Professional Documents
Culture Documents
Paediatrics
CONTENTS
1) Nasogastric tube 10)IV Cannula
2) Peak Flow Meter 11) O2 Therapy
3) Pulse Oximetry 12)Suction
4) Nebulizer 13)MDI
5) AMBU 14)Spacer
6) Lumbar Puncture 15)Thoracocentesis
7) Urinary Catheterization 16)Paracentesis
8) Endotracheal Intubation 17)Bone Marrow aspiration
9) Peritoneal Dialysis 18)Arterial Blood collection
Dr Mohiuddin Ahmad Masum
DCH Student, Dept. of Pediatrics
Chittagong Medical College Hospital
Nasogastric
Tube Insertion
Nasogastric Tube:
Indications of use:
i)Feeding or admistration of medications
ii)Suction/gastric decompression
iii)Gastric lavage(e.g. in non-corrosive poisoning) NG tube
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.
• Hold the child, lubricate 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.
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
Peak Flow Meter
Peak Flow Meter:
Measuring scale
Parts:
Indicator
i) Mouth piece
ii) Indicator/cursor
iii) Measuring scale
Uses:
Peak flow meter can be used- Mouth piece
• To classify severity of asthma
• To see whether the management plan
Peak Flow Meter
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.
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
Nebulization
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
Parts of Nebulizer-
• Motor/Compressor
• Filter
• Air outlet & Air tube
• Nebulizer cup or Mixing
chamber
• Mouth piece or T piece
• Mask
Nebulizer
Procedures:
1) Clean all parts before use
2) At first, attach the air tube to
the outlet of the machine
3) Fit the air tube with mixing
chamber and mask
4) Take measured amount of drugs
into the mixing chamber by
syringe or dropper and mix with
normal saline
5) Connect the electrical line and
turn on the switch
6) Look whether fine mist is
coming out through the mask
adequately
7) Place the child in
comfortable position (head
upright)
8) 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.
9) Continue nebulization until
fine mist is no longer
present.
10) Clean the machine after use.
Pulse
Oximeter
Pulse Oximeter:
A Pulse Oximeter is a device used to determine the-
Desktop Finger/Mobile
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.
3-way CBI
Condom catheter
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
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)
Catheterization Procedure:
1. Assurance to the child.
2. Maintain adequate Lighting.
3. Position:
1. Female Child: Dorsal recumbent (supine with knees
bent & hips flexed)
2. Male Child: Supine position
4. If soiling evident, clean genital area with soap and water
first.
5. Perform hand hygiene
6. Assemble all the equipments.
Catheterization(continued):
7. Open the sterile catheterization kit, using sterile technique.
8. Put on the sterile gloves.
9. Apply sterile drapes. Place a fenestrated drape-
• Female child – over perineum
• Male child- over penis
10. Lubricate the catheter.
11. Pour the antiseptic solution over the cotton balls.
12. Place the urine specimen collection container within easy
reach.
Catheterization(continued):
14. 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.
15. For older boys insert the Xylocaine gel into the urethra
(Holding the penis perpendicularly) and wait 2-5 minutes
before proceeding to next step.
Catheterization(continued):
15. Insert catheter until urine flows, advance 2.5-5cm
more.
16. Then inflate the balloon with distilled water.
17. Gently pull catheter until resistance is felt.
18. Connect catheter to drainage system.
19. Secure the catheter to thigh.
20. Position drainage bag lower than the bladder.
21. Dispose the gloves & other disposable articles.
22. Perform hand hygiene.
23. Documentation of the procedure.
Lumbar Puncture
Indications of LP: Contraindications:
i)Diagnostic: – Raised ICP
– Infection e.g. meningitis, – Localized skin infection
encephalitis, GBS – Bleeding disorders e.g.
– Systemic diseases e.g. SLE, haemophilia
multiple sclerosis
– Subarachnoid haemorrhage
ii)Therapeutic:
– Intrathecal chemotherapy in
leukaemia
– Spinal anaesthesia
– Removal of CSF in benign
intracranial hypertension
Lumbar Puncture:
Instrument:
Lumbar puncture needle having-
i) Trocar(stilette) with knob
ii) Cannula Lumbar Puncture Needle
Site:
Usually done in 3rd or 4th 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.
Procedure(continued):
• After positioning, site of lumbar puncture is identified by 4th 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.
CSF Collection Tubes:
Ideally CSF should be collected in 4 pre-numbered tube to be used as
following-
a) Tube 1 should be reserved for non-routine studies.
b) Tube 2 can be used for immunology and chemistry testing.
c) Tube 3 can be used for microbiology testing.
d) 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.
ET Tube(uncuffed)
Size of ET tube(Internal Diameter):
ii. Slowly advance the blade and lift epiglottis till larynx is visualized. To better
visualize an assistant can place gentle pressure on the thyroid cartilage.
iii. 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).
iv. 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.
v. Secure the tube in place using tape . Cut the tube at about 0.5cm from
where it is taped (to reduce dead space).
Complications:
• Tracheal perforation
• Esophageal perforation
• Laryngeal oedema
• Subglottic stenosis
Peritoneal
Dialysis
PERITONEAL DIALYSIS
Procedures:
PREPARATION OF THE PATIENT:
1. Take written informed consent.
2. Baseline vital signs, weight, and serum electrolyte levels are recorded
3. Bladder must be emptied first.
4. Position- Patient should be lying(supine) on bed.
5. Broad-spectrum antibiotic agents may be administered to prevent
infection.
Peritoneal Dialysis(continued)
CATHETER INSERTION:
1. Drapping of the patient’s abdomen is done using chlorehexidine,
povidone iodine & drawing sheet.
2. Site selection:
1. Midline
1. 3 cm below umbilicus
2. Lateral site
1. At the lateral border of the rectus muscles
2. On a line, half way between the umbilicus and anterior
superior iliac spine
3. Left lateral side is preferred as it avoids caecum
3. 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.
4. 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.
5. 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.
Peritoneal Dialysis(continued)
Peritoneal Dialysis(continued)
5. 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.
6. Then the wound is cleaned & the catheter is fixed with dressing.
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.
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
Dr. Mumtahena Mahmuda
Indoor Medical Officer
Dept. of Pediatrics
Chittagong Medical College Hospital
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.
IV Cannula of Different Sizes
Suctioning
Devices
Yankauer
Bulb syringe
Neosucker
What size catheter
should I use?
Age Catheter Size
Preemie 5/6 fr.
Neonates 60 – 80 mmhg
• 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.
METERED DOSE
INHALER
Metered dose Inhaler
Step1:Shake the inhaler Step 4: Continue breathing in slowly and
well. steadily until the lungs are full.
Contraindications:
• Patient with DIC
• Massive ileus with bowel distension.
• Near the surgical scar because scars are associated with tethering of
bowel to abdominal wall and will cause bowel perforation.
• Infections
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
• Proper consent
Procedure:
• 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
• in 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.
• 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.
complications
• Ascitic fluid leakage
• Bleeding from injury to inferior epigastric
artey.
• Bowel perforation .
• Infection.
BONE MARROW ASPIRATION
INDICATIONS :
Lymphoma
Leukemia LD bodies in
kala-azar
Aplastic Storage
Anemia disorders- PUO
SKIN • Infection.
BONE • Osteomyelitis
DISORDERS • Osteogenesis imperfecta.
Common site for bone marrow aspiration
POSITION
STERILIZE
LOCAL
ANESTHESIA
INCISION
NEEDLE IN
MARROW
ASPIRATE
SAMPLE
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.
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 .
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.
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.
Complications:
• Pain at the biopsy site.
• Excessive bleeding particularly in
people with low numbers of platelets.
• Infection
What is an ABG: