Procedures and iatrogenic disorders






  • Chapter Contents



  • Introduction 1261



  • Consent for procedures 1262



  • Pain management 1262



  • Aseptic technique and skin preparation 1262




    • Preparation for minor procedures 1262



    • Preparation for a major procedure 1262



    • Equipment 1263



    • Dressings 1263




  • Procedures and their complications 1263




    • Airway 1263




      • Endotracheal intubation 1263




    • Breathing 1265





    • Access to the circulation 1268




      • Capillary heelpricks 1268



      • Venepuncture blood samples 1269



      • Arterial puncture 1270



      • Peripheral venous cannulation 1270



      • Percutaneous central venous catheters 1271



      • Peripheral arterial cannulation 1273



      • Umbilical artery catheterisation 1273



      • Umbilical venous catheterisation 1277



      • Exchange transfusion 1280



      • Partial dilutional exchange transfusion 1281



      • Intraosseous lines 1282



      • Bone marrow aspiration 1283



      • Needle pericardiocentesis 1283




    • Feeding tubes 1284




      • Nasogastric/orogastric feeding tubes 1284



      • Nasojejunal feeding tubes 1284



      • Complications from nasogastric and nasojejunal tubes 1284




    • Urine collection 1286




      • Suprapubic aspiration 1286



      • Suprapubic catheterisation 1286



      • Transurethral catheterisation 1287



      • Abdominal paracentesis 1287



      • Peritoneal dialysis 1288




    • Cerebrospinal fluid collection 1288




      • Lumbar puncture 1288



      • Ventricular tap 1288



      • Complications of cerebrospinal fluid drainage 1289



      • Tapping ventricular reservoirs 1289




    • Punch skin biopsy 1289







Introduction


The word ‘iatrogenic’ is derived from the Greek ‘iatros’, meaning physician, and ‘genic’, meaning produced by. An iatrogenic disorder is any adverse condition that occurs as a result of a diagnostic procedure or therapeutic intervention that is not the natural consequence of the underlying disease. ‘Pathos’ is Greek for suffering, hence the term ‘iatropathic’, meaning suffering caused by medical examination or treatment.


Many iatrogenic events in neonatology are avoidable. The most commonly reported iatrogenic events in neonates include nosocomial infections, catheter-related complications, medication errors and respiratory events, including intubation injury and unplanned extubations. Low birthweight and gestational age, length of stay, presence of a central venous line, mechanical ventilation and support with continuous positive airway pressure have been identified as major risk factors for iatrogenic events ( ).


Good infection control and safe drug-prescribing and administration practices must be established to ensure that vulnerable infants are exposed to a minimum of hazards during their admission to neonatal intensive care. Considerable progress is being made in reducing nosocomial infection rates in intensive care units across the world. In 2009, The UK National Patient Safety Agency began a quality improvement project, Matching Michigan , in adult and paediatric intensive care units with the aim of reducing catheter-associated bloodstream infections ( ; Matching ). This quality improvement project has now been rolled out to neonatal units across the UK. The Matching Michigan model incorporates electronic reporting of infections with a number of technical and non-technical interventions that are aimed at promoting a safety culture within the critical care environment.


Medication errors occur all too frequently in busy neonatal units. A neonatal clinical pharmacist is a valuable addition to a multidisciplinary team caring for sick neonates. Medication errors will be minimised if the pharmacist attends daily rounds, checks drug and total parenteral nutrition (TPN) prescription charts and is available to give advice about therapeutic drug monitoring and pharmacokinetics. Errors can also be reduced by using electronic prescribing and smart infusion pumps ( ). Individualised, computer-generated emergency medication sheets decrease the risk of errors in emergency situations and using standardised drug infusion concentrations should eliminate the risk of 10-fold dosing errors. There should also be clear procedures in every neonatal unit to ensure that the right patient receives the right drug, in the right dose, by the right route, at the right time ( ).


The remainder of this chapter deals with how and when to perform many of the practical procedures that are undertaken during neonatal intensive care and describes the most important complications that are associated with each procedure. Every procedure performed on a baby carries risks. Knowledge of anatomy and standardised operating procedures, meticulous hand hygiene ( ) and careful observation will help to reduce many of the procedure-related iatrogenic events in neonatal intensive care units. It is imperative that doctors and nurses performing practical procedures receive training and supervision until they are competent at performing the necessary tasks.




Consent for procedures


Implicit consent is considered acceptable for many of the routine, low-risk procedures performed in neonatology ( ). However, explicit verbal or written consent should be taken for complex procedures, procedures involving significant risks and procedures that require general or regional anaesthesia or sedation.


In an emergency, when informed consent cannot be, or has not been, obtained, procedures considered to be in the best interests of the baby should be performed without delay, but clinical staff should always notify the parents as soon as possible after an emergency procedure has been performed.




Pain management ( Ch. 25 )


recommends that neonatal units should develop strategies to minimise the number of minor painful or stressful procedures and to provide effective non-pharmacological and/or pharmacological pain relief for all procedures. The continuous infusion of morphine in ventilated neonates may not effectively prevent acute pain from minor painful procedures.


‘Kangaroo care’ (skin-to-skin contact), swaddling and developmental care have been shown to reduce the response to pain from minor procedures. If available, breastfeeding or breast milk should be administered to neonates undergoing single painful procedures. Sucrose (0.05–0.50 ml of 24% sucrose), given approximately 2 minutes before and 1–2 minutes after a single heelprick or venepuncture, also modifies the response to pain in neonates ( ).


Topical anaesthetics, such as 4% tetracaine gel (Ametop), reduce pain from procedures such as venepuncture ( ), lumbar puncture and intravenous catheter insertion. The gel must be applied for 30–45 minutes before the procedure and appears to be ineffective for heelpricks ( ). In practice, topical anaesthesia is not much used in the newborn because of the time taken for it to work, and because it is not always possible to achieve cannulation in a single attempt.




Aseptic technique and skin preparation


Gloves should be used for all procedures. Consider using restraints (e.g. swaddling or immobilisation of one or more of the limbs) in order to maintain asepsis.


Preparation for minor procedures





  • Blood taking.



  • Insertion of peripheral venous or arterial catheters.



  • Suprapubic aspiration.



Wash hands with an antibacterial soap and apply alcohol gel. Put on disposable non-sterile gloves. Clean the baby’s skin with antiseptic or alcohol and allow to dry. Use a no-touch technique during the procedure.


Preparation for a major procedure





  • Central line placement.



  • Insertion of umbilical lines.



  • Insertion of chest drains.



  • Lumbar puncture or ventricular tap.



Wear a cap and mask. Scrub up for 4–5 minutes using antiseptic solution. Hands should be dried thoroughly with sterile towels. Put on sterile gown and sterile gloves.


Apply antiseptic to the skin, cleaning from the centre of a circle and working out to a diameter of ~5 cm. 10% Povidone-iodine and 0.5% chlorhexidine/70% isopropyl alcohol solution (Hydrex) are the most widely used antiseptic solutions. 2% Chlorhexidine/70% isopropyl alcohol solution has been shown to enhance skin antisepsis; however, the manufacturer does not recommended its use in infants <2 months of age. In extremely preterm babies, 0.5% chlorhexidine in aqueous solution (Sterexidine 200) may reduce the risk of chemical burns, but limited data exist to indicate the best preparation for this group of babies.




  • Always allow antiseptics to dry for at least 30 seconds before starting any procedure.



  • Avoid chemical burns ( Fig. 44.1 ) by ensuring that there is no pooling of the antiseptic solution under the baby.




    Fig. 44.1


    Chemical burn from pooling of antiseptic solution under a premature baby who was lying on bubble wrap. Fortunately the burn healed without scarring.



Equipment


Where possible, use disposable sterile instruments. Many manufacturers provide procedure-specific trays, which contain all of the required instruments and accessories. Always lay out the equipment trolley so that the sterile instruments and accessories are near to hand ( Fig. 44.2 ). Assemble equipment and flush lines with saline before commencing the procedure.




Fig. 44.2


Arrange instruments/equipment in the order of use and avoid contaminating the sterile equipment with dirty swabs.


Dressings


Transparent, semipermeable adhesive dressings have become a popular means of dressing catheter insertion sites. Ensure good haemostasis and minimise the amount of dressing that adheres to the baby’s skin. Never allow tapes or dressings to extend around an extremity as they will act as a tourniquet if there is venous congestion. Change dressings if they become damp, soiled or non-adherent.




Procedures and their complications


Airway


Endotracheal intubation


This is one of the most commonly performed life-saving procedures.


It is generally accepted that premedication drugs should be used for all elective or semielective intubations where intravenous access is established or can easily be obtained. Drugs that are commonly used include:




  • fentanyl 4 µg/kg (give slowly over 30 seconds)



  • suxamethonium 2 mg/kg or Atracurium 300 µg/kg



  • atropine 20 µg/kg.



Fentanyl has a nearly immediate onset of action, with duration of 1–2 hours. Adverse effects include chest wall rigidity and laryngospasm. Suxamethonium must be drawn up and ready for immediate administration, in case chest wall rigidity occurs. Do not give Suxamethonium if there is significant hyperkalaemia.


Indications





  • Stabilisation of the airway to allow tracheal suctioning and removal of meconium or other secretions.



  • The administration of surfactant.



  • When mechanical ventilation is required for babies with respiratory failure, circulatory problems or neurological dysfunction, or during intra- or interhospital transfers.



Equipment


A complete set of equipment for endotracheal intubation must be kept together in an intubation tray or resuscitation trolley and should be available for immediate use in every delivery room, neonatal nursery and emergency room.




  • Neopuff circuit or resuscitation bag and mask.



  • 2 × straight-blade laryngoscopes, Miller size 0 for a preterm baby and 1 for a term baby ( ). Disposable blades are recommended.



  • Suction equipment with 8–10 F suction catheters.



  • Endotracheal tubes (ETTs), straight or shouldered tubes, with internal diameters of 2.0–4.0 mm.



  • An introducer (optional – if used the introducer must not extend beyond the tip of the ETT).



  • Magill forceps and lubricating jelly (for nasal intubation)



  • Fixation devices, hydrocolloid dressing, adhesive tapes or bonnet and ties.



Procedure


Prepare all equipment and select an appropriate-size ETT ( Table 44.1 ). If gestation/weight is unknown the distance from the base of the nasal septum to the tragus +1 cm is a reasonable guide for the length of an oral ETT ( ).



Table 44.1

Oral endotracheal tube (ETT) size and approximate length by gestational age and weight







































Gestational age (weeks) Weight (grams) ETT size (internal diameter: mm) Approx. length for orotracheal route (cm)
23–24 500–600 2.0–2.5 5.5
25–26 700–800 2.5 6.0
27–29 900–1000 2.5 6.5
30–34 1000–2000 3.0 7.0–7.5
34–38 2000–3500 3.0–3.5 7.5–8.0
>38 >3500 3.5–4.0 8.5–9.0

(Adapted from .)


Orotracheal intubation


The orotracheal route is best for emergency intubations. To minimise hypoxia, each intubation attempt should last no more than 20–30 seconds.



  • 1

    Position the baby’s head in the midline in a neutral position. Do not hyperextend the neck as this makes visualisation of the cords more difficult.


  • 2

    Use gentle suctioning to clear the oropharynx.


  • 3

    Hold the laryngoscope in the left hand and introduce the blade into the right-hand side of the mouth, sweeping the tongue to the left as the blade is advanced.


  • 4

    The tip of the blade should be introduced into the vallecula ( Fig. 44.3 ).




    Fig. 44.3


    The tip of the laryngoscope should be placed in the vallecula.


  • 5

    In extremely preterm infants, the vallecula may be too small, in which case gently elevate the epiglottis with the laryngoscope blade.


  • 6

    Apply gentle anterior traction to the laryngoscope (in the direction of the handle). Do not use the upper gum as a fulcrum, as this will not produce a clear view of the glottis and will traumatise the gum. Applying cricoid pressure will help to bring the vocal cords into view ( Fig. 44.4 ).




    Fig. 44.4


    Visualisation of the vocal cords.


  • 7

    Under direct vision, the ETT tip should be inserted about 1 cm below the cords. Do not try to pass the ETT down the laryngoscope blade as this will obstruct your line of sight. Do not force the ETT through closed cords. Wait for the cords to open. If necessary, stop, mask ventilate the baby and try again.


  • 8

    Confirm the position of the tube by looking for symmetrical chest wall movement and listening for equal breath sounds over both lung fields. Colorimetric end-tidal CO 2 detectors can be used to confirm that the tube is lying within the trachea.


  • 9

    Secure the ETT using adhesive tape or a purpose-made fixation device ( Fig. 44.5 ).




    Fig. 44.5


    Fixation device for oral endotracheal tube.


  • 10

    After fixation, listen to the breath sounds again and observe chest wall movement. Shorten the ETT to reduce dead space.


  • 11

    The ETT position must be confirmed with a chest X-ray. The tip of the ETT is best placed opposite the body of the first thoracic vertebra (T1) ( ). Note that the carina lies variably between T3 and T5.


  • 12

    Note the final length of the tube at the lips.



Nasotracheal intubation


Nasotracheal tubes may be preferred in infants who are very active on the ventilator. Foot length has been reported as an accurate predictor of nasotracheal tube length in neonates ( ).


Do not use an introducer.



  • 1

    Insert the laryngoscope to visualise the oropharynx. Avoid hyperextending the neck.


  • 2

    Insert a lubricated straight ETT through the nostril, following the curve of the nasopharynx, until the tip is in line with the glottis.


  • 3

    Apply gentle cricoid pressure and advance the tube through the cords under direct vision. Magill forceps can be used in larger babies to thread the tip of the ETT through the cords.


  • 4

    Nasal ETTs are commonly secured with two half split tapes. One-half of each split tape is used to encircle the tube, while the remainder of the tape adheres to a hydrocolloid dressing on the upper lip and cheek.



Complications of intubation


Minor degrees of stridor secondary to laryngeal oedema are common in the first 24 hours following extubation. At present there is no evidence to support the routine use of corticosteroids prior to elective extubation. However, a trend towards reduced rates of reintubation or postextubation stridor following administration of steroids has been demonstrated in high-risk neonates ( ).


The risk of iatrogenic injury increases with decreasing gestational age and birthweight. Damage to the pharynx or oesophagus has been reported to occur in 0.44% of babies born at 1000–1500 g and 0.47% of babies born at <1000 g ( ). This complication can usually be treated conservatively with intravenous antibiotics and withholding of oral feeds; however, many of the complications of intubation will require referral to a paediatric ENT, plastic or dental surgeon for more definitive management ( Table 44.2 ).



Table 44.2

Complications of intubation












































Injury Presenting signs Management
Nasal damage Erosion of nasal septum. Nasal cartilage necrosis Nasal damage more likely in infants <1000 g. Avoid upward traction on the nostril. Damage more likely from nasal ETT than CPAP tubes. Refer to plastic surgeon
Pharyngeal tear ( ) Respiratory distress, difficulty passing a nasogastric tube. Ectopic nasogastric tube. Pneumomediastinum, pneumothorax, surgical emphysema and pleural effusion The site most commonly perforated is the pharynx, posterior to the cricopharyngeal muscle; the second most common site is the piriform sinus. Remove ectopic NG tube. Seek expert ENT advice. May require early surgical exploration. Treat with antibiotics
Laryngeal injury including trauma to vocal cords and arytenoids ( ; ) Weak cry, aphonia, respiratory distress, stridor, poor feeding. Risk of injury increased if intubation for more than 7 days and 3 or more intubations Refer to ENT for diagnostic laryngoscopy
SGS ( ) Biphasic stridor and airway obstruction. Acquired SGS occurs in ~1–2% of intubated neonates Once SGS is mature, medical therapy (oral or inhaled steroids) is almost always unsuccessful. Treat suspected gastro-oesophageal reflux preoperatively and postoperatively for optimal surgical results
Subglottic granuloma or cysts ( ) Upper airway obstruction May require tracheostomy and laser therapy
Tracheal tear ( ; ) Surgical emphysema, pneumomediastinum, pneumothorax, respiratory distress Secure airway: tip of the ETT must lie distal to the tear. Tracheotomy may be required. Manage small tears conservatively with antibiotic cover. Large tears usually require primary closure. Seek expert ENT advice
Palatal grooves ( ; ) Narrow channel of variable depth near midline of the palate Role of palatal protection plates remains unclear. Nasal intubation protects against palatal grooving. Palatal appearance usually normalises within 2 years
Defective dentition ( ; ) Altered dental arch dimensions in premature infants. Malocclusion, delayed eruption of maxillary central incisors. Enamel hypoplasia Minimise trauma during intubation. Referral to paediatric dentist once teeth have started to erupt
Acquired oral commissure defect ( ) Lateral placement of the ETT holder against the oral commissure Prevent by maintaining the ETT in the desired position. Refer to plastic surgeon

ETT, endotracheal tube; CPAP, continuous positive airway pressure; NG, nasogastric; ENT, ear, nose and throat; SGS, subglottic stenosis.


Breathing


Needle thoracocentesis


Indications





  • Emergency drainage of a simple or tension pneumothorax.



  • Diagnostic tap of a pleural effusion.



Equipment





  • Cold light, with sterile glove to cover the tip of the fibreoptic lead.



  • 21–25 G butterfly needle, three-way tap, universal container, sterile water.



  • If draining an effusion: 21–25 G venous cannula (Venflon), extension set, three-way tap and syringe.



Procedure


Simple or tension pneumothorax




  • 1

    Confirm the diagnosis:



    • (a)

      Clinical examination: look for signs of mediastinal shift, abdominal distension and increasing oxygen requirement.


    • (b)

      Transilluminate the chest.


    • (c)

      Perform a chest X-ray if unsure of the diagnosis, but do not delay treatment of clinically obvious tension pneumothorax.



  • 2

    Prepare equipment. Attach the three-way tap, open to air, to the tubing of the butterfly needle and place under water. The weight of the three-way tap will keep the end of the tubing submerged.


  • 3

    Clean the skin.


  • 4

    Using a no-touch technique, insert the needle into the second intercostal space in the midclavicular line.


  • 5

    Air will bubble out, confirming the diagnosis of a pneumothorax. If the pneumothorax was under tension, leave the needle in situ, while preparing to insert a formal chest drain.


  • 6

    In the case of a simple pneumothorax, a syringe can be attached to the three-way tap to remove any residual air. When all the air has been aspirated, remove the needle and repeat a chest X-ray.



Diagnostic pleural tap




  • 1

    Confirm the diagnosis:



    • (a)

      Examination: reduced/absent breath sounds.


    • (b)

      Chest X-ray to assess the size of the effusion.



  • 2

    Prepare the equipment. Clean and drape the skin.


  • 3

    Using a no-touch technique, insert the catheter needle into the fourth to fifth intercostal space in the midaxillary line, keeping the catheter needle at right angles to the skin until the pleural space is penetrated. Advance the catheter over the needle and withdraw the needle. Attach a short extension to the catheter and aspirate the pleural fluid slowly with a syringe.


  • 4

    When enough fluid has been aspirated, remove the catheter and apply a sterile gauze dressing.



Complications


See complications of chest drains, below.


Chest drain insertion


This procedure is often performed as an emergency. The majority of infants requiring a chest drain for treatment of a pneumothorax will need ventilation. Remember that positive-pressure ventilation may convert a simple pneumothorax into a tension pneumothorax.


Insertion of a chest drain for pneumothorax or pleural fluid drainage is painful. The recommends infiltration of the skin site with a local anaesthetic before incision and the use of opioids before or after chest drain insertion.


Indications





  • Drainage of a pneumothorax that is causing significant respiratory or haemodynamic compromise.



  • Drainage of a large pleural effusion or chylothorax.



Note that rapid and complete drainage of a large pleural effusion may cause haemodynamic compromise: if possible drain enough fluid to improve respiratory status and then consider clamping the tube and draining the effusion intermittently over the next few hours.


Equipment





  • Chest drain insertion pack containing drapes, intercostal drains, scalpel, forceps if using blunt dissection technique, silk suture, Steri-Strips, gauze, adhesive dressings.



  • Chest drains – select according to the preferred technique:




    • Classic method: 8 or 10 Fr chest tubes.



    • Seldinger method: Fuhrman straight or pigtail chest tubes (5, 6 or 8.5 Fr gauge).




  • Underwater sealed drainage system or a Heimlich valve.



Procedure


Classic (blunt dissection) method




  • 1

    Position the infant with a towel under the back so the affected side is raised ~30° above the horizontal. Ask an assistant to hold, or secure, the arm above the infant’s head.


  • 2

    Clean the skin with antiseptic solution, taking care not to allow the solution to pool under the baby’s back.


  • 3

    Identify the fourth or fifth intercostal space, midaxillary line. Infiltrate 1% lidocaine into the skin and subcutaneous tissues.


  • 4

    Assemble the equipment and remove the trochar from the chest drain tube.


  • 5

    Using a no. 11 scalpel blade, make a 1-cm-long incision in the skin, parallel to and just above the rib. Insert a pair of artery forceps into the incision, and, keeping the forceps perpendicular to the chest wall, use blunt dissection to penetrate the muscle layer.


  • 6

    The pleura can be incised with the scalpel or opened by applying pressure with the closed tip of the forceps. A definite give will be felt as the tip of the forceps pierces the pleura. Use your index finger as a guard to prevent the forceps from penetrating too deeply.


  • 7

    Keep the forceps in place and thread the chest drain tube between the opened tips of the forceps and advance it 2–3 cm into the pleural space. Alternatively, withdraw the artery forceps and clip the chest tube via the side hole and advance the chest drain into the pleural space. The disadvantage of this second technique is that it is not always easy to relocate the tract through the intercostal muscles.


  • 8

    Direct the chest drain anteriorly and apically to drain a pneumothorax and posteriorly to drain a pleural effusion. Ensure that all of the side holes in the chest drain tube are contained within the pleural cavity.


  • 9

    Connect the tube to the drainage system with an underwater seal and look for bubbling and/or a swinging meniscus.


  • 10

    Secure the chest drain to the skin with a simple suture: the ends of the suture should be tied around the chest drain tube four or five times and knotted securely. An additional suture may be required to close the incision. Do not use a pursestring suture as this leaves an unsightly scar.


  • 11

    Apply a small square of gauze to the insertion site and secure the chest drain tube at right angles to the skin with two transparent adhesive dressings, applied to the tube and chest wall in an inverted T.


  • 12

    X-ray to confirm the position of the chest drain and that the pneumothorax has resolved.


  • 13

    A low-pressure vacuum (–5–10 cmH 2 O) can be applied to the drainage system to assist with drainage of a pneumothorax.


  • 14

    If a large pleural effusion is present, control the rate of drainage by intermittent clamping of the drain.



Seldinger technique


If appropriate equipment is available, this is a less traumatic procedure. Straight or pigtail chest drain tubes are available for use in neonates.



  • 1

    Position the baby and clean and drape the skin as before.


  • 2

    Infiltrate the skin and subcutaneous tissues with local anaesthetic and make a 0.5-cm incision in the skin. Remember to aspirate on the needle before infiltrating the local anaesthetic.


  • 3

    Attach a saline-filled syringe on to the introducer needle and insert the introducer needle into the pleural space, keeping the needle at right angles to the skin. Fluid or bubbles of air should be aspirated into the syringe to confirm that the needle lies in the pleural space.


  • 4

    Remove the syringe and pass the guidewire into the pleural space and remove the introducer needle.


  • 5

    Thread a dilator over the guidewire and gently dilate the tract, using a twisting motion.


  • 6

    Remove the dilator and thread the chest drain tube over the guidewire, angling the tube anteriorly for a pneumothorax and posteriorly for a pleural effusion.


  • 7

    Withdraw the guidewire, secure the chest drain in place, connect to the underwater drain and apply an adhesive dressing as described above.


  • 8

    Confirm the position of the tube with an X-ray.



Complications of chest drains


See Table 44.3 and Figure 44.6 .



Table 44.3

Complications of chest drains







































Complication Comments Precautions and management
Haemorrhage The intercostal artery and vein lie in the intercostal groove below the rib During insertion try to roll the dissecting forceps or introducer needle over the top of the rib
The internal thoracic artery runs down the inside of the chest wall, ~1 cm from the sternum Use the midclavicular line as the anatomical landmark for needle thoracocentesis
Trauma Lung perforation or laceration ( ) The risk of lung perforation is reduced by removing the trochar from a conventional chest drain prior to insertion. Be careful not to push the introducer needle too far into the chest when using the Seldinger technique
Pericardial damage ( ), including haemorrhagic pericardial effusion and tamponade Confirm diagnosis urgently with ultrasound if baby develops signs of reduced cardiac output. Proceed to pericardiocentesis if tamponade is confirmed
Thoracic duct damage with resultant chylothorax ( ) Avoid inserting the chest drain in too far. The chylothorax usually resolves with conservative management
Phrenic nerve injury ( ) Avoid inserting the chest drain in too far
Phrenic nerve injury may lead to diaphragmatic paralysis or eventration of the diaphragm. Nerve injury may recover following removal of the chest drain
Permanent damage to breast tissue ( ) In term infants, breast tissue extends from the second to sixth rib and almost to the anterior axillary line. Use the midaxillary line, and avoid the anterior approach for formal chest drains
Infection Inoculation of pleura with skin organisms/local cellulitis Meticulous skin care. Change dressings if soiled
Failure to drain/reaccumulation of the pneumothorax Check all connections are tight and open to the water trap. Look to see if the drain has fallen out, or if the side holes are outside the chest – if so, it will bubble continuously if under suction. There may be surgical emphysema on chest X-ray. If the chest drain is misplaced or blocked with blood or protein, it will require replacement. Consider intubation of the main bronchus and unilateral lung ventilation for 48 hours for recalcitrant pneumothorax ( )





Fig. 44.6


(A) Bilateral chest drains. The drains have been inserted in the seventh intercostal space and are too long, risking injuries to the liver, diaphragm and mediastinal structures, including phrenic nerves and thoracic duct. The drains should have been inserted in the fourth or fifth intercostal space. Note the endotracheal tube is at T3 and should be shortened. The nasogastric tube is in the stomach. The umbilical venous line is in a satisfactory position at T9. (B) Right pigtail chest drain has been inserted via the fourth intercostal space and is in a satisfactory position. Endotracheal tube at T2. The umbilical venous line is at T6, and is lying within the right atrium.


Chest drain removal


Once the pneumothorax or pleural effusion has resolved, clamp the tube for several hours. Removal of the chest drain is known to be very painful and a short-acting, rapid-onset systemic analgesic should be given before proceeding.


Equipment





  • Dressing pack, stitch cutter, suture or Steri-Strips, sterile dressing.



Procedure




  • 1

    Remove dressings and clean the skin in the area of the chest drain with antiseptic solution.


  • 2

    Remove any sutures.


  • 3

    Pull the chest drain out, keeping the edges of the wound approximated. Apply Steri-Strips to close the wound. Use a simple suture if the wound is gaping or if the Steri-Strips do not stick. Dress with sterile gauze and cover with a transparent dressing.


  • 4

    Perform a chest X-ray to exclude reaccumulation of the pneumothorax.



Drainage of pneumomediastinum


Pneumomediastinum may occur in association with birth injury, pneumonia, meconium aspiration syndrome and following tracheal injury. X-ray appearances include the spinnaker-sail sign (upwards and outwards deviation of the thymic lobes) and continuous-diaphragm sign (due to the interposition of air between the pericardium and diaphragm) ( ). The presence of free air in the mediastinum can usually be managed conservatively, with resolution of the pneumomediastinum within 72 hours. Tension pneumomediastinum associated with mechanical ventilation may compress the heart and large blood vessels, leading to cardiorespiratory compromise. High-frequency oscillatory ventilation may help to reduce tension within the mediastinum ( ).


Indications for drainage





  • Tension pneumomediastinum with major cardiorespiratory compromise.



Equipment





  • 21–25 G venous cannula (Venflon), extension set, three-way tap and syringe.



Procedure




  • 1

    Clean the skin.


  • 2

    Assemble equipment. Depending on how the mediastinal air is distributed, either insert the cannula via the second intercostal space, midclavicular line, or use the subxiphoid approach: insert the cannula just below the xiphoid cartilage, 0.5 cm to the left of the midline, and advance the cannula towards the left shoulder whilst aspirating gently on the syringe.


  • 3

    Once the needle is within the collection of air, slide the catheter forward and remove the needle. Reconnect the syringe and aspirate as much air as possible.


  • 4

    Withdraw the catheter and X-ray.



Complications




  • 1

    Cardiac puncture.


  • 2

    Pneumopericardium.


  • 3

    Pneumothorax.


  • 4

    Arrhythmias.



Access to the circulation


Capillary heelpricks


Capillary blood samples are easy to obtain, conserve the veins in critically ill infants and can be used for most haematological and biochemical tests. However, capillary samples cannot be used for blood cultures and the capillary P o 2 value bears little relationship to the arterial P a o 2 .


Indications





  • Capillary blood gas sampling.



  • Routine haematology and biochemistry analyses requiring a limited amount of blood (i.e. less than 1.5 ml).



  • Bilirubin and glucose measurements.



  • Newborn screening tests (Guthrie card).



Equipment





  • Automated heel-lancing device (Tenderfoot, Minilet or Glucolet lancets).



  • Heparinised capillary blood gas tubes, sample bottles.



Procedure




  • 1

    The foot must be warm and well perfused.


  • 2

    Clean the heel with an antibacterial swab.


  • 3

    The preferred areas for capillary sampling are the outer aspects of the heel ( Fig. 44.7 ). Do not sample from the end of the heel because the perichondrium of the calcaneum lies superficially and the risk of osteomyelitis is increased.




    Fig. 44.7


    The shaded areas indicate the lateral and medial aspects of the heel, which are suitable for heelpricks.


  • 4

    Dorsiflex the foot, hold the automated device against the skin and activate. Apply gentle pressure and allow a drop of blood to form.


  • 5

    When samples have been collected, apply pressure with sterile cotton wool or gauze and dress with a plaster.



Complications




  • 1

    Pain.


  • 2

    Scarring.


  • 3

    Infection, including osteomyelitis of the calcaneum ( ).



Venepuncture blood samples


Use veins in the dorsum of the hand or feet. Try to conserve the long saphenous veins and veins in the antecubital fossa in babies who are likely to need a long line.


Indications





  • Larger volumes of blood for laboratory analyses.



  • Samples for coagulation.



  • Blood cultures.



Equipment





  • 23 G flanged collection needle.



  • Specimen bottles.



Procedure




  • 1

    Clean skin with antiseptic or with an alcohol swab and allow to dry.


  • 2

    Occlude the vein proximally, using gentle pressure


  • 3

    Insert the needle or butterfly at an angle of 30–45° to the skin. Inserting the needle where the vein bifurcates prevents the vein rolling away from the point of the needle.


  • 4

    Allow blood to drip into the specimen bottles from the needle ( Fig. 44.8 ).




    Fig. 44.8


    Venous blood sampling from a flanged needle.


  • 5

    After needle removal, apply gentle pressure with sterile gauze to prevent bruising/haematoma formation.



Complications




  • 1

    Pain.


  • 2

    Scarring.


  • 3

    Infection.



Arterial puncture


The radial artery is most commonly used, providing the ulnar collateral circulation is intact. The posterior tibial and dorsalis pedis arteries can also be used. Avoid using the brachial or femoral arteries, as they are end-arteries.


Indications





  • Arterial blood gas sampling.



  • Large volumes of blood for laboratory analyses when venous and capillary samples are unsuitable or unobtainable.



Equipment





  • 24 G needle or cannula.



  • Heparinised blood gas syringes, capillary tubes, sample bottles.



Procedure


Radial artery puncture




  • 1

    Before proceeding, perform the modified Allen’s test:




    • Elevate the arm.



    • Occlude both the radial and ulnar arteries at the wrist.



    • Release pressure from over the ulnar artery: colour should be restored to the hand in less than 10 seconds.



  • 2

    Identify the artery, using palpation and/or transillumination with a cold light.


  • 3

    Extend the wrist in a supine position, but do not overextend the wrist.


  • 4

    Clean skin with antiseptic and allow to dry.


  • 5

    Insert the needle at an angle of ~30°; blood should flow freely into the needle.


  • 6

    Blood can be collected with a syringe or by the drip method.


  • 7

    Remove the needle and apply compression with a sterile gauze swab for 5 minutes, or until haemostasis is achieved.



Complications


See complications of peripheral arterial cannulation ( Box 44.1 ).



Box 44.1

Management of digital ischaemia




  • 1

    Remove the needle or cannula.


  • 2

    Application of 1/4 of a cutaneous glyceryl trinitrate patch over the ipsilateral brachial or popliteal artery may improve the distal circulation.




Peripheral venous cannulation


Veins in the back of the hand, forearm and foot should be used first. Confirm that the vessel empties following proximal occlusion and fills distally. Limit the number of attempts at cannulation to two or three per person.


Indications





  • Administration of intravenous medications, fluids, blood products and short-term parenteral nutrition.



Equipment





  • 24 G cannula.



  • Extension tube with Luer-Lok and valved connector.



  • 0.9% saline in 5-ml syringe.



  • Steri-Strips, transparent dressing.



Procedure




  • 1

    Flush the extension tubing with saline.


  • 2

    Clean skin with antiseptic and allow to dry.


  • 3

    Occlude the vessel proximally and apply gentle traction to the skin.


  • 4

    Insert the cannula at an angle of 30–45° to the skin. As the needle pierces the vein, blood will appear in the hub of the cannula. Push the cannula in a further 1–2 mm, partially withdraw the needle and advance the cannula forward into the vessel. Remove the needle. Collect blood samples by the drip method or by aspirating blood from the hub of the cannula with a needle and syringe.


  • 5

    Connect the extension tubing to the cannula and flush gently with saline.


  • 6

    Secure the cannula using Steri-Strips and a transparent adhesive dressing to allow inspection of the cannula site ( Fig. 44.9 ). Do not apply the dressing around the whole circumference of the limb.




    Fig. 44.9


    Fixation of a peripheral venous catheter.


  • 7

    Use a size-appropriate splint if the cannula is inserted over the elbow or ankle joint. Do not fix the limb too tightly to the splint.


  • 8

    Intravenous infusions should be infused via pressure-sensitive pumps and cannula sites must be checked hourly.


  • 9

    Cannulae should be removed promptly if the insertion site or vein becomes erythematous or if the limb becomes swollen.



Complications




  • 1

    Haematoma formation: apply gentle pressure to secure haemostasis before applying the dressing.


  • 2

    Thrombophlebitis occurs in ~13% of babies with a peripheral intravenous infusion ( ). Redness and tenderness over the course of the vein usually resolve with removal of the cannula.


  • 3

    Infection: Staphylococcus epidermidis may be grown from the site and the cannula. Septicaemia from peripheral intravenous sites is uncommon in paediatric populations ( ); however, any breach in the integrity of the skin can predispose to infection in the newborn.


  • 4

    Extravasation injury is a common complication, presenting with pain and swelling that progress to superficial blistering, ischaemia and tissue necrosis.



Management of extravasation injury


Extravasation injuries must be treated promptly in order to minimise tissue damage and subsequent scarring. Seek specialist advice for stage III and IV extravasations ( Table 44.4 ).



  • 1

    Stop the intravenous infusion immediately, but do not remove the cannula.


  • 2

    Remove the dressing and elevate the limb.


  • 3

    Try to aspirate fluid from the extravasated area via the cannula, using a 1-ml syringe.


  • 4

    In more severe extravasation injuries, where there is blistering or discoloration of the skin or if the infusion contained calcium, potassium, sodium bicarbonate, antibiotics or inotropes, inform the plastic surgeons and seek their advice regarding the following treatments:



    • (a)

      Multiple puncture technique ( ): applying a strict aseptic technique, use a blood-drawing stylet or scalpel to make multiple punctures over the most oedematous area. Gently express the extravasated fluid. Dress the area with room-temperature saline soaks to aid drainage.


    • (b)

      Hyaluronidase + saline flush-out ( ): hyaluronidase is a dispersing agent that is effective in extravasations involving calcium, TPN, antibiotics and sodium bicarbonate. It is most effective if administered within 1 hour of the injury but may be used up to 12 hours:




      • After cleaning and infiltrating the area with 1% lidocaine, inject 500–1000 units of hyaluronidase subcutaneously. Make 2–4 small stab incisions at the periphery of the injury.



      • Inject up to 500 ml of saline through a blunt cannula inserted through one of the puncture sites and flush the saline towards the other incisions to wash out the extravasated material ( Fig. 44.10 ).




        Fig. 44.10


        (A) An acute extravasation injury to the dorsum of the hand. (B) Kit required for hyaluronidase + saline flush-out. There is marked improvement (C) immediately following irrigation and (D) at 24 hours.



    • (c)

      Topical nitroglycerine 2% ointment 4 mm/kg body weight applied 8-hourly to the affected area has been shown to be effective in extravasation injuries involving dopamine ( ).



  • 5

    Elevate the limb to reduce oedema.


  • 6

    Dress with Jelonet and sterile gauze.


  • 7

    Review daily: complete healing may take up to 3 months.



Table 44.4

Staging of extravasation injuries



















Stage Characteristic
I Painful intravenous site, no erythema or swelling
II Painful intravenous site, slight swelling, no blanching. Good pulse and brisk capillary refill below extravasation site
III Painful intravenous site. Marked swelling. Blanching. Skin cool to touch. Good pulse and brisk capillary refill below extravasation site
IV Painful intravenous site. Very marked swelling. Blanching. Cool to touch. Decreased or absent pulse. Capillary refill >4 seconds. Skin breakdown or necrosis

(Adapted from .)


Percutaneous central venous catheters


The veins most commonly used for peripheral inserted central venous catheters (CVCs) are shown in Table 44.5 .



Table 44.5

Veins commonly used for peripherally inserted central venous catheters
































Site Vein Comments
Upper limb Median cubital and basilic veins These veins lie medially in the antecubital fossa and drain directly into the axillary vein. They are the best veins to use in the upper limb
Cephalic vein Lies laterally in the antecubital fossa. It often divides into a number of branches before joining the axillary vein just below the clavicle. If this vein is used, lines tend to get caught around the shoulder or below the clavicle
Axillary vein If the arm is raised and abducted, the axillary vein lies anteriorly and inferiorly to the axillary artery and nerves of the brachial plexus
Lower limb Long saphenous vein Lies anterior to the medial malleolus and runs up the medial aspect of the leg to join the femoral vein. Vein of choice in the lower limb
Short saphenous vein Lies inferior and posterior to the lateral malleolus and runs up the posterior aspect of the leg passing between the heads of the gastrocnemius muscle and drains into the popliteal vein, around the level of the knee joint
Scalp Preauricular veins or superficial temporal vein These drain via the deep facial vein into the internal jugular. Avoid using the posterior auricular vein, as lines tends to get stuck in the external jugular vein at the root of the neck


Indications





  • Long-term administration of TPN.



  • Drug infusions such as inotropes.



Equipment





  • Instrument pack containing drapes, fine non-toothed forceps and artery forceps.



  • Long line with insertion butterfly, splitting needle or cannula.



  • Gauze, Steri-Strips, transparent adhesive dressing.



  • Luer-Lok connectors and extension sets.



  • Injectable X-ray contrast.



Procedure




  • 1

    Identify the vein. If an upper limb or scalp vein is being catheterised, measure the distance to the third intercostal space to the right of the sternum. If a lower limb vein is used, measure from the insertion site to the inguinal ligament, across to the umbilicus and up to the xiphoid cartilage.


  • 2

    Restrain the limb if necessary.


  • 3

    If the CVC is inserted via a vein in the upper limb, turn the baby’s head towards that arm to reduce the likelihood of the line entering the external jugular vein.


  • 4

    Clean and drape the skin. Apply a sterile tourniquet (a piece of sterile gauze can be wrapped around the limb and secured tightly with the artery forceps).


  • 5

    Flush the CVC with saline.


  • 6

    Insert the introducer needle into the vein. Release the tourniquet and thread the catheter into position with non-toothed fine forceps. Attach the extension set to the catheter. If the CVC is correctly sited, it should be easy to aspirate blood back down the line.


  • 7

    Remove the introducer needle. Secure the line with Steri-Strips and apply pressure over the insertion site to secure haemostasis.


  • 8

    Neatly coil the external length catheter and fix to the skin with Steri-Strips. Place a small square of gauze under the hub to protect the skin and apply a temporary sterile dressing to the insertion site.


  • 9

    Flush the line with 0.5 ml of contrast material and X-ray to confirm the position of the catheter tip. If the line has been inserted via an arm or scalp vein, the tip of the CVC should lie in the superior vena cava, ideally above T2 on X-ray, outside the cardiac silhouette. If the line has been inserted via the leg, the tip of the catheter should lie just below the diaphragm (T9–10) .


  • 10

    Maintain a sterile field whilst the X-ray is taken.


  • 11

    Shorten the CVC if it is too long. If the line has coiled back on itself or is kinked or misplaced ( Fig. 44.11 ), replace the line or pull it back to midhumerus or midfemur and use as a short line for a few days. The only exception to this rule is that CVCs that inadvertently enter the jugular vein from the upper limb often ‘flip’ into the correct position if they are left overnight. Run an infusion of heparinised saline at 0.5 ml/h through the line and repeat X-ray with contrast the following morning ( Fig. 44.12 ).


Apr 21, 2019 | Posted by in PEDIATRICS | Comments Off on Procedures and iatrogenic disorders
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