Procedures in Pediatrics

Some practical procedures & use of some equipments in Pediatrics

1. Practical Procedures in Paediatrics

2. CONTENTS Nasogastric tube Peak Flow Meter Pulse Oximetry Nebulizer AMBU Lumbar Puncture Urinary Catheterization Endotracheal Intubation Peritoneal Dialysis IV Cannula O 2 Therapy Suction MDI Spacer Thoracocentesis Paracentesis Bone Marrow aspiration Arterial Blood collection

3. Dr Mohiuddin Ahmad Masum DCH Student, Dept. of Pediatrics Chittagong Medical College Hospital

4. Nasogastric Tube Insertion

5. Nasogastric Tube: Indications of use: i)Feeding or admistration of medications ii)Suction/gastric decompression iii)Gastric lavage (e.g. in non-corrosive poisoning) Procedures: Patient position: Semi-Fowler’s position if possible ( Sitting , straight upright, knees bent) , otherwise Supine. Gather equipments, proper handwashing & gloving. Measurement & marking the NG tube- From Tip of the nose to earlobe, then to xiphisternum . NG tube

6. Hold the child, lubricat e tip of the tube with water/jelly & then pass it directly through the nostril, push it slowly in. After reaching the measured distance , fix the tube with tape on nose or face. Check the tube placement by aspirating some stomach contents or injecting air down the tube & listening over the abdomen with stethoscope.

7. Complications: Traumatic bleeding in neonate Tube into the lungs Aspiration following feeding Damage to ciliary epithelium > infection(long term use) Rare complications include oesophageal perforation, brain injury etc. Contraindications: Absolute contraindications : Severe midface trauma Following nasal surgery Relative contraindications: Coagulation abnormality Esophageal varices or stricture Recent banding of esophageal varices

8. Peak Flow Meter

9. Peak Flow Meter: Parts: i ) Mouth piece ii) Indicator/cursor iii) Measuring scale Uses: Peak flow meter can be used- To classify severity of asthma To see whether the management plan is working or not To decide when to add or stop medicine Peak Flow Meter is not usually applicable for less than 5 years of age. Measuring scale Indicator Mouth piece Peak Flow Meter

10. Procedures: Place the indicator at the base of numbered scale Position: Stand up or sit in the upright posture Take a deep breath Place the meter in mouth and close lips around the mouth piece. Do not put tongue inside the hole & do not put finger over measuring scale Blow out as hard & as fast as can Write down the number you get Repeat the steps two more times Note the highest reading

11. Nebulization

12. Nebulization: Purpose of Nebulization : To administer various drugs to the airways like- Bronchodilator (mostly used) Steroids etc. To hyrdate thick sputum and prevent mucus plugging To add moisture to oxygen delivery system

13. Parts of Nebulizer- Motor/ Compressor Filter Air outlet & Air tube Nebulizer cup or Mixing chamber Mouth piece or T piece Mask Nebulizer

14. Procedures: Clean all parts before use At first, attach the air tube to the outlet of the machine Fit the air tube with mixing chamber and mask Take measured amount of drugs into the mixing chamber by syringe or dropper and mix with normal saline Connect the electrical line and turn on the switch Look whether fine mist is coming out through the mask adequately

15. Place the child in comfortable position (head upright) Put the mask to the face of the child covering nose and mouth adequately (but not so tight). In case of mouthpiece, place it between patient’s lips into oral cavity. Continue nebulization until fine mist is no longer present. Clean the machine after use.

16. Pulse Oximeter

17. Pulse Oximeter : A Pulse Oximeter is a device used to determine the- Percentage of hemoglobin ( Hb ) that is saturated with oxygen The oxygen saturation (SpO2) is a measure of how much oxygen the blood is carrying as a percentage of the maximum it could carry. The heart rate The heart rate refers to the number of times that the heart contracts in a period of one minute.

18. TYPES OF PULSE OXIMETER: Desktop Finger/Mobile Desktop Finger/Mobile

19. How it works? The measurements are obtained by simply shining two wavelengths of light (1 is a visible red beam, the other an invisible infrared beam) at e.g. the fingertip. By measuring how much light has been absorbed by the oxygen in the blood, an oxygen saturation reading is established and displayed as a percentage of the maximum amount of oxygen the blood could carry.

20. Benefit of Pulse Oximeter : A Pulse Oximeter can detect hypoxia (too little oxygen to fulfill the needs of the brain and body) before a patient shows signs of becoming cyanotic In the ICU, Pulse Oximetry is used extensively on mechanically ventilated patients, as it can frequently detect problems with oxygenation before they are noticed clinically, as well as a valuable guide for weaning patients off ventilation and helping to assess the adequacy of a patient's oxygen therapy.

21. AMBU

22. AMBU (Artificial manual breathing unit) : Parts: AMBU bag proper/Ventilation bag Mouth piece/mask O xygen connector Tube Oxygen reservoir pop-up valve Indications of use: Neonatal resuscitation in case of perinatal asphyxia RDS Respiratory failure due to any cause(any age) like- pneumonia severe acute asthma poisoning GBS etc. Contraindications : Diaphragmatic hernia Tracheo -esophageal fistula Reservior Bag Ventilation Bag Face Mask Oxygen Tube Pressure Limiting Valve Figure: AMBU

23. Bag & mask ventilation: “ Sniffing”position Thumb + index finger to maintain face seal Middle finger under mandibular symphysis Ring and little finger under the angle of mandible

24. Urinary Catheterization

25. INDICATIONS OF URINARY CATHETERIZATION: Diagnostic: Collection of uncontaminated urine specimen. For accurate measurement & monitoring of urine output. For urodynamic studies. Therapeutic: To relieve urinary retention. For bladder irrigation. Intermittent decompression for neurogenic bladder. To empty the Bladder before, during, or after surgery. Intravesical chemotherapy.

26. TYPES OF URINARY CATHETER: Straight catheter , is used when the catheter is to be used for very temporary cause. Indwelling catheter , also known as Foley catheter, is left inside the bladder to provide continuous urine drainage. Suprapubic catheter is a type of indwelling catheter, it is inserted into the bladder through a surgical incision made in the abdominal wall, right above the pubic symphysis .

27. Condom catheter , is used for continuous collection of urine when there is no need for catheter insertion. 3-way catheter for continuous bladder irrigation (CBI) is a type of indwelling catheter. It is inserted to irrigate the bladder to prevent obstruction ( i.e bleeding) Condom catheter 3-way CBI

28. Typical weights and  tube sizes for age: Foley catheters Age Weight (kg) Foley (Fr) 0-6 months 3.5-7 6 1 year 10  6-8 2 years  12  8 3 years 14 8-10 5 years  18 10  6 years  21 12 8 years 27  12 > 12 years Varies  12-14 Adult Female Varies 14-16 Adult Male varies 16-18

29. Equipments: Catheter tray (with drapes, fenestrated drape, cotton balls, forceps) Catheter(appropriate size) Sterile drainage tubing with collection bag Correct size syringe (check catheter balloon) Sterile water Cleansing solution like povisep Lubricant Sterile gloves Specimen container Tape (to anchor tubing)

30. Catheterization Procedure: Assurance to the child. Maintain adequate Lighting. Position: Female Child : Dorsal recumbent (supine with knees bent & hips flexed) Male Child : Supine position If soiling evident, clean genital area with soap and water first. Perform hand hygiene Assemble all the equipments.

31. Catheterization(continued): Open the sterile catheterization kit, using sterile technique. Put on the sterile gloves. Apply sterile drapes. Place a fenestrated drape- Female child – over perineum Male child- over penis Lubricate the catheter. Pour the antiseptic solution over the cotton balls. Place the urine specimen collection container within easy reach.

32. Catheterization(continued): Cleanse meatus : Female child: Using swabs held in forceps in the other hand clean the labial folds and the urethral meatus . Move swab from above the urethral meatus down towards the rectum. Discard swab after each urethral stroke. Male child: retract foreskin if not circumcised, hold penis below glans , Using other hand, clean the meatus with swabs held in forceps. Use a circular motion from the meatus to the base of the penis. For older boys insert the Xylocaine gel into the urethra (Holding the penis perpendicularly) and wait 2-5 minutes before proceeding to next step.

33. Catheterization(continued): Insert catheter until urine flows, advance 2.5-5cm more. Then inflate the balloon with distilled water. Gently pull catheter until resistance is felt. Connect catheter to drainage system. Secure the catheter to thigh. Position drainage bag lower than the bladder. Dispose the gloves & other disposable articles. Perform hand hygiene. Documentation of the procedure.

34. Lumbar Puncture

35. Indications of LP: i )Diagnostic: Infection e.g. meningitis, encephalitis, GBS Systemic diseases e.g. SLE, multiple sclerosis Subarachnoid haemorrhage ii)Therapeutic: Intrathecal chemotherapy in leukaemia Spinal anaesthesia Removal of CSF in benign intracranial hypertension Contraindications: Raised ICP Localized skin infection Bleeding disorders e.g. haemophilia

36. Lumbar Puncture: Instrument: Lumbar puncture needle having- i ) Trocar ( stilette ) with knob ii) Cannula Site: Usually done in 3 rd or 4 th intervertebral space (between L3 &L4 Or L4 & L5 vertebra) Procedure: Written informed consent Patient should be lying on his/her side on a firm table/bed with the knees & chin as nearly apposed as possible (restrained position). Back of the patient should be right at the edge of the table, its transverse axis that is a line passing through the posterior superior iliac spine should be vertical. An expert assistant is needed to hold the patient in position comfortably. Lumbar Puncture Needle

37. Procedure(continued): After positioning, site of lumbar puncture is identified by 4 th lumbar vertebra, which is in the same plane with iliac crest. Physician must wear mask, gown & gloves. After putting skin wash draping, LP is done with all aseptic precautions by putting thumb of left hand on the spine & introducing the needle by right hand firmly through the skin in the midline between spines. Direction of the needle should be forward & slightly towards the head. As the dura is pierced there is sense of pressure release and as the needle enters the subarachnoid space CSF comes out. After collecting essential amount of fluid LP needle is withdrawn & a sterile dressing is applied. Patient should lie flat for 8-12 hours without pillow and should be given drink immediately after maneuver.

38. CSF Collection Tubes: Ideally CSF should be collected in 4 pre-numbered tube to be used as following- Tube 1 should be reserved for non-routine studies. Tube 2 can be used for immunology and chemistry testing. Tube 3 can be used for microbiology testing. Hematology analysis is typically performed on the last tube collected (3 or 4) to assure that any peripheral blood that may have contaminated the sample during the lumbar puncture has cleared. When only three tubes are obtained- Tube 2 is often reserved for microbiology Tube 3 is shared, with the hematology testing performed first, followed by any chemistry or immunology testing.

39. What should be seen in CSF: Pressure Physical character- colour Biochemistry: Protein, Sugar, chloride Cytology: cell count, differential count Microbiology: Gram stain, culture and sensitivity, AFB Serology: viral serology, VDRL, cryptococcus etc.

40. Complications: Headache Local pain Bleeding Herniation of brain stem Persistent CSF leaking Injury to local structures like intervertebral disc, vessels, nerves etc. Infection (causing meningitis etc.)

41. Endotracheal Intubation

42. Endotracheal Intubation: Indications: To provide mechanical respiratory support Obtain aspirates for culture Assist in bronchopulmonary hygiene(pulmonary toilet) Alleviate subglottic stenosis Endotracheal medications (e.g. epinephrine, lidocaine , atropine etc.) Instruments: ET Tube with or without cuff Laryngoscope with blade Suction apparatus Bag & mask with adjustable oxygen source Cardio-respiratory monitor

43. Endotracheal Tube: ET tubes can be : - cuffed - uncuffed Cuffed ET tubes are usually used in children >8 years The cuff when inflated maintains the ET tube in proper position and prevents aspiration of contents from GI tract into respiratory tract In children <8 years uncuffed ET tubes are usually used because the narrow subglottic area performs the function of a cuff and prevents the ET tube from slipping.

44. Pilot Ballon Cuff Oneway Valve Connector Stylet ET Tube(cuffed) with stylet Tracheal tube Murphy’s Eye ET Tube( uncuffed ) Endotracheal Tube( continiued ):

45. Age Gestation(wk) Weight(gm) Size(mm) Neonate ˂28 ˂1000 2.5 28-34 1000-2000 3.0 ˃34-38 ˃2000 3.5 ˃38 ˃3000 4.0 Infant upto 1year 4.0 Age ˃1 year (Age/4 + 4)mm Size of ET tube(Internal Diameter):

46. Laryngoscope

47. Procedures: Assembly & preparing all equipments. Preparing the patient: Position- Sniff position (rolled towel under shoulder) or, Supine (do not hyperextend) Suctioning oropharynx and nasopharynx as needed. Pre-oxygenation with high flow oxygen for 1 minute if possible (do not bag if meconium aspiration, diaphragmatic hernia) Monitoring vital signs & SpO 2

48. Procedures (continued): Giving drugs: Following drugs should be used unless patient is flaccid & unresponsive- i ) 1st Hypnotic such as thiopentone (3-5mg/kg), midazolam (0.5 mg/ kg) or propofol (2-4 mg/kg) ii) 2nd Muscle relaxant such as suxamethonium (1 mg/kg) or rocuronium (1mg/kg). Then intubate the trachea as soon as relaxed.

49. Intubation: Position self at patient’s head, hold scope in left hand, open mouth with fingers , insert blade into right side of the mouth, move blade to center of mouth pushing tongue to the left side. Slowly advance the blade and lift epiglottis till larynx is visualized. To better visualize an assistant can place gentle pressure on the thyroid cartilage. Insert ET tube into right side of the mouth using right hand alongside of blade, down past the vocal cords during inspiration. The stylet should be withdrawn gently (if present). Hold tube in position & confirm the position. The resuscitstion bag is attached to the tube & auscultation of the chest on both side (& also of stomach) with mechanichal breath is done to confirm proper ET tube position. Secure the tube in place using tape . Cut the tube at about 0.5cm from where it is taped (to reduce dead space).

50. Complications: Tracheal perforation Esophageal perforation Laryngeal oedema Improper tube positioning Tube obstruction or kinking Subglottic stenosis

51. Peritoneal Dialysis

52. PERITONEAL DIALYSIS Procedures: PREPARATION OF THE PATIENT: Take written informed consent. Baseline vital signs, weight, and serum electrolyte levels are recorded Bladder must be emptied first. Position- Patient should be lying(supine) on bed. Broad-spectrum antibiotic agents may be administered to prevent infection.

53. Peritoneal Dialysis(continued) PREPARING THE EQUIPMENT: Concentration of dialysate is determined according to the physician’s consultation and following medications are added to it accordingly- Heparin- to prevent clotting Potassium chloride - to prevent hypokalemia Antibiotics- peritonitis Insulin- for diabetic patients Before medications are added, the dialysate is warmed to body temperature to prevent patient discomfort and abdominal pain and to dilate the vessels of the peritoneum to increase urea clearance. Assemble the administration set and tubing. Fill the tubing with the prepared dialysate to reduce the amount of air entering the catheter and peritoneal cavity, which could increase abdominal discomfort and interfere with instillation and drainage of the fluid .

54. Peritoneal Dialysis(continued) CATHETER INSERTION: Drapping of the patient’s abdomen is done using chlorehexidine , povidone iodine & drawing sheet. Site selection: Midline 3 cm below umbilicus Lateral site At the lateral border of the rectus muscles On a line, half way between the umbilicus and anterior superior iliac spine Left lateral side is preferred as it avoids caecum Local anaesthetic is administered around that area. A small transverse incision is given on that point just to facilitate the insertion of the PD catheter.

55. The Y connector should be taken out from sterile PD set. Attach the long arm of elbow ban with th administration set and keep the short arm ready to attach to the catheter. Another arm of connector is then attached through tube to drain bag. The catheter is prepared by inserting stylet into it to maximum and is held vertically. Then the catheter is introduced through the incision by continuous twisting motion & pressure. As the catheter pierces the peritoneum there is sudden release of pressure is felt. Stylet should be withdrawn somewhat at this point & then the catheter is pushed towards iliac fossa . Stylet is then withdrawn completely. Short arm of the connector is attached to the catheter.

56. Peritoneal Dialysis(continued)

57. Peritoneal Dialysis(continued) Open the flow of the administration set while keeping drainage set closed & allow the dialysis fluid to flow into peritoneal cavity. The flow should be in continuous stream; if not, withdrawl a little of the catheter. Then the wound is cleaned & the catheter is fixed with dressing. Each EXCHANGE consists of- Infusion Dwell or Equilibration time Drainage So, during each exchange of cycle, 25-30 ml/kg PD fluid is infused into abdominal cavity >> then stop the control of infusing set >> wait up to pre-set dwell time >> then open the control of drainage set and thus the cycles are continued.

58. Complications of Peritoneal Dialysis: Infection: Peritonitis is common complication Perforation of bladder or bowel. Difficulty in drainage: this may occur due to kinking of the catheter, catheter blockage by omental plugging or by fibrin clots. Loss of ultrafiltration due to repeated episodes of peritonitis

59. Dr. Mumtahena Mahmuda Indoor Medical Officer Dept. of Pediatrics Chittagong Medical College Hospital

60. INRAVENOUS CANNULATION : An intravenous cannula is inserted into a vein, primarily for the administration of intravenous fluid, for obtaining blood sample and for administering medicines.

61. IV Cannula of Different Sizes 14G 16G 18G 20G 22G 24G

62. Repeated blood sampling Intravenous administration of fluid, medications, chemotherapy, parenteral nutrition and blood or blood products. Indication of IV cannulation :

63. Common site for IV cannulation in children: Hand : dorsum of non dominant hand is preferred between 4 th and 5 th digit. Foot : greater saphenous vein at ankle. 1 fingers breath anterior to medial malleolus.

64. Common site for IV cannulation in children continue….: Scalp veins are most appropriate for neonates. Antecubital veins : cephalic, basilic or median cubital vein are easy to locate but these sites are uncomfortable and require immobilizing of elbow .

65. Introduce your self to patient. Explain the procedure. Approach with a confident , calm,caring attitude . Procedure

66. Collect your equipment.

67. Wash hand

68. Apply tourniquet Clean area with alcohol

69. Remove needle cover

70. Insert the needle bevel up ward at about 30 ᶜ̊ & advance the rest of cannula into the vein

71. Release the tourniquet & apply pressure at the tip of cannula & remove the needle .

72. Apply the plaster to fix it on the place

73. 1-local complication: -Infiltration. -Extravasation. -Thrombosis. -Cellulitis. -Phlebitis. Complicatoins of cannulation : 2-systmic complication: -Embolism -Hematoma. - S ystemic infection. -Circulatory overload. -Allergic reaction.

74. Indications: According to WHO guideline 2016 Central cyanosis Nasal flaring Unable to drink or feed (due to respiratory distress) Grunting with every breath Depressed mental state Severe lower chest indrawing Respiratory rate >/ 70 or head nodding Spo2 < 90% Prolonged convulsion Coma Heart failure Shock Severe anaemia OXYGEN THERAPY:

75. LOW FLOW (VARIABLE PERFORMANCE ) HIGH FLOW (FIXED PERFORMANCE ) OXYGEN DELIVERY DEVICES Nasal prong Nasal catheter Nasopharyngeal catheter Face mask headbox Incubator Tent

76. It is disposable plastic device with two protruding prongs for insertion into the nostrils, connected to an oxygen source. Nasal prongs:

77. Nasal cannula: Measurement: From the side of nostril to inner margin of eyebrow. This usually reaches the back of the nasal cavity. If it is unavailable, even a cut down nasogastric tube is sufficient as a nasal catheter through which O2 can be delivered.

78. Measurement: from the side of the nose to the tragus of the ear. Tip of the catheter should be visible just below the the soft palate. In neonate and infant 6 to 8 fr catheter is used. Nasopharyngeal catheter:

79. Standard flow rate for nasal cannula or nasal prong or nasopharyngeal catheters are 0.5 to1L for neonate, 1 to 2L for infant and 2to 5 L for older children. Higher flow rate >5L without significant humidification may cause drying of nasal mucosa, associated bleeding and airway obstruction. It provides low medium concentration of oxygen 23% to44%. Flow above 5L does not increase Fio2 >44%.

80. Formula for an estimation of the Fio2 during use of a nasal cannula is as follows: FiO2 % of O 2 delivered= 21% + nasal cannula flow L/min x 3

81. Advantages Disadvantages Safe, simple and effective Client able to talk and eat with oxygen in place. Humidification is not required for cannula and prong. R eusable Nasal prongs are expensive chance of nasal obstruction by mucous secretion . Can dislodge from nares easily. Causes excessive mucosal dryness and epistaxis at 6 L/min or higher . Nasopharyngeal catheter can be displaced downward to oesophagus and cause vomiting, abdominal distension

82. The simple Oxygen mask

83. It delivers 40 % to 60% oxygen . Flow rate for simple mask range from 5 to 10L liters per minute, which usually require some room air to be entrained via the side ports of the mask to meet the patient’s minute ventilatory needs. The flow rate of a simple mask should never be <5 L/min; below this level, carbon dioxide rebreathing may occur, along with an increased resistance to inspiration .

84. Advantages Disadvantages Can provide increased delivery of oxygen for short period of time. The face mask is indicated in patients with nasal irritation or epistaxis Tight seal required to deliver higher concentration Difficult to keep mask in position over nose and mouth Uncomfortable for pt while eating or talking.

85. OXYGEN HOOD Clear plastic shell with covers the patient’s head Allows access to chest, trunk and extremities Flow of oxygen- 5-10 L/min 80 to 90 % of oxygen conc. can be achieved. Inappropiately tight seal causes retention of O 2 . A gas flow 2-3L/kg/min is necessary to avoid rebreathing of CO 2. Can be used in neonates and infants only.

86. Why do we give suction?

87. YES to suction NO to suction Infants, young children, total care kids who are unable to remove their own secretions Secretion removal for patients with bronchiolitis Bronchiolitis is caused by a respiratory virus (most often RSV) Causes congestion and swelling of the small airways of the lungs Child with a basilar skull fracture Child with suspected croup or epiglottitis Patient who demonstrates adequate ability to clear own secretions Able to spontaneously cough Able to blow nose

88. Suctioning Devices Yankauer Neosucker Mushroom tip nasal aspirator Bulb syringe Suction catheter

89. What size c atheter s hould I use?

90. Age Catheter Size Preemie 5/6 fr. Term Newborn 5/6 – 8 fr. Newborn – 6 mo. 8 – 10 fr. 1 yr. – 8 yrs. 10 fr. 8 yrs. or older 10 – 14 fr.

91. What suction p ressure s hould I use?

92. Age Suction Pressure Neonates 60 – 80 mmhg Infants 80 – 100 mmhg Children 100 – 120 mmhg Adults 100 – 150 mmhg

93. How do I measure for NP suctioning?

94. Measure from the tip of the nose to the bottom of the earlobe Note on catheter how many mm this is Measurement

95. Matierals needed: Clean gloves Suction catheter Facemask with shield Surgi -lube Saline drops Place 2-3 saline drops in each nostril Lubricate tip of catheter with surgi -lube Insert the catheter down to your measurement Initiate suction by putting thumb over suction port Pull back slowly while moving the catheter in a circular motion Technique

96. Oropharyngeal suction: measurement : from centre of incisor to angle of jaw and insert approximately 3 cm further. Tips for suctioning: A pply suction and rotate the catheter to suction the secretion. Do not push the catheter in and out against the wall o f the throat as this may injure the m ucus membrane. For suctioning the mouth a firm metallic suction tip may be used like yankauer catheter. Care must be taken to avoid injury to oral mucosa.

97. Complications: Hypoxia: Suction should not be more than 10 seconds at a time to prevent hypoxia. Do not apply suction pressure during insertion catheter. Pre-oxygenated the patient. Wait 3 minutes interval before each suction. Bradycardia: It occurs due to stimulation of vagus nerve. To prevent this gentle insertion and manipulation of catheter is needed. Catheter should be lubricated before insertion. Careful monitoring of patients pulse. infection: Follow strict asepsis. Suction patient only when needed.

98. METERED DOSE INHALER

99. Metered dose Inhaler

100. Step1 :Shake the inhaler well. Step 2: Breathe out gently, place the mouthpiece in the mouth with lips curled around it. Step 3: Begin breathing in slowly but at the same time, press down on the inhaler canister. Step 4: Continue breathing in slowly and steadily until the lungs are full. Step 5: Hold your breath for 10 seconds or for as long as comfortable. Breathe out slowly. Fig: Use of MDI

101. SPACER

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

103. Requires perfect co-ordination between inspiration and activation of device. Not possible in small children To eliminate this problem spacer is adviced . DISADVANTAGE OF MDI

104. Remove the cap of MDI shake it and insert in to spacer device. Place mouth piece of spacer in mouth or attach to face mask in case of infants and younger children Start breathing in and out gently and observe movements of valve. How to use MDI with spacer device

105. THORACOCENTESIS

106. Indications To diagnose pleural effusion or empyema. Therapeutically when large collection of fluid compromise ventilatory function. Thoracocentesis contraindication Uncontrolled Coagulation disorder Active skin infection Only one functioning lung Severe cough or hiccup Atelectesis Uncooperative patient.

107. 114

108. Procedure: Consent is taken from the patient

109. Arms folded in front Patient sitting on edge of bed

110. 117

111. 118

112. A wide gauze aspiration needle (blood transfusion needle can be used) having tubing attached with it is introduced perpendicular to the skin. Fluid my be withdrawn by a sterile 50ml syringe. It is safe to use a stopcock between the needle and syringe to avoid the risk of pneumothorax. After removal of fluid sterile dressing is applied over the puncture site. Procedure:

113. Infection Pneumothorax bleeding complications:

114. P ARACENTESIS

115. Indication: Determine etiology of ascites; diagnose peritonitis. To remove large volume of ascetic fluid when causing respiratory compromise. Contraindications: Patient with DIC Massive ileus with bowel distension. Near the surgical scar because scars are associated w ith tethering of bowel to abdominal wall and will cause bowel perforation. Infections

116. Position: Patient sitting upright on a chair. Or, lying supine on bed with head elevated 45-90 degrees. Site of Puncture: Midline between umbilicus and symphysis Pubis. Left lower quadrant lateral to the rectus muscle. Right side can also be used

117. Proper consent Put on sterile gloves & sterilize the site with povidone iodine and then alchohol . Place sterile drapping towel. Inject 2% lidocaine to peritoneum. Insert 18-20 gauge needle on 10 cc syringe slowly into the abdominal cavity at a slightly oblique angle to the skin Procedure:

118. i n a “ Z track technique” and aspirate intermittently. Gently aspirate 10cc fluid & then attach 50cc syringe to aspirate further amount of fluid. Detach the needle from the syringe after confirming that there is a steady flow of fluid, attach the tubing and stopcock in case of therapeutic tap.

119. After removing adequate amount of fluid close the stopcock and remove the needle. Apply pressure and dressing to the site. Fluid is then send for ascitic fluid study.

120. Ascitic fluid leakage Bleeding from injury to inferior epigastric artey . Bowel perforation . Infection. complications

121. BONE MARROW ASPIRATION

122. INDICATIONS :

123. CONTRAINDICATIONS :

124. Children below 2 years: Upper third of the medial aspect of the shaft of the tibia. Children above 2 years: Posterior superior iliac crest is the preferred site. Manubrium sterni may also be used – in the sternum the site is just above or below the manubrio -sternal angle . Common site for bone marrow aspiration

125. After taking proper consent the child should be kept in prone position or lying on his or her side. The area of the skin is then cleaned with povidone iodine and spirit. Then after drapping skin is infiltrated with 2% lignocaine upto periosteum.

126. The tip of the trocher & cannula is introduced to the skin on a point 1 cm below the post superior iliac crest & 1to 2cm posterior to mid- axillay line by boring motion. The entry into the marrow cavity is indicated by sudden lack of resistance .

127. The trohcar is then removed and 2-3 ml of marrow Is aspirated by suction using a 20ml syringe. Then the cannula is removed and firm pressure with a sterile gauze is applied over the site of puncture.

128. Procedure continued….. Films are prepared immediately by placing the aspirated material on a glass slide, sucking of most of the blood, and preparing a film where the particles are drawn along by a spreader to leave trails of dislodged bone marrow cells. C omplications: Pain at the biopsy site. Excessive bleeding particularly in people with low numbers of platelets. Infection Retroperitoneal hematoma Injury to the surrounding soft tissue .

129. What is an ABG: ABG sampling is a commonly performed procedure which allows health professionals to quickly obtain information on a patients respiratory status (blood oxygen and carbon dioxide levels), as well as patients acid base status. It is an invasive procedure. Blood is drawn from an artery rather than a vein. Helps differentiating oxygen deficiencies from primay ventilatory deficiencies from primary metabolic acid base abnormalities.

130. Information obtained from an ABG : Acid base status Oxygenetion Dissolved oxygen (PO2 ) Saturation of haemoglobin CO2 elimination Electrolyte status Levels of caboxyhaemoglobin and methemoglobin

131. Which artery to choose : The radial artery is superficial, has collaterals and is easily compressed. It should almost always be the first choice. Other arteries like femoral, brachial, dorsalis pedis can be used in emergencies.

132. Procedure

133. Complications : The commonest complication from an arterial puncture is hematoma at the site. Less common but important complications are thrombus in the artery and infection at the site.