Procedures

CHAPTER 3 Procedures



David Cartwright, Mark Davies



Skin disinfection — general principles


Whenever we break the skin integrity of a baby, we run the risk of making a skin-colonising organism into an infecting organism. Risks are minimised:


1. by limiting the number of times skin integrity is breached

2. by ensuring adequate skin preparation whenever it is necessary to breach skin integrity.


Skin preparation solutions



• Alcoholic chlorhexidine may be used routinely as a skin preparation solution for procedures. Aqueous chlorhexidine is recommended for extremely low birth weight (ELBW) infants in the first few days of life.

Alcohol wipes (isopropyl alcohol) may be used for heelprick blood tests, arterial ‘stabs’ and intramuscular/ subcutaneous injections. In addition, use iodine for central venous line insertions before the alcoholic chlorhexidine.


• Skin disinfecting solutions take time to work.

Iodine and chlorhexidine need about 2–3 minutes skin contact time for optimal disinfection; alcohol about 30–60 seconds, or until the alcohol evaporates.


• Never allow too much alcoholic chlorhexidine to sit on a baby’s skin, especially that of ELBW infants.

• Skin preparation solutions should always be allowed to dry of their own accord. They should never be ‘wiped off’. A minute or two of waiting may save a week or two of antibiotics! — a good trade-off.


Pain relief


The options for analgesia during procedures are:


• none

• swaddling

• cuddling and facilitated tucking

• breast feeding

• skin-to-skin contact

• non-nutritive sucking

• oral sucrose

• IV narcotics.


Vascular access



Peripheral intravenous (IV) cannula



• A 24G cannula is adequate for almost all neonatal applications.

• This is a two-person procedure.

• Use a sterile disposable dressing pack.


Technique



1. Wear sterile gloves.

2. Lay a sterile paper towel (or drape) under the limb.

3. Cleanse the insertion site thoroughly with a suitable skin preparation solution, allowing this to dry before inserting the cannula.

4. Try not to touch the insertion site at all.

5. Reapply skin preparation solution to the skin if multiple attempts at insertion are necessary.

6. Use a new cannula for each new attempt. The person inserting the IV should not open new cannulae themselves, nor get new ones out of a drawer.

7. If the task looks or becomes too difficult, get someone more experienced.

Remember, every new hole in the skin increases the infection risk and the pain for the baby.



Umbilical arterial catheter (UAC) insertion




If in a Level 2 nursery do not put a UAC in an ELBW or critically ill baby without consulting your Level 3 regional centre, and never use the second umbilical artery once attempted cannulation of the first umbilical artery has been unsuccessful. Vascular access for these babies in the first week of life is critical.



General preparation



• Inserting a UAC is a two-person procedure — the assistant holds and monitors the baby during the procedure.

• Use a full sterile technique.

• We suggest direct consultant supervision for infants <28 weeks GA and <1000 g BW.

Most nurseries will have a pre-prepared catheter insertion tray set up. In addition you will need the following items, all sterile:


• a cord tie

• a 5 mL syringe

• heparinised Normal saline (Nsaline, 0.9%) (10 units/mL)

• catheter — use size 5FG catheter for babies ≥ 1500 g, 3.5FG for <1500 g

• scalpel blade

• 3-way tap

• suture.

Insert the 3-way tap into the catheter and fill with heparinised Nsaline.



If inserting both an umbilical artery (UA) and an umbilical vein (UV) line, insert the UA line first, then the UV line. Tie in the UV line first, then the UA line. (See page 21.)




Technique for UAC insertion



1. If working in an incubator, ‘line’ the insides of the entry doors first with a sterile dressing towel each to minimise the risk of unsterilising your hands on entry to the cot.

2. Cleanse abdomen, cord and cord clamp: use alcoholic chlorhexidine unless baby is <1000 g BW; if so use aqueous chlorhexidine. Then place a cord tie around the base of the cord to prevent ooze from the umbilical vein. The top of the cord tie should be level with the skin line (Fig 3.1).

3. Be careful not to let any skin preparation solution (especially alcoholic chlorhexidine) spill down the sides of the abdomen — a small infant lying in this for even a short time may receive 2nd or 3rd degree burns over the flanks and buttocks.
image

Figure 3.1 Suturing an umbilical catheter — side view



Never use so much alcoholic chlorhexidine that it sits for prolonged periods of time in contact with the baby’s skin, and never let it dribble down the sides of the baby so that the baby is lying in contact with alcohol-soaked drapes, nappies or bedding.


4. Cut cord cleanly (with a single slicing motion) about 1 cm above the skin line. Discard cord clamp and forceps used to hold clamp.

5. Use fine-toothed forceps to hold the stump near the vessel to be cannulated

Some use artery forceps to do this, or place a suture through the upper part of the stump to hold it.


6. Identify the vessels (usually 2 arteries and 1 vein) — the arteries are smaller with thicker walls and sit proud of the cut surface; the vein is larger with a loose, thin wall.

7. Dilate the artery carefully with iris forceps.

8. Insert catheter to the correct distance:
— use the shoulder tip to umbilicus distance as a guide: measure from the tip of the left shoulder to the bottom of the umbilicus and put the catheter in this distance

— or use the ‘ready reckoner’ tables on pages 166–8.

9. Make sure you can aspirate blood back.

The number of different methods used to secure umbilical catheters is almost limitless. Best to learn what they do in your local intensive care nursery and do it. Our scheme is outlined below — it works well.


10. Place a purse-string suture around the stump (not the skin) and secure the catheter (Figs 3.1 and 3.2).
image

Figure 3.2 Suturing an umbilical catheter — top view


We use chromic-gut, as it grips the catheter well and if any is left behind after catheter removal it will dissolve away.


11. The first knot on the catheter should be 0.5 to 1 cm above the purse-string knot.

12. The knots on the catheter should be tight enough that the catheter cannot be pulled through the knots, but not so tight that they occlude the catheter lumen — check that you can still aspirate blood back.

13. Attach infusion line (with pressure transducer). An X-ray is required to check position.

14. An acceptable position for the tip is T6–T12. If it is lower than T12, pull back to L3–L4. Do not leave at L1–L2.

15. Now arrange more permanent strapping of the catheter. There are numerous ways of strapping the catheter and each neonatal unit will have their own method. We suggest sandwiching the catheters between two strips of tape along the abdominal wall and up the catheter. (This is similar to taping intercostal catheters — see Fig 4.8 on page 52.) Apply a transparent, bio-occlusive, polyurethane dressing (such as Bioclusive, Tegaderm, Opsite) to the abdominal skin so that the tape is stuck to this and not directly to the skin.

16. Make sure you have taken the cord tie off.

17. Check that lower limb perfusion is OK.

18. Usually UACs are left in situ for a maximum of 10 days.


Notes on UA infusions



• Standard UA infusion is Nsaline or 10% dextrose with 1 unit/mL of sodium heparin (NaHeparin).

• Parenteral fluids, including Na+ and Ca2+, can be administered through these lines, and antibiotics can also be given.

• Boluses of NaHCO3 (sodium bicarbonate) may be given slowly (<1 mmol/min — total dose should not be given over less than 5 minutes).

• Boluses of Ca2+ should only be given with great care — you must take all responsibility for the potential complications.

• Vasodilating drugs such as tolazoline and prostaglandin may be given through UA lines. Vasoconstricting drugs such as dopamine should not, and neither should potentially particulate material such as blood or platelets (fresh frozen plasma/albumin are OK). Indomethacin is never given via an UA.


Umbilical venous catheter (UVC) insertion


Technique and equipment as for UAC insertion, page 15.



If inserting both an umbilical artery (UA) and an umbilical vein (UV) line, insert the UA line first, then the UV line. Tie in the UV line first, then the UA line. (See page 21.)



General preparation



• Prime the catheter with heparinised saline (10 units/mL).

• Use size 5FG catheter for babies ≥1500 g, 3.5FG for <1500 g. Use a dual lumen catheter if <1000 g or critically ill.
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  2. Care of the extremely preterm baby
  3. Surgical problems
  4. Immunisation

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Jul 18, 2016 | Posted by in PEDIATRICS | Comments Off on Procedures

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