A. Consideration of alternatives. For each procedure, all alternatives should be considered, and risk—benefit ratios should be evaluated. Many procedures involve the placement of indwelling devices made of plastic. Polyvinylchloride-based devices leach a plasticizer, Di(2-ethylhexyl)-phthalate (DEHP), which may be toxic over a long-term exposure. Alternatives exist and devices that are DEHP-free should be used for procedures on neonates whenever possible.

B. Monitoring and homeostasis. Ideally, the operator should delegate another care provider to be responsible for the ongoing monitoring and management of the patient during a procedure. This person’s primary focus should be on the patient rather than the procedure being performed. They must assess cardiorespiratory and thermoregulatory stability throughout the procedure and apply interventions when needed. For sterile procedures, a particularly important function is ensuring the integrity of the sterile field. Continuous monitoring can be accomplished through a combination of invasive (e.g., arterial blood pressure monitoring) or noninvasive (e.g., oximeter) techniques. This monitoring can most effectively be standardized through the use of a procedure checklist so that the monitoring caregiver can ensure that each step is appropriately completed and documented by sign-off on the part of all providers at the conclusion of the procedure.

C. Pain control. Treatment of procedure-associated discomfort can be accomplished with pharmacologic or nonpharmacologic approaches (see Chap. 67). The potential negative impact of any medication on the patient’s cardiorespiratory status should be considered. Oral sucrose (e.g., 24% solution, 0.2—0.4 mL/kg) is very effective in reducing pain of minor procedures and blood drawing. It can also be used as an adjunctive therapy for more painful procedures when the patient can tolerate oral medication. Morphine or fentanyl is commonly administered before beginning potentially painful procedures. The use of neonatal pain scales to assess the need for medication is recommended.

D. Informing the family. Other than during true emergencies, we notify parents of the need for invasive procedures in their child’s care before we perform them. We discuss the indications for and possible complications of each procedure. In addition, alternative procedures, where available, are also discussed. Informed consent should be obtained for procedures with a significant degree of invasiveness or risk.

E. Precautions. The operator should use universal precautions, including wearing gloves, impermeable gowns, barriers, and eye protection to prevent exposure to blood and bodily fluids that may be contaminated with infectious agents.

F. The safety pause. Before beginning any procedure, the entire team should take a “safety pause” or “time out” to ascertain that the correct procedure is to be performed on the correct patient and, if appropriate, on the correct side (e.g., thoracostomy tube, central venous catheter placement). This pause should be incorporated into the checklist for the procedure.

G. Education and supervision. Individuals should be trained in the conduct of procedures before performing the procedure on patients. This training should include a discussion of indications, possible complications and their treatment, alternatives, and the techniques to be used. For some procedures, there are mannequins or other options for simulation training, which also offer the opportunity to refine team skills. Experienced operators should be available at all times to provide further guidance and needed assistance.

H. Documentation. Careful documentation of procedures enhances patient care. For example, noting difficulties encountered at intubation or the size and positioning of an endotracheal tube used provides important information if the procedure must be repeated. We routinely write notes after all procedures, including unsuccessful attempts. We document the date and time, indications, performance of the safety pause, monitoring, premedication for pain control, the techniques used, difficulties encountered, complications (if any), and results of any laboratory tests performed.

The preparations for withdrawing blood depend somewhat on the blood studies that are required.

A. Capillary blood is drawn when there is not a need for many serial studies in close succession.

B. Venous blood for blood chemistry studies, blood cultures, and other laboratory studies can be obtained from a peripheral vein of adequate caliber to enable access and withdrawal of blood. The antecubital and saphenous veins are often promising sites. For blood cultures, the area should be cleaned with an alcohol or iodine-containing solution; if the position of the needle is directed by using a sterile-gloved finger, the finger should be cleaned in the same way. A new sterile needle should be used to insert the blood into the culture bottles.

C. Arterial blood may be needed for blood gases, some metabolic studies, and when the volume of blood needed would be difficult to obtain from a peripheral vein and no indwelling catheter is available. Arterial punctures are usually carried out by using the radial artery or posterior tibial artery. Rarely, the brachial artery is used when no other site is available. Radial artery punctures are most easily done using a 25- to 23-gauge butterfly needle and transillumination often aids in locating the vessel. After performing an Allen test to ensure collateral perfusion, the radial artery is visualized and entered with the bevel of the needle facing up and at a 15-degree angle against the direction of flow. (Recently, it has become controversial whether or not the Allen test should be considered the standard of care, especially regarding the interpretation of an abnormal test.) If blood is not obtained during the initial insertion of the needle, it can be advanced until the artery is transfixed, and then slowly withdrawn until blood flow occurs.

The insertion and management of intravenous catheters require great care. As in older infants, hand veins are used most often, but veins in the arms, foot, ankle, and scalp can be used. Transillumination of an extremity can help identify a vein, and newer devices that enhance the detection of veins may be even more useful.

A. Because bladder taps are most often used to obtain urine for culture, a sterile technique is crucial. Careful cleaning with an antiseptic such as alcohol or an iodine solution over the prepubic region is essential.

B. Technique. Bladder taps are done with a 5- to 10-mL syringe attached to a 22- or 23-gauge needle or to a 23-gauge butterfly needle. Before the tap, one should try to determine that the baby has not recently urinated. Ultrasonographic guidance is useful. One technique is as follows:

B. Examination of the spinal fluid. CSF should be inspected immediately for turbidity and color. In many newborns, normal CSF may be mildly xanthochromic, but it should always be clear.