• Explain the necessity of the procedure, the steps involved, and the risks.
  
• Obtain informed consent, except in life-threatening emergencies.
  
• Request a Child Life Specialist.
  
• Gather all necessary equipment for the procedure.
  
• Consider procedural sedation (see Chapter 2).
  
• Consider having a crash cart for any procedures involving airway or sedation.
  
• Recruit an assistant and explain what is expected of him or her during the procedure.
  
• Perform a “time-out” to ensure the correct patient and the correct site for the procedure.
  
• Position the child and provide adequate restraint if required.
  
• Carry out the procedure.
  
• Document the procedure in the chart (elements: consent, from whom consent was obtained, preparation, anesthesia used, equipment used, site of procedure, outcome of procedure, and any complications).

• Indications: (1) Tension pneumothorax
  
• Complications: Pneumothorax, bleeding, nerve damage, infection

Setup

Procedure

• Attach the patient to a cardiorespiratory monitor and apply oxygen per nonrebreather mask.
  
• On the affected side, locate the second intercostal space at the midclavicular line.
  
• Prep the skin using sterile techniques if patient is stable.
  
• If the patient is stable, raise a wheal with 1% lidocaine over the superior edge of the rib below the intercostal space (third rib).
  
• Penetrate the skin over the superior edge of the rib using a 16- to 20-gauge IV catheter.
  
• Advance the IV catheter gradually until a pop is heard or felt on entry of the pleural space.
  
• Remove the needle (a rush of air may be audible as tension is released).
  
• Attach a syringe with a stopcock to the hub of the catheter.
  
• Withdraw desired air, releasing further tension.
  
• Withdraw the needle at the end of the procedure and apply an occlusive dressing to the site (preferably with 3 of 4 sides fixed to skin to create a one-way flap-valve for further decompression).
  
• Obtain a CXR to assess the results of the procedure.

• Complications: Bleeding; hemothorax; perforation of visceral organs (lungs, heart, liver, spleen); intercostal neuralgia caused by trauma of neuromuscular bundles; subcutaneous empyema; infection, occlusion of chest tube with blood, pus, or debris
  
• Additional information:NEJM 2007;357:e15.

Setup

Procedure eFigure 3-1

• Place the patient in the supine position with the ipsilateral arm raised above the head.
  
• Locate the fourth or fifth intercostal space in the anterior axillary line at the level of the nipple.
  
• Prep the skin using antiseptic solution; arrange a sterile field if patient is stable.
  
• Anesthetize the skin, subcutaneous tissue, muscles, and pleura: Raise a wheal with 1% lidocaine over the superior edge of the rib that is below the selected intercostal space (the inferior portion of the selected intercostal space to avoid neurovascular bundle); insert needle and anesthetize by injecting lidocaine as the needle is withdrawn.
  
• Make a 1- to 2-cm incision parallel to the rib with #11 scalpel.
  
• Use a Kelly clamp to bluntly dissect the sub-Q tissue and intercostal muscles down to the pleura.
  
• Insert your index finger or Kelly clamp through the incision, palpating within the pleural layer, ensuring that the lung falls away from the pleura.
  
• Clamp the distal end of the chest tube with a Kelly clamp.
  
• Grasp the proximal end of chest tube with Kelly clamp and insert tube through the incision.

• When the tube has entered the thoracic cavity, remove the Kelly clamp and advance the chest tube until all of the tube fenestrations are within the thoracic cavity.
  
• Aim the tube apically/anteriorly for pneumothorax and basally/posteriorly for fluid collection.
  
• Use a continuous, purse-string suture (purse-string) to secure chest tube.
  
• Tape the chest tube to the side of the patient.
  
• Wrap petroleum gauze around the tube at the point where it enters the skin, and cover it with sterile gauze.
  
• Secure the site with pressure dressings.
  
• Attach the chest tube to suction unit and then unclamp the distal end.
  
• Obtain a CXR to confirm placement and adjust the tube accordingly in a sterile fashion (once unsterile, tube can be withdrawn but never advanced).

Removal of the Chest Tube

• Sutures, sterile gauze, and a suture kit should be available at bedside.
  
• Cut the skin sutures.
  
• Ask the patient to exhale fully and pull the tube out at end-expiration.
  
• Quickly occlude the site with sterile gauze.
  
• Additional sutures may be required to close the opening.
  
• Secure the site with pressure dressing.
  
• Obtain a CXR 4 to 6 h after the chest tube is removed. If abnormalities are seen then repeat another CXR in approximately 24 h after removal.

• Indications: (1) Enteral feeding, (2) abdominal decompression, (3) obtaining gastric contents for studies, (4) drainage or lavage in drug overdose or poison ingestion, (5) bowel obstruction
  
• Contraindication: Severe facial trauma with cribriform plate disruption
  
• Complications: Gagging and emesis, endotracheal intubation, tissue trauma
  
• Additional information:NEJM 2006;354:e16.

Setup

Procedure

• Measure the desired length of the enteral feeding tube.
  
  
  
  • For NG tubes: From the tip of the patient’s nose to the earlobe to the xiphoid process.
    
  • For ND tubes: From the tip of the patient’s nose to the earlobe to the umbilicus.
  
  
• Lubricate the tip of the tube with jelly.
  
• Immerse or flush the tube with ice-cold water for 2–3 minutes (especially for ND tubes).
  
• Position the child sitting upright, tilt the head back slightly, and slide the tube into the nostril along the base of the nose, advancing the tube slowly in a horizontal plane.
  
• For infants or unconscious children, lay them supine with head turned toward the side.
  
• When the tube has reached the nasopharynx, tilt the patient’s head forward to open the esophagus, direct the tube toward the posterior pharynx, and ask the patient to swallow.
  
• When the tube is past the pharynx, advance it slowly to the premeasured distance.
  
• Check the position by aspirating gastric contents and testing the pH, auscultating for bowel sounds by injecting air into the stomach via the tube. If these maneuvers are equivocal, obtain an abdominal radiograph to check the placement. For ND tubes, it is recommended to check the placement with an abdominal radiograph.
  
• Tape the tube securely after the position is acceptable.
  
• Withdraw the tube if there is excessive choking or coughing because this may indicate tracheal intubation.
  
• To withdraw an enteral tube, clamp the tube and withdraw it slowly.

Indications: (1) Obtain CSF sample for diagnostic studies, (2) measurement of opening pressure, (3) administration of anesthesia, (4) administration of medications for chemotherapy, (5) CSF drainage for symptomatic relief of benign intracranial hypertension

Contraindications: Overlying skin infection, suspected intracranial mass, suspected spinal cord mass or defect (eg, spina bifida), bleeding diathesis (relative contraindication)

Complications: Herniation, cardiorespiratory compromise, local or referred pain, post-lumbar puncture headache, bleeding, infection, leakage of CSF, subarachnoid epidermal cyst

Additional information:NEJM 2006;355:e12.

Setup

Procedure (Figure 3-2)

• Anesthetize the patient by topical anesthetic cream at the intended site and wait 30 minutes or for infants give ≤2 ml oral sucrose solution 2 minutes before the LP.
  
• Position the child.
  
  
  
  • Use the lateral recumbent position with the neck flexed and the knees to the chest. Use this position when measuring opening pressure (the child has to be as relaxed as possible).
    
  • The sitting position is an option in young children or when not measuring opening pressure.
  
  
• Identify the L4 spinous process (a line between the iliac crests).
  
• Identify the L4–L5 (or L3–L4) space by palpating above or below the L4 spinous process.
  
• Sterilize the anticipated puncture site with antiseptic solution; start at the proposed site and work outward in a circular manner. Repeat 2-3 times.
  
• Drape the area with sterile drapes.
  
• Check the child’s position to ensure correct spine flexion, maximizing the interlaminar space.
  
• Using a 20 or 22-gauge needle and a stylet with the bevel pointed cephalad, puncture the skin midway between the spinous processes of L4–L5 (or L3–L4). Remove the stylet (Ann Emerg Med 2007;49(6):762).

• Advance the needle perpendicularly in the midline and sagittal plane, aimed slightly cephalad.
  
• Advance the needle until a “pop” is felt and CSF starts flowing. (If the needle does not advance, withdraw it slightly and redirect the angle.)

• If measuring opening pressure: Reinsert the stylet and ask the patient to straighten the legs and neck. Remove the stylet, connect the manometer to the spinal needle, and measure the opening pressure prior to specimen collection.
  
• Allow CSF to drip into the collecting tubes.
  
• When CSF collection is complete, replace the stylet and withdraw the needle.
  
• Cover the site with an adhesive bandage.
  
• Clean the antiseptic solution off the skin with damp warm towel.
  
• Ideally, instruct the child to stay in the supine position for 4 to 6 hours to lessen the risk of a post-LP headache.

• Indications: (1) Capillary blood gas analysis, (2) blood sample for studies
  
• Contraindication: Overlying skin infection
  
• Complications: Hemolysed sample, bruised tissue

Procedure

• Ensure adequate restraint.
  
• Identify a suitable site: In children, use the medial or lateral palmar surface of the distal phalanx of the second, third, or fourth fingers. For infants, use the medial or lateral plantar surface of the heel. (Avoid a midline plantar heelstick to avoid the risk of periosteum puncture and subsequent osteomyelitis.)
  
• The sampling site may be warmed with an infant heel warmer or a cloth soaked in warm water.
  
• Clean the puncture site with alcohol swabs and then wipe or air dry.
  
• Massage the fleshy portion of the finger tip or heel.
  
• Puncture the skin using a lancet needle.
  
• Wipe away the first drop of blood, which contains excessive interstitial and intracellular fluid.
  
• Hold the patient’s heel or finger below the level of the heart and gently massage blood to drop into the collection container. Avoid excessive squeezing or milking, which may worsen hemolysis.

• Indications: (1) Parenteral medication administration, (2) fluid resuscitation, (3) expectant placement while obtaining a blood sample for laboratory testing
  
• Contraindications: Extremities with edema, burns, overlying skin infection, indwelling fistula
  
• Complications: Infection at the site, extravasation, superficial thrombophlebitis
  
• Additional information:Nursing Standard 2005;19(49):48.