 Fr > 11 yrs 14 – 18 Fr Sizes 5-10 in infants

44. Ryle’s tube CONTRAINDICATIONS: Severe facial trauma Skull base fracture } Risk of intracranial placement Oesophageal stricture Oesophageal varices

45. ryle’s tube insertion Take consent / assent Measure NTG to get approx. length of Ryle’s tube to be inserted.( Measure tubing from tip of nose to tragus, then to the point halfway between the xiphisternum and the umbilicus Under sterile conditions, wear gloves, apply lignocaine jelly Insert ryle ’ tube into nares with child in sitting position and push it backwards Ask child to swallow if possible (older child, can offer water) Withdraw immediately if tube coils in mouth or there is respiratory distress Advance tube till you reach desired depth Confirm tube position (either aspirate and check pH using ph strips or attach syringe and push air into it, auscultate via stethoscope Fix tube in position and document the same.

46. Ryle’s tube GIT : Misplaced – pharynx / Pyriform sinus Coiling of tube Oesophagitis – reflux coz of impaired lower oesophageal sphincter LUNGS : (due to misplaced tube) Pneumonia Lung abscess Tracheal perforation NOSE : Alar ulcer & necrosis – large tube unconscious pt COMPLICATIONS

47. 10. Foley’s catheter Self – retaining catheter , made up of latex

48. Foley’s catheter INDICATIONs Monitor urine output accurately in shock / renal failure To drain urine before , during or after surgery To obtain sterile urine sample for investigations: analysis & culture To differentiate anuria from retention of urine To relieve retention of urine and incontinence For urinary incontinence ,,procedure,,

49. Foley’s catheter SIZES Age Size Preterm 6 Fr Newborn – 10 yrs 8 Fr 11-15 yrs 10 Fr >16 yrs 12 Fr The above info as per harriet lane

50. Foley’s catheter complications Hematuria Infection Urethral stricture Trauma to Urethra / Bladder Intravesical knot of catheter ( rare) Paraphimosis due to failure to return foreskin to normal position following catheter insertion

51. MDI : metered dose inhaler INDICATIONS: Treat acute asthma As maintenance therapy for prevention of recurrent attacks of asthma ADVANTAGES : as eff as nebulisation Multidosing Low cost Low risk of bacterial contamination Decreases oropharyngeal drug deposition Reduces oral and systemic side effects, esp with inhaled steroids

52. MDI Usage Has a metal canister containing medicine with propellant Canister is inverted and fixed to inhaler before actuating device Metered dose inhaler has to be primed before 1 st use- to discharge 1-2 doses of medicine prior to use Pt breathes out, puts mouth piece of inhaler in mouth; presses on top of inverted canister and takes deep inspiration as soon as puff of aerosolized medicine is generated Determining when an MDI is empty : is essential. The MDI’s now have an in built dose counter, which shows zero in RED colour , when its empty.

53. Drugs given via mdi Inhaled β 2 agonists: a) Short acting: Salbutamol, Terbutaline – to terminate acute attack of asthma b) Long acting : Salmeterol, Formeterol – maintenance therapy in persistent asthma 2. Inhaled anticholinergics: Ipratropium bromide 3. Inhaled mast cell stabilizer : Cromolyn sodium 4. Inhaled steroids: Fluticasone, Beclomethasone or Budesonide

54. MDI SIDE EFFECTS Tremors Tachycardia Palpitations Oral Candidiasis – deposition of steroids in the mouth Disadvantage: requires coordination between inspiration and activation of device, impossible in smaller kids

55. Spacer of MDI Mouth piece at one end Other end has opening to attach the MDI Once canister s pressed, aerosolized drug enters the spacer. By breathing about 10 times, all medicine in spacer can be delivered to the liungs ADVANTAGES: Use of spacer eliminates the need for coordination of actuation and inhalation Increases efficiency and decreases side effects of MDI

56. SPACER Cleaning instructions  Clean spacer once a week.  Remove mask and take apart the spacer.  Rinse in warm soapy water.  Rinse with clean water and air dry.  Do not put in the dishwasher.  Clean the small hole in the MDI once a week with a wet Q-tip.  Replace the MDI when the counter reaches 000. It may continue to spray but no medicine is coming out. d/ adv : plastic spacer has electrostatic charge which attracts aerosol particles during first 10-20 actuations, reducing drug deposition in lungs. Reduced by washing with dilute detergent.

57. Tuning fork 3 frequency: 128, 256, 512 Weber and Rinne ‘s tests Test Vibration sense: 128Hz tuning fork

58. THANK YOU