PCC Pediatric Procedures 5.

Massage the area gently with sterile gauze before

inserting the BMN
Notes were taken from PCC videos with extra notes from blue book
o To allow spread of the local anesthetic
(blue color)
6. Insert the BMN vertically with a boring (like bore) and
October 20, 2018 slightly rotating motion, insert the BMN into the bone
until a sudden “give” is felt meaning the marrow cavity
Goodluck! – M has been entered
7. Remove the stylet from the needle, attach 10ml (10-
20ml) syringe from the needle. Apply suction by
Bone Marrow Aspiration withdrawing the plunger until the first drop of blood
appears in the syringe at which point REMOVE THE
MATERIALS: Prepare a tray with:
NEEDLE
• Sterile gloves 8. APPLY PRESSURE!!!
• Cotton balls 9. Discharge a small amount of the aspirated marrow to
• Betadine one end of each glass slide
• Sterile eye sheet (inaudible) 10. Tile the glass slide to allow excess peripheral blood to
• Syringes (5 and 10 mm) drip and concentrate on the bone marrow spicules prior
to spreading
• 2% Lidocaine
o Presence of white clumps of salt-like material
• Bone marrow needle (BMN)
represent: BONE MARROW SPICULES
• Glass slides
o This indicates adequate and appropriate bone
• Test tubes
marrow collection
PROCEDURES: 11. Use another glass slide as a spreader or pusher, at an
angle of 30 to 45 degrees in front of the BM aspirate
and move it back to make contact with the specimen
1. Disinfect the preferred site of puncture using betadine 12. When spreader and aspirate come in contact: MUST
antiseptic solution. Swab the area several times in a SPREAD QUICKLY
direction moving from INWARD TO OUT • Do NOT lift spreader without the last drop of blood
o For most children, the POSTERIOR ILIAC being spread out.
CREST is used.
o For children <3 mo: TIBIA can be used
o Position patient in a PRONE position and a
PILLOW to elevate the pelvis.
2. Sterile eye sheet (inaudible still) may be used to localize
the site of puncture.
3. Start by infiltrating the skin and periosteum using 2%
lidocaine solution. (1% lidocaine)
Infiltrate the most superficial layer of the skin. Advance
13. Film must be at least 300mm long.
the needle until it reaches the bone BEFORE giving the
14. Air dry and label all slides with the patient’s NAME
anesthetic
with a sharpened pencil
o Total amount used should not be >5ml!
15. Fix and stain at least TWO representative bone marrow
o Insert needle (16-18 gauge)
slides.
o Needle should be directed
16. Prepare a labelled container for the bone marrow slides
PERPENDICULAR to the bone and firmly
anchored to the bone. Indications:
4. Note the depth the needle penetrates before reaching
the bone! • Evaluation of patients with hematopoietic and non-
o This is a good indication saying how far the hematopoietic diseases
bone marrow needle must go • Splenomegaly
• Dysproteinemias
 • Suspected lysosomal storage disease Procedures:
• An unexplained deficiency or excess of peripheral blood
1. Wear sterile gloves (you don’t want pee on yo hands jk)
leukocytes or platelets
2. Cleanse area (yun lang literally)
• Presence of immature or morphologically atypical cells
o Infant should not have voided within 1
in the peripheral blood
hour of procedure
Complications 3. Apply antiseptic solution around the genitalia (not in
the video, wala siyang sinasabi)
• Hemorrhage 4. Lubricated catheter tip is held about 5cm from its
• Osteomyelitis terminal end and gently inserted into the urethra (poor
• Paraplegia baby ☹)
5. Male: Gentle traction is applied to the penis in a
Methods of Urine Collection
CORDAL direction
FOUR METHODS OF URINE COLLECTION: o Help straighten the course of the penile
urethra
1. Collection by voluntary voiding (clean catch) Catheter is slowly advanced until RESISTANCE is felt
2. Collection in containers attached to genitalia at the external sphincter
3. Bladder catherization o Continued pressure will overcome this
4. Suprapubic bladder aspiration resistance, and catheter will enter the bladder
Collection in containers attached to genitalia
Female: Labia are held wide apart, urethral orifice is
Indications: Infants clearly identified, lubricated catheter tip is gently
introduced into the opening
Procedure:
o Urethra is somewhat C-shaped with the
1. Cleanse the genitalia with the antiseptic solution. meatus representing the bottom of the C.
2. Dry the skin surface (Under da sea)
3. Remove the paper backing from the upper part of o Catheter started on a downward direction d/t
the bag exposing the adhesive surface. C shape
4. Male: Insert the penis through the round opening o Urethral orifice may be difficult to visualize
of the bag but is usually immediately ANTERIOR to the
Female: Apply a round opening on the bag, only the vaginal orifice
upper part of the vulva (wtf?) 6. Only a few cm of advancement is required to reach the
5. Press the adhesive surface firmly towards the skin bladder.
Diaper can be used over the bag but the bag must Catheter held in place until specimen is collected,
be examined EVERY 15 MINS carefully removed after.
o Specimen collected must be sent for culture
Indications:
or refrigerated IMMEDIATELY after
voiding • Obtain urine for urinalysis and culture in a sterile
6. Seal container fashion
• Accurately monitor hydration status
Bladder Catherization
Complications
Materials Used:
• Hematuria
• Rubber gloves
• Infection
• Sterile cotton balls
• Trauma to urethra or bladder
• Antiseptic solution
• Intravesicular knot of catheter (Rare)
• Collection bottle
• Lubricant
• Urethral catheters
Contraindications: • Dorsal metacarpal veins
• Median (antebrachial) vein
• Pelvic fractures
• Greater and lesser saphenous vein
• Known trauma to the urethra
• Blood at the meatus Materials

There is also the Suprapubic Bladder Aspiration but its not 1. Infusion set
mentioned in the video. Study this part if trip niyo lang hehe 2. Solution and tubing
3. Antiseptic solution w/ sponges
Suprapubic Bladder Aspiration
4. Gauges 22 or 24 IV catheter
Indications: 5. 3mL Pre-filled syringe (w/ NSS)
6. Tourniquet
• Urine for urinalysis and culture in a sterile fashion
o FOR CHILDREN <2 YEARS OF AGE!! Procedure:
o Avoid in children with GUT anomalies;
1. Cleanse the hand with antiseptic solution (allow to dry)
coagulopathy; intestinal obstruction
2. Apply tourniquet to the forearm.
• Bypasses URETHRA thereby minimizing risk for o If veins are not visible, grasp surface briskly to
INFECTION distend the vessel
Complications: 3. Select a vein in the metacarpal area
4. Stretch the skin down over the dorsum of the patient’s
• Infection (cellulitis) hand and pull distally in the opposite direction of the
• Hematuria (microscopic) needle insertion
• Intestinal perforation 5. Check patency of the system by infusing 2 or 3mL of
saline from the syringe.
Procedures:
6. Connect infusion set and regulate the drip.
1. Anterior rectal pressure in girls or gentle penile pressure 7. Splint the hand to avoid unnecessary movement
in boys may be used to prevent urination (shown in the video, not stated)
o Must have not voided 1 hr prior to procedure
Lumbar Puncture
2. Restrain infant in the supine, frog leg position
3. Prepare suprapubic area in a sterile fashion • Most frequently used source for collection of CSF
4. Site for puncture is 1 TO 2 CM ABOVE THE • Adaptable to all subjects of all ages, and relatively safe
SYMPHYSIS PUBIS IN THE MIDLINE.
5. Use a syringe with a 22-gauge, 1 inch needle and Indications:
puncture at a 10-20 degree angle to the perpendicular
• Suspected infection
plane, slightly caudad
• Malignancy
6. Exert suction GENTLY as the needle is advanced until
• Instillation for intrathecal chemotherapy
urine enters the syringe. Needle should NOT HAVE
ADVANCED more than 1 inch. Aspirate gently • Measurement of opening pressure
7. Clean iodine from the skin. Materials:

IV Insertion • 1% lidocaine
Indication: Obtain access to peripheral venous circulation, • Betadine
deliver fluid, medications or blood products • Sterile hand towels
• 26 gauge hypodermic needle
Infants: 5th interdigital plane is recommended
• 22-gauge hypodermic needle
• D/t its fairly CONSTANT position • 5mL syringe
• Sterile test tubes with stoppers
• Sterile cotton balls
Other venous access sites are:
 • Sterile 4x4 gauze sponges
• 3-way stopcock
• Sterile sponge forceps
• Manometer
Procedures:
1. STRONGLY EMPHASIZED!!
Proper position and adequate restraint are
ESSENTIAL for a successful tap
2. Patient on the side, near the edge of the table,
head is supported by a pillow, neck flexed, knees
drawn upward to meet the down-coming head
• Sitting or lateral recumbent position
• DO NOT COMPROMISE AN INFANT’S
CARDIORESPIRATORY STATUS BY
POSITION
3. Site for lumbar puncture is easily located
o A line joining the highest points of the 2
iliac crests passes just above the 4th lumbar
spine.
o Spinous processes of the 3rd and 5th
vertebrae are palpated in the midline,
locating the L3 to L4 interspace, as well as
the L4-L5 interspace
4. Gauze sponge is held with forceps, dipped in
tincture of iodine (Betadine), applied first to the
exact puncture site. Swab in circles of increasing
radii away from the operative site
o Removed by 70% alcohol swabs in the
SAME MANNER
o Service are of 10cm in every direction
around the puncture site SHOULD BE
STERILIZED
o Use a 20-22 gauge spinal needle with
stylet
o A smaller gauge needle will decrease
incidence of spinal headache and CSF
leak
5. Sterile towels are draped up and below the
operative area leaving an adequately exposed
working space
6. Selected interspace is carefully located, marked by
FINGERNAIL pressure
7. A wheal is produced with 1% lidocaine over the
puncture site, underlying tissues are infiltrated
down to the lamina
o Always aspirate before each injection to
assure that the needle is not in a vessel or
the spinal canal
8. Wait 3 to 5 mins for anesthetic to take effected
9. Needle is introduced exactly at the midline. May
be held with one hand with about 1cm of the
needle barrel visible or held with both hands with
the thumbs on either side of the needle hub with
the index fingers supporting the needle barrel
• Puncture skin midline just caudad to the palpated
spinous process, angling slightly cephalad toward
the umbilicus
10. As the needle passes to the deeper tissues, a pop
feeling is encountered in the dura, the stylus is
removed to see if spinal fluid is present
• In small infants, one may not feel a resistance or
“pop” as the dura is penetrated
• If resistance is met initially (you hit bone),
withdraw needle to skin surface and redirect angle
slightly
11. When the needle is at the proper place, a pre-drip
of CSF is established, the final pressure
manometer is attached to the needle hub via 3-
way stopcock
12. Fluid is allowed to fill the manometer and the
height of the column is measured in mm.
13. Spinal fluid pressure is measured BEFORE and
AFTER fluid is removed.
• Accurate measurement of CSF pressure can only
be made with the patient lying quietly on his or
her side in an unflexed position.
• Not accurate if SITTING
14. Collect the CSF in 4 diff test tubes
• Test tubes! IN ORDER!
1. Culture and gram stain
2. Glucose and protein levels
3. Cell count and differential count
4. Save specimen
Indications: • To remove the gastric contents ff: the ingestion of
a poison
• Examination of CSF for suspected infection or
• To remove amniotic fluid in the neonate
malignancy
• To obtain material for diagnostic tests
• Instillation of intrathecal chemotherapy
• For postoperative decompression
• Measurement of opening pressure
• Feeding, lavage and decompression
Complications
Insertion of the Nasogastric tube
• Local pain
1. Place the terminal end (with 2 small holes) of the
• Infection
NGT 5 to 8 cm below the xyphoid process and
• Bleeding
measure to the patient’s nares. Mark with crayon
• Spinal fluid leak or tape
• Hematoma o Represents the length of tubing required.
• Spinal headache o (bluebook method) Tip of the nose and
• Acquired epidermal spinal cord tumor (Caused by measure to his ear lobe. Then from the
implantation of epidermal material into spinal point of the tube, measure down halfway
canal if no stylet is used on skin entry) between the tip of the breastbone and the
navel (belly button)
Cautions and Contraindications
2. Examine the nasal passage and select the passage
• Increased ICP site
o Do fundoscopic exam BEFORE 3. Grab the tube 5 to 8cm from the terminal tip
LUMBAR PUNCTURE 4. When ready for use, dip the tip in a water-soluble
 CI: presence of Papilledema, lubricant
retinal hemorrhage or clinical o Never use OIL BASED substance!
suspicion of increased ICP 5. The tip of the nose is pressed upward with the
operator’s free thumb
• Bleeding diathesis o Enlarges the external nasal opening
o >50,000 uL is desired 6. Slide the tube into the nostril along the base of the
• Overlying skin infection nose, aiming towards occiput
o d/t inoculation of CSF with organisms 7. When the tube reaches the pharynx, ask the
• CI in unstable patient patient to swallow or offer him water to drink
o Antibiotics if needed with a straw.
8. Simultaneous with the swallowing maneuver, the
tube is advanced into the esophagus.
9. Tube is inserted in the pre-measured site. When
Nasogastric tube insertion
the tube has been inserted to the pre-measured
Relatively safe procedure, and easily accomplished site, the ff: tests may be utilized to determine
in infants and children. whether it is properly placed in the stomach or
whether it has entered the respiratory tract.
A tube may be introduced from the nose or
10. Attach a syringe at the end of the tube and
mouth to the stomach or duodenum
aspirate.
Indications: o If gastric contents are withdrawn, the tube
is in the proper position
• To instill a formula, electrolyte solutions or
o Draw up to 5mL of air
medication
 o Do not throw away the aspirate as it is a
very important liquid that should be
returned to the stomach
11. Place the external end of the tube in a glass of
water.
o If air bubbles appear during the expiratory
phase of respiration, the tube is in the
RESPIRATORY TRACT
12. Use a stethoscope and listen for air as it is being
instituted.
o if the tip is in the stomach bowel sounds
are audible
o Inject air into the tube and listen for a
“whoosh” sound
13. Tape.

Nursery Care

CORD CARE

• To reduce the skin and periumbilical colonization

of pathogenic bacteria and infection
o Entire skin and cord should be cleansed
with 70% ethyl alcohol followed by an
antiseptic agent such as Povidone Iodine
(Betadine)

EYE CARE

• The eyes of ALL newborns must be protected

against gonococcal infections
o By instilling 1% silver nitrate drops,
erythromycin or tetracycline

VITAMIN K INJECTION

• an IM injection of 1mg of water soluble Vit K.

(phytonadione) is recommended to all infants
directly after birth
o to prevent hemorrhagic disease of the
newborn

There are many more pediatric procedures in the blue

book but don’t have any video demos. Refer to page
106 for more information.