Pediatric instruments.pptx

Exam preparation

1. PEDIATRIC INSTRUMENTS Dr. Lakshmi Prasad Senior resident ICH, Kottayam

2. LUMBAR PUNCTURE/ LP NEEDLE

3. Indications of Lumbar puncture T herapeutic Analgesia ,anaesthesia Administration of antibiotics Intra thecal anti neoplastics. Diagnostic Infections ie meningitis Inflammatory conditions e.g.. GBS,MS Malignancy Metabolic Spontaneous SAH

4. Contraindications Increased ICT Cerebral herniation Impending herniation Focal neurological deficits Coagulopathy Hemodynamically unstable

5. Complications Herniation Cardiorespiratory compromise Head ache Pain Infection CSF leak

6. Procedure Patient position Lateral decubitus Sitting( mostly in adults)

7. A line connecting the posterior superior iliac crest will intersect the midline at approx,the L4 spinous process A topical anaesthetic (e.g.: EMLA cream) can be applied 30-60minutes before the procedure to minimise pain on penetration Make sure hips and shoulders are aligned & are perpendicular to the bed surface. Spine should be maximally flexed to increase spacing between spinous processes monitor the patient visually and with pulse oxymetry for any signs of cardio respiratory compromise as a result of the assumed position

8. Correct dehydration Position Needle size 23/22/21 with stylet is used Clean & drape the area. L3-L4 interspinous space is the preferred site. Repeat attempt if done, should be attempted one space above in older child and one space below in an infant. Needle is inserted in the midline just below the spinous process, directing towards the umbilicus. Needle is then slowly advanced horizontally till the feel of penetrating dura is felt. Stylet is removed and check for clear fluid. CSF is allowed to drain slowly

9. Samples are collected for analysing protein,sugar,culture & sensitivity, gram stain and antigen detection Last sample is collected for cell counts Collected in aliquots of 1-4ml in 3(or sometimes 4) sterile tubes, which are labelled 1,2,3,4 in the order in which they are collected.

10. WBCs & RBCs begin to degrade as soon as 1 hour after collection As many as 40% of neutrophils can disintegrate in 2-3hours. CELL COUNT SHOULD BE DONE STAT Specimen can be refrigerated for up to 4 hours

11. BONE MARROW ASPIRATION NEEDLE

12. INDICATIONS Diagnostic ITP Aplastic anemia Megaloblastic anemia Leukaemia Myelofibrosis Infections PUO Storage disease

13. Therapeutic Bone marrow transplantation Intra osseous drug administration

14. CONTRAINDICATIONS Hemorrhagic disorders e.g. coag factor deficiencies, DIC etc. Skin Infection(local site) Bone disorders e.g. Osteomyelitis, Osteogenesis imperfecta

15. Site In more than 2 Years: iliac crest Less than 2 years: proximal tibia medial to tibial tuberosity(to prevent injury to pelvic structures)

16. PROCEDURE Use sterile technique Prone position Drape the area Anesthetize the area with 1% xylocaine. Anesthetize the periosteum also Enter the ileum, at the posterior superior iliac spine which is visible & palpable bony prominence, superior to lateral to intergluteal cleft. It is inferior & medial to the crest. Introduce the needle by screwing (boring) motion, directing the needle perpendicular to the bone.

17. When needle enters the bone marrow, a decreased resistance may be felt & the needle does not sway side to side . Aspirate the marrow using a 10 or 20ml syringe Marrow is smeared over 8-10 clean glass slides kept in slanting position Apply pressure for 5 minutes at the site & give a dressing.

18. COMPLICATIONS Haemorrhage Infection Persistent pain at marrow site Retroperitoneal hematoma Trauma to neighbouring structures( gluteal artery injury, soft tissue injury )

19. Bone marrow biopsy needle

20. JAMSHIDI-SWAIN marrow biopsy needle PROCEDURE Anesthetize the skin, subcutaneous tissue & periosteum Make a small skin incision Lock the stylet to the needle Needle is pushed through cortex of bone by gentle firm screwing motion Remove the stylet

21. Introduce the needle little more Move the needle sideways to 15˚ so as to break any biopsy material within the needle Repeat the procedure in another direction Remove the needle by pulling it out by rotation or by attaching a syringe & applying gentle suction Prepare imprint smears by touching the biopsy material to clean slides or rolling it over clean slides . Seal the area Bone specimen is placed in fixative and sent for HPE

22. SEMIAUTOMATED LIVER BIOPSY GUN

23. INDICATIONS Cirrhosis of liver e.g. ICC,Biliary Cirrhosis Storage disorders e.g. GSD,Wilsons,Hemochromatosis Malignancy , primary & metastasis. E.g. hepatoblastoma, Neuroblastoma Leukemia,Lymphoma Infiltrations e.g. Tb,sarcoidosis,Infections

24. COMPLICATIONS Local pain & infection Bleeding in the liver Intrathoracic & intra peritoneal bile leak Pleural pain & Pneumothorax Penetration of other abdominal organs.

25. CONTRAINDICATIONS Bleeding disorders Extreme dyspnoea Pyogenic abscess in Right lobe of liver Biliary tract infection Peritoneal infection Hydatid disease

26. PROCEDURE Percutaneous approach Epigastric S ub Costal Right lateral approach (most common)- Intercostal( 10 th ICS in mid axillary line) Patient is asked to lie down & put right hand on head Anesthetize the skin , subcutaneous tissue, capsule of liver(2% lignocaine) Make a tract to the capsule of liver with large bore needle Assistant should fix liver by applying firm pressure from the right hypochondrium Older children- ask to hold breath

27. Needle of gun is introduced through the track into the liver, trigger is released and gun is withdrawn Apply firm pressure over the puncture site Linear piece of liver tissue will be collected inside the o uter sheath of the biopsy Liver tissue obtained is taken with a fine needle & transferred to alcohol( if for GSD) or formaldehyde Monitor the patient’s PR,BP, & abdominal girth before and half hourly after the procedure. Abdomen should be palpated gently for signs of peritoneal irritation( next 6 hours)

28. Liver abscess aspiration Under USG guidance, introduce the aspiration needle into the abscess cavity & drain out the pus. Or the needle can be introduced through the intercostal space directing the tip of the needle cephaloid pointing towards the tip of the opposite shoulder or to the area of maximum tenderness on percussion

29. INFANT FEEDING TUBE/NASOGASTRIC TUBE

30. Plastic tube with a blunt tip to prevent damage to structures while introducing it Opening on the lateral side close to the tip It also has a radio opaque marker so that it can be easily visualised on x-ray.

31. INDICATIONS DIAGNOSIS OF Internal bleeding in stomach & upper GI Tuberculosis (gastric lavage) TEF Poisoning Localisation of oesophageal strictures Gastric analysis

32. . THERAPEUTIC Nasogastric feeds Remove gastric contents in poisoning, persistent GI bleed, abdominal distension with bilious emesis, hepatic encephalopathy Administration of drugs Gastric decompression pre operatively, when sufficient time for fasting is not available. Gastric decompression after BMV, post operative etc.

33. Other uses As an oxygen catheter For nasal, endotracheal & tracheostomy suction As a tourniquet

34. CONTRAINDICATIONS Head trauma coagulopathy

35. COMPLICATIONS Trauma to nose & pharynx Placement of tube in trachea Vomiting with aspirations during the procedure Ulceration/ infection of nasal mucosa.

36. PROCEDURE Select the appropriate tube Determine the approximate length to be passed by measuring the distance from tip of nose to tragus to xiphisternum. Alternative method is measuring the distance from top of manubrium sterni to xiphisternum and double this and add 2.5cm for feeding tube and 5cm for aspiration or drainage.

37. Position the child at a 45 degree angle with head in midline Lubricate the lower 3-4cm of the tube and pass it through a nostril directing towards the occiput Slight neck flexion may help the tube to correctly enter the oesophagus Withdraw the tube, if there is severe coughing, choking or cyanosis Introduce the selected length and fix the tube lightly to cheek Confirm the position in stomach by aspirating the stomach contents or air pushed through the tube, a gurgling sound confirms the position.

38. SUCTION TUBE

39. Size in french Premature : 5-6 Fr Term : 6-8 Fr Infant : 8 Fr Older chldren : 10-14 Fr

40. INDICATIONS Orotracheal/ nasotracheal suction both direct & ET/tracheostomy clearance E.g.: MAS Inability to clear airway Also for urethral catheterisation in distended bladder/ sampling of urine. Keep suction pressure at 80-100mm hg Max 3cm for nose & 5cm for mouth Max time of suctioning: 15s

41. CONTRAINDICATIONS Laryngospasm Basal skull fracture Nasal bleeding Severe bronchospasm

42. COMPLICATIONS Vasovagal attack Mechanical trauma Hypoxia Gagging/vomiting Laryngospasm/ bronchospasm Infection

43. SCALP VEIN NEEDLE

44. Consists of a metallic needle attached to plastic tubing At the junction of tubing and the needle, there is a butterfly shaped plastic holder which facilitates easy insertion of the scalp needle into the vein Plastic holder is flexible & colour coded Commonly used needles are from no:22 to no:24 There is inverse relation between gauge number & the internal diameter Higher the number, small is the diameter of the needle. Thus 24G needle is smaller in diameter than 22 G needle

45. USES Collection of blood Infusion of IV fluids, drugs, blood etc. ABG analysis

46. AMBU BAG

47. PARTS Patient outlet One way valve(fish mouth) Pressure release/pop off valve( set to release at pressure of 30-35cm water) The bag(250-750ml) Oxygen inlet Air inlet ( if its kept open, the oxygen reaching patient is around 40%,on attaching oxygen reservoir, it increases to 90-100%)

48. Intermittent positive pressure ventilation during resuscitation Mask can be cushioned or uncushioned Round/anatomical( triangular) Mask should cover nose, mouth including tip of chin, but not the EYES

49. In the resting stage, the AMBU bag is filled with air. On squeezing the bag to initiate ventilation, the one way valve proximal to the patients outlet opens resulting in release of air, stored in the bag to the patient. On releasing the pressure, the bag gets re inflated with air. The patients exhaled air cannot re enter the bag due to one way mechanism of valve at the patient outlet.

50. CONTRAINDICATIONS Congenital diaphragmatic hernia

51. BAG VALVE MASK

52. Usually made of plastic or rubber Types Shapes Uncushioned * Round Cushioned * Triangular Mask should cover nose, mouth including tip of chin, but not the EYES  RIGHT SIZED MASK

53. Advantages of Cushioned mask Mask conforms to the face Requires less pressure to obtain air tight seal Less chances of damage to eyes or other structures of the face.

54. GUEDEL AIRWAY

55. As necessary, clear the oropharynx of obstructing secretions, vomitus, or foreign material . Determine the appropriate size of the oropharyngeal airway. Hold the airway beside the patient’s cheek with the flange at the corner of the mouth. The tip of an appropriately sized airway should just reach the angle of the mandibular ramus . Next, begin inserting the airway into the mouth with the tip pointed to the roof of the mouth (ie, concave up ). To avoid cutting the lips, be careful not to pinch the lips between the teeth and the airway as you insert the airway.

56. Rotate the airway 180 degrees as you advance it into the posterior oropharynx. This technique prevents the airway from pushing the tongue backwards during insertion and further obstructing the airway . When fully inserted, the flange of the device should rest at the patient’s lips . Alternatively, use a tongue blade to depress the tongue as you insert the airway with the tip pointed to the floor of the mouth (ie, concave down). Use of the tongue blade prevents the airway from pushing the tongue backward during insertion.

57. INDICATION Oropharyngeal airways are indicated for unconscious patients in the setting of Bag-valve-mask ventilation Spontaneously breathing patients with soft tissue obstruction of the upper airway who are deeply obtunded and have no gag reflex

58. CONTRAINDICATIONS Absolute contraindications: Consciousness or presence of a gag reflex Relative contraindications: Insertion of an oropharyngeal airway may not be feasible in some settings, such as Oral trauma Trismus (restriction of mouth opening including spasm of muscles of mastication)

59. COMPLICATIONS Airway obstruction by an improperly sized or improperly inserted oropharyngeal airway Gagging and the potential for vomiting and aspiration

60. LARYNGOSCOPE

61. It has 2 parts A handle( has batteries) A blade(contains light source) – straight(miller) -- curved (Macintosh) Straight blade more useful in young children, since larynx is placed more anteriorly and above Curved blade in older children & adults, helps to displace the tongue.

62. SIZE 0 : Preterm & LBW 1 : Term 2 : Children between 2-10 years 3 : Children > 10 years.

63. USES DIRECT LARYNGOSCOPY IN In Cord palsy To detect foreign body Anatomical lesion PRIOR TO ET INTUBATION Neonatal asphyxia Meconium aspiration RDS GA administration for surgeries CDH/TEF etc Resuscitation

64. PROCEDURE Align the areas of mouth,pharynx,trachea by extension of neck by small pillow or blanket below shoulder Hold the laryngoscope handle in left hand and insert blade into the mouth in midline to base of tongue After proper positioning of blade, traction is exerted upward in the direction of long axis of handle to expose glottis Insert the ET tube from the right corner of the mouth, with cricoid pressure by an assistant to visualise glottis. The black glottic marker of tube is placed at level of vocal cords, placing tip of tracheal tube in mid trachea. Secure tube after confirming tube placement.

65. CONTRAINDICATIONS Diseases or injuries of cervical spine Moderate or marked respiratory obstruction

66. STRUCTURES EXAMINED SERIALLY……… Base of tongue Right & left valleculae Epiglottis Right & left pyriform sinuses Aryepiglottic folds Arytenoids Post cricoid region False cords Anterior & posterior commissures Ventricles & vocal cords Subglottic area.

67. COMPLICATIONS Mechanical injury Hyperextension of neck- stimulation of posterior pharyngeal wall- vasovagal attack Cough Vomiting Displacement/obstruction of tube Pneumothorax

68. ENDORACHEAL TUBE

69. Made of PVC(plastic) Easy disposable, hypoallergenic,& transparent Parts : proximal end , 15mm adapter. Connects to the ventilator/ AMBU Bag Central portion : vocal cord guide (black line) which should be placed at the level of opening of vocal cord, so that tip of ET tube is above bifurcation of trachea. Distal end : murphys eye (opening in the lateral wall) which prevents complete blockage in case distal end is impacted

70. Cuffed tube is used in older children Inflating the cuff helps in keeping the ET in place and avoids aspiration. Uncuffed- younger children with narrow subglottic area.

71. SIZE From 2mm to 16mm (internal diameter) Size of tube can be determined by- Internal diameter of ET tube (mm) = age in years + 4 4 Length to be fixed in cm = internal diameter x 3

72. Premature : 2-2.5mm Full Term : 3-3.5mm Young infants : 4-4.5mm 6m – 1 yr :4-4.5mm 12m- 5yr : increase by 0.5mm 6 monthly.

73. USES Mechanical ventilation Resuscitation IPPV Tracheal suctioning in meconium aspiration Epiglottitis & Croup Tetanus Angioneurotic edema

74. COMPLICATIONS Mechanical trauma Pressure necrosis Pneumothorax Posterior pharyngeal wall stimulation

75. THREE –WAY CONNECTOR

76. T shaped device Device contains 2 inlets and 1 outlet

77. The connector is devised in such a way that by turning the handle (which operates the screw) either of the 2 inlets can be connected with the outlet, whereas remaining inlet is disconnected from outlet Facilitates administration of IV medications through one inlet while Iv fluids pass through the other inlet

78. USES Administration of IV fluids and IV medications simultaneously by connecting the 3 way connector to IV set Exchange transfusion in case of neonatal hyperbilirubinemia Haemodialysis in case of renal failure/ poisonings Pleural/ ascitic tap CVP monitoring.

79. IV CANULA

80. Being plastic in nature, it doesn’t damage the endothelium of the vein Plastic sheath being flexible, can be inserted into thin & tortuous vein easily Uses: venepuncture, transfusion of drugs/ blood etc..

81. INTRA OSSEOUS NEEDLE

82. INDICATIONS Any age group where vascular access is indicated but difficult to establish Cardiac arrest or shock when immediate vascular access is required for resuscitation

83. SITE Proximal tibia Distal tibia Distal femur

84. CONTRAINDICATIONS Absolute Fracture of the bone or previous IO insertion in the same site Crush injuries Osteogenesis imperfecta RELATIVE Infection at point of insertion Osteoporosis

85. COMPLICATIONS Failure to enter bone marrow Through and through penetration of bone Osteomyelitis Epiphyseal plate injury Local infection/ necrosis/pain/compartment syndrome, fat & bone micro emboli

86. TUBERCULIN SYRINGE

87. It is a 1 cc syringe with a plastic piston (plastic syringe), or a metal piston(glass syringe)

88. USES To administer PPD for Mantoux test To administer BCG vaccine To administer test doses of drugs such as penicillin Provocative testing – to test for allergies in Bronchial asthma, atopy Insulin injection in Diabetes mellitus Giving small doses of drugs

89. FOLEY’S CATHETER Self retaining catheter, made up of latex self retaining by means of a balloon which should be inflated with saline

90. Use 5ml distilled water for inflating balloon ( NS will crystallise)

91. INDICATIONS URINARY NON-URINARY CBD # Arrest postnasal bleedin g Monitor urine O/P in intractable epistaxis in case of shock/renal failure # Arrest bleeding from Differentiate anuria oesophageal varices in from retention portal hypertension Haematuria- bladder injury # EASI Urinary incontinence Bladder wash (cystitis0 Supra pubic cystotomy Intra vesical chemotherapy

92. Equipment Sterile gloves - consider Universal Precautions Sterile drapes Cleansing solution Cotton swabs Forceps Sterile water Foley catheter Syringe (usually 10 cc) Lubricant (water based jelly or xylocaine jelly) Collection bag and tubing

93. Gather equipment. Explain procedure to the patient Assist patient into supine position with legs spread and feet together Open catheterization kit and catheter Prepare sterile field, apply sterile gloves Check balloon for patency.

94. 7 . Generously coat the distal portion (2-5 cm) of the catheter with lubricant 8 . Apply sterile drape 9. If female, separate labia using non-dominant hand. If male, hold the penis with the non-dominant hand. Maintain hand position until preparing to inflate balloon. 10. Using dominant hand to handle forceps, cleanse peri -urethral mucosa with cleansing solution. Cleanse anterior to posterior, inner to outer, one swipe per swab, discard swab away from sterile field .

95. 11 .Pick up catheter with gloved (and still sterile) dominant hand. Hold end of catheter loosely coiled in palm of dominant hand. 12. In the male, lift the penis to a position perpendicular to patient's body and apply light upward traction (with non-dominant hand) 13. Identify the urinary meatus and gently insert until 1 to 2 inches beyond where urine is noted 14. Inflate balloon, using correct amount of sterile liquid (usually 10 cc but check actual balloon size)

96. Gently pull catheter until inflation balloon is snug against bladder neck Connect catheter to drainage system Secure catheter to abdomen or thigh, without tension on tubing Place drainage bag below level of bladder Evaluate catheter function and amount, color , odor , and quality of urine Remove gloves, dispose of equipment appropriately, wash hands Document size of catheter inserted, amount of water in balloon, patient's response to procedure, and assessment of urine

97. COMPLICATIONS Injury to urethra or urinary bladder Inadvertent catheterisation of the vagina may occur Urinary tract infection in the absence of aseptic precautions

98. 3 way Foley In haematuria for continuous bladder irrigation to prevent formation of clots blocking drainage of urine Post operative bladder irrigation

99. CONTRAINDICATION Urethral rupture (blood at tip of meatus)

100. METERED DOSE INHALER

101. PARTS Metallic canister Which contains the medicine along with the propellant 9 usually a CFC) which delivers the medicine to the patient in the form of an aerosol Plastic actuator Cap The canister is inverted and fixed to the inhaler and fixed to the inhaler before actuating the device.

102. STEPS Remove cap and shake inhaler in vertical direction Breathe out gently Put mouth piece in mouth. At start if inspiration, that should be slow and deep, press canister down and continue to inhale deeply Hold breathe for 10s or as long as possible, then breathe out slowly Wait for a few seconds before repeating steps 2-4 MDI

103. Spacers are bottle shaped plastic devices which have a mouth piece at one end and other end has an opening where the MDI can be attached.

104. ADVANTAGES Deliver the drug into lower airways Less coordination between inspiration and activation USED IN Children Adults without coordination

105. MDI with Spacer Remove cap, shake inhaler and insert into spacer device Place mouth piece of spacer in mouth Start breathing in and out gently and observe movements of valve Once breathing pattern is established, press canister and continue to breathe 5-10times( tidal breathing) Remove the device from mouth and wait for 30s, before repeating steps 1-4

106. USES Prevention and management of asthma Medicines given via MDI Short acting drugs e.g. salbutamol, terbutaline Long acting e.g. salmetrol, formetrol Inhaled anti cholinergic drugs e.g. ipratropium bromide Inhaled steroids e.g. budesonise, fluticasone etc. S/E: oral candidiasis ( tackled by rinsing mouth after use of steroid inhaler)

107. DISADVANTAGES of MDI Perfect coordination between inspiration and activation of device Not possible in small children To eliminate problem, spacer is advised.

108. DRY POWDER INHALERS Rotahaler Diskhaler Spinhaler Turbohaler Acuhaler Can be used in children above 4-5 years of age Do not require coordination of actuation and breathing Do not contain CFC Salbutamol, salmetrol, budesonide etc. are available.

109. Dry powdered inhalers consists of 2 halves The upper half consists of mouth piece and raised square slot into which a capsule containing the medication in dry powdered form can be inserted The lower half is a kind of reservoir which can be attached to the upper half The lower half consists of a fin like device which cuts the capsule on rotating , thus depositing the powder into the reservoir The patient breathes out , puts the mouth piece in his mouth and takes a deep breath thus inhaling the powder DPIs are suited for children over5 years as they require greater inspiratory effort

110. ADVANTAGES Small portable device No need to coordinate inspiration with device actuation DISADVANTAGES Cannot be used in less than 5 years Dry powder can be deposited in the mouth or pharynx if inspiratory effort is not good Dry powder might be affected by humid climate

111. OXYGEN DELIVERY SYSTEMS

112. NASAL CANULA

113. Nasal Cannula Delivered FiO2 is 22-60% Appropriate oxygen flow rate is 0.25L-4l/min Suitable for infants and children who require low concentrations of supplimental oxygen

114. SIMPLE OXYGEN MASK

115. Delivers FiO2 35-60% Appropriate flow rate 6-10L/min

116. NRM

117. Delivers FiO2 95% Flow rate 10-15L/min Device has 2 one way valves A valve in one or both exhalation port(s) to prevent entrainment of room air during inhalation A valve between reservoir bag and the mask to prevent the flow of exhaled gas into the reservoir

118. OXYGEN HOOD

119. THANK YOU