Some practical procedures & use of some equipments in Pediatrics

1. Practical Procedures in
Paediatrics

2. CONTENTS
1) Nasogastric tube
2) Peak Flow Meter
3) Pulse Oximetry
4) Nebulizer
5) AMBU
6) Lumbar Puncture
7) Urinary Catheterization
8) Endotracheal Intubation
9) Peritoneal Dialysis
10)IV Cannula
11) O2 Therapy
12)Suction
13)MDI
14)Spacer
15)Thoracocentesis
16)Paracentesis
17)Bone Marrow aspiration
18)Arterial Blood collection

3. Dr Mohiuddin Ahmad Masum
DCH Student, Dept. of Pediatrics
Chittagong Medical College Hospital

4. Nasogastric
Tube Insertion

5. Nasogastric Tube:
Indications of use:
i)Feeding or admistration of medications
ii)Suction/gastric decompression
iii)Gastric lavage(e.g. in non-corrosive poisoning)
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.
NG tube

6. • 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.

7. 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

8. Peak Flow Meter

9. Peak Flow Meter:
Parts:
i) Mouth piece
ii) Indicator/cursor
iii) Measuring scale
Uses:
Peak flow meter can be used-
• To classify severity of asthma
• To see whether the management plan
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.
Measuring scale
Indicator
Mouth piece
Peak Flow Meter

10. 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

13. Nebulization

14. 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

15. Parts of Nebulizer-
• Motor/Compressor
• Filter
• Air outlet & Air tube
• Nebulizer cup or Mixing
chamber
• Mouth piece or T piece
• Mask
Nebulizer

16. 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

17. 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.

18. Pulse
Oximeter

19. Pulse Oximeter:
A Pulse Oximeter is a device used to determine the-
 Percentage of hemoglobin (Hb) that is saturated with
oxygen
The oxygen saturation (SpO2) is a measure of how
much oxygen the blood is carrying as a percentage of
the maximum it could carry.
 The heart rate
The heart rate refers to the number of times that the
heart contracts in a period of one minute.

20. TYPES OF PULSE OXIMETER:
1) Desktop
2) Finger/Mobile
Desktop Finger/Mobile

21. 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.
By measuring how much light
has been absorbed by the
oxygen in the blood, an
oxygen saturation reading is
established and displayed as
a percentage of the maximum
amount of oxygen the blood
could carry.

22. Benefit of Pulse Oximeter:
• A Pulse Oximeter can detect hypoxia (too little oxygen to fulfill
the needs of the brain and body) before a patient shows signs of
becoming cyanotic
• In the ICU, Pulse Oximetry is used extensively on mechanically
ventilated patients, as it can frequently detect problems with
oxygenation before they are noticed clinically, as well as a
valuable guide for weaning patients off ventilation and helping to
assess the adequacy of a patient's oxygen therapy.

23. AMBU

24. AMBU (Artificial manual breathing unit):
Parts:
• AMBU bag proper/Ventilation bag
• Mouth piece/mask
• Oxygen connector Tube
• Oxygen reservoir
• pop-up valve
Indications of use:
a) Neonatal resuscitation in case of
perinatal asphyxia
RDS
b) Respiratory failure due to any
cause(any age) like-
pneumonia
severe acute asthma
poisoning
GBS etc.
Contraindications:
• Diaphragmatic hernia
• Tracheo-esophageal fistula
Reservior Bag
Ventilation Bag
Face Mask
Oxygen Tube
Pressure
Limiting Valve
Figure: AMBU

26. Bag & mask ventilation:
• “Sniffing”position
• Thumb + index finger to
maintain face seal
• Middle finger under
mandibular symphysis
• Ring and little finger under
the angle of mandible

27. Urinary
Catheterization

28. INDICATIONS OF URINARY CATHETERIZATION:
Diagnostic:
a) Collection of uncontaminated urine specimen.
b) For accurate measurement & monitoring of urine output.
c) For urodynamic studies.
Therapeutic:
a) To relieve urinary retention.
b) For bladder irrigation.
c) Intermittent decompression for neurogenic bladder.
d) To empty the Bladder before, during, or after surgery.
e) Intravesical chemotherapy.

29. TYPES OF URINARY CATHETER:
a) Straight catheter, is used
when the catheter is to
be used for very
temporary cause.
b) Indwelling catheter, also
known as Foley catheter,
is left inside the bladder
to provide continuous
urine drainage.
c) Suprapubic catheter is a
type of indwelling
catheter, it is inserted
into the bladder through
a surgical incision made
in the abdominal wall,
right above the pubic
symphysis.

30. d) Condom catheter, is used
for continuous collection
of urine when there is no
need for catheter
insertion.
e) 3-way catheter for
continuous bladder
irrigation (CBI) is a type of
indwelling catheter. It is
inserted to irrigate the
bladder to prevent
obstruction (i.e bleeding)
Condom catheter
3-way CBI

31. 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

32. 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)

33. 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.

34. 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.

35. 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.

38. 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.

39. Lumbar Puncture

40. Indications of LP:
i)Diagnostic:
– Infection e.g. meningitis,
encephalitis, GBS
– Systemic diseases e.g. SLE,
multiple sclerosis
– Subarachnoid haemorrhage
ii)Therapeutic:
– Intrathecal chemotherapy in
leukaemia
– Spinal anaesthesia
– Removal of CSF in benign
intracranial hypertension
Contraindications:
– Raised ICP
– Localized skin infection
– Bleeding disorders e.g.
haemophilia

41. Lumbar Puncture:
Instrument:
Lumbar puncture needle having-
i) Trocar(stilette) with knob
ii) Cannula
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.
Lumbar Puncture Needle

42. 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.

43. 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.
When only three tubes are obtained-
• Tube 2 is often reserved for microbiology
• Tube 3 is shared, with the hematology testing performed first,
followed by any chemistry or immunology testing.

44. What should be seen in CSF:
• Pressure
• Physical character- colour
• Biochemistry: Protein, Sugar, chloride
• Cytology: cell count, differential count
• Microbiology: Gram stain, culture and sensitivity, AFB
• Serology: viral serology, VDRL, cryptococcus etc.

45. Complications:
– Headache
– Local pain
– Bleeding
– Herniation of brain stem
– Persistent CSF leaking
– Injury to local structures like intervertebral disc, vessels, nerves etc.
– Infection (causing meningitis etc.)

46. Endotracheal
Intubation

47. Endotracheal Intubation:
Indications:
i. To provide mechanical respiratory support
ii. Obtain aspirates for culture
iii. Assist in bronchopulmonary hygiene(pulmonary toilet)
iv. Alleviate subglottic stenosis
v. Endotracheal medications (e.g. epinephrine, lidocaine,
atropine etc.)
Instruments:
• ET Tube with or without cuff
• Laryngoscope with blade
• Suction apparatus
• Bag & mask with adjustable oxygen source
• Cardio-respiratory monitor

48. Endotracheal Tube:
• ET tubes can be :
- cuffed
- uncuffed
• Cuffed ET tubes are usually used in children >8 years
• The cuff when inflated maintains the ET tube in proper
position and prevents aspiration of contents from GI tract into
respiratory tract
• In children <8 years uncuffed ET tubes are usually used
because the narrow subglottic area performs the function of
a cuff and prevents the ET tube from slipping.

49. Pilot Ballon
Cuff
Oneway Valve
Connector Stylet
ET Tube(cuffed) with stylet
Tracheal tube
Murphy’s Eye
ET Tube(uncuffed)
Endotracheal Tube(continiued):

50. Age Gestation(wk) Weight(gm) Size(mm)
Neonate ˂28 ˂1000 2.5
28-34 1000-2000 3.0
˃34-38 ˃2000 3.5
˃38 ˃3000 4.0
Infant upto 1year 4.0
Age ˃1 year (Age/4 + 4)mm
Size of ET tube(Internal Diameter):

51. Laryngoscope

52. Procedures:
• Assembly & preparing all equipments.
• Preparing the patient:
i. Position- Sniff position (rolled towel under shoulder) or, Supine (do not
hyperextend)
ii. Suctioning oropharynx
and nasopharynx as
needed.
iii. Pre-oxygenation with
high flow oxygen for 1
minute if possible (do
not bag if meconium
aspiration, diaphragmatic
hernia)
iv. Monitoring vital signs & SpO2

53. Procedures (continued):
• Giving drugs: Following drugs should be used unless patient is flaccid &
unresponsive-
i) 1st Hypnotic such as thiopentone (3-5mg/kg), midazolam
(0.5 mg/ kg) or propofol (2-4 mg/kg)
ii) 2nd Muscle relaxant such as suxamethonium (1 mg/kg) or
rocuronium (1mg/kg).
 Then intubate the trachea as soon as relaxed.

54. • Intubation:
i. Position self at patient’s head, hold scope in left hand, open mouth with
fingers , insert blade into right side of the mouth, move blade to center of
mouth pushing tongue to the left side.
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).

56. Complications:
• Tracheal perforation
• Esophageal perforation
• Laryngeal oedema
• Improper tube positioning
• Tube obstruction or kinking
• Subglottic stenosis

57. Peritoneal
Dialysis

58. 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.

59. Peritoneal Dialysis(continued)
PREPARING THE EQUIPMENT:
1. Concentration of dialysate is determined according to the
physician’s consultation and following medications are added to it
accordingly-
• Heparin- to prevent clotting
• Potassium chloride - to prevent hypokalemia
• Antibiotics- peritonitis
• Insulin-for diabetic patients
2. Before medications are added, the dialysate is warmed to body
temperature to prevent patient discomfort and abdominal pain
and to dilate the vessels of the peritoneum to increase urea
clearance.
3. Assemble the administration set and tubing. Fill the tubing with
the prepared dialysate to reduce the amount of air entering the
catheter and peritoneal cavity, which could increase abdominal
discomfort and interfere with instillation and drainage of the fluid.

60. 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.

61. 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.

62. Peritoneal Dialysis(continued)

63. 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.
 Each EXCHANGE consists of-
• Infusion
• Dwell or Equilibration time
• Drainage
 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.

64. 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

65. Dr. Mumtahena Mahmuda
Indoor Medical Officer
Dept. of Pediatrics
Chittagong Medical College Hospital

66. 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.

67. IV Cannula of Different Sizes
14G 16G 18G 20G 22G 24G

68. • Repeated blood sampling
• Intravenous administration of fluid,
medications, chemotherapy, parenteral
nutrition and blood or blood products.
Indication of IV cannulation :

69. Common site for IV cannulation in children:
• Hand : dorsum of non dominant hand is
preferred between 4th and 5th digit.
• Foot : greater saphenous vein at ankle. 1
fingers breath anterior to medial malleolus.

70. Common site for IV cannulation in children continue….:
• Scalp veins are most appropriate for neonates.
• Antecubital veins : cephalic, basilic or median
cubital vein are easy to locate but these sites
are uncomfortable and require immobilizing
of elbow.

71. • Introduce your self to
patient.
• Explain the procedure.
• Approach with a confident,
calm,caring attitude.
Procedure

72. • Collect your equipment.

73. • Wash hand

74. • Apply tourniquet • Clean area with
alcohol

75. • Remove needle cover

76. • Insert the needle bevel up ward at about 30ᶜ̊ &
advance the rest of cannula into the vein

77. • Release the tourniquet & apply pressure
at the tip of cannula & remove the
needle .

78. • Apply the plaster to fix it on the place

80. 1-local complication:
-Infiltration.
-Extravasation.
-Thrombosis.
-Cellulitis.
-Phlebitis.
Complicatoins of cannulation :
2-systmic
complication:
-Embolism
-Hematoma.
-Systemic infection.
-Circulatory overload.
-Allergic reaction.

81. Indications: According to WHO guideline 2016
 Central cyanosis
 Nasal flaring
 Unable to drink or feed (due to respiratory distress)
 Grunting with every breath
 Depressed mental state
 Severe lower chest indrawing
 Respiratory rate >/ 70 or head nodding
 Spo2 < 90%
 Prolonged convulsion
 Coma
 Heart failure
 Shock
 Severe anaemia
OXYGEN THERAPY:

82. • LOW FLOW (VARIABLE
PERFORMANCE)
• HIGH FLOW (FIXED
PERFORMANCE)
OXYGEN DELIVERY DEVICES
• Nasal prong
• Nasal catheter
• Nasopharyngeal catheter
• Face mask
• headbox
• Incubator
• Tent

83. • It is disposable plastic device with two protruding prongs for insertion
into the nostrils, connected to an oxygen source.
Nasal prongs:

84. Nasal cannula:
• Measurement: From the side of nostril to inner margin of
eyebrow. This usually reaches the back of the nasal cavity. If it
is unavailable, even a cut down nasogastric tube is sufficient
as a nasal catheter through which O2 can be delivered.

85. • Measurement: from the side of the nose to
the tragus of the ear. Tip of the catheter
should be visible just below the the soft
palate. In neonate and infant 6 to 8 fr catheter
is used.
Nasopharyngeal catheter:

86. • Standard flow rate for nasal cannula or nasal
prong or nasopharyngeal catheters are 0.5
to1L for neonate, 1 to 2L for infant and 2to 5 L
for older children. Higher flow rate >5L
without significant humidification may cause
drying of nasal mucosa, associated bleeding
and airway obstruction. It provides low
medium concentration of oxygen 23% to44%.
Flow above 5L does not increase Fio2 >44%.

87. • Formula for an estimation of the Fio2 during use of a nasal
cannula is as follows:
• FiO2 % of O2 delivered=
• 21% + nasal cannula flow L/min x
3

88. Advantages Disadvantages
• Safe, simple and effective
• Client able to talk and eat with
oxygen in place.
• Humidification is not required
for cannula and prong.
• Reusable
• Nasal prongs are expensive
• chance of nasal obstruction by
mucous secretion .
• Can dislodge from nares easily.
• Causes excessive mucosal
dryness and epistaxis at 6 L/min
or higher .
• Nasopharyngeal catheter can be
displaced downward to
oesophagus and cause
vomiting, abdominal distension

89. The simple Oxygen mask

90. • It delivers 40 % to 60% oxygen .
• Flow rate for simple mask range from 5 to 10L liters per minute,
which usually require some room air to be entrained via the side
ports of the mask to meet the patient’s minute ventilatory needs.
• The flow rate of a simple mask should never be <5 L/min; below
this level, carbon dioxide rebreathing may occur, along with an
increased resistance to inspiration.

91. Advantages Disadvantages
•Can provide increased delivery of
oxygen for short period of time.
• The face mask is indicated in
patients with nasal irritation or
epistaxis
• Tight seal required to deliver higher
concentration
• Difficult to keep mask in position
over nose and mouth
• Uncomfortable for pt while eating
or talking.

92. OXYGEN HOOD
Clear plastic shell with covers
the patient’s head
Allows access to chest, trunk
and extremities
Flow of oxygen- 5-10 L/min
80 to 90 % of oxygen conc. can
be achieved.
Inappropiately tight seal causes
retention of O2. A gas flow 2-
3L/kg/min is necessary to avoid
rebreathing of CO2.
Can be used in neonates and
infants only.

93. Why do we give
suction?

94. YES to suction NO to suction
• Infants, young children,
total care kids who are
unable to remove their
own secretions
• Secretion removal for
patients with bronchiolitis
• Bronchiolitis is caused
by a respiratory virus
(most often RSV)
• Causes congestion and
swelling of the small
airways of the lungs
• Child with a basilar skull
fracture
• Child with suspected
croup or epiglottitis
• Patient who demonstrates
adequate ability to clear
own secretions
• Able to spontaneously
cough
• Able to blow nose

95. Suctioning
Devices
Yankauer
Neosucker
Mushroom
tip nasal
aspirator
Bulb syringe
Suction
catheter

96. What size catheter
should I use?

97. Age Catheter Size
Preemie 5/6 fr.
Term Newborn 5/6 – 8 fr.
Newborn – 6 mo. 8 – 10 fr.
1 yr. – 8 yrs. 10 fr.
8 yrs. or older 10 – 14 fr.

98. What suction
pressure should I
use?

99. Age Suction Pressure
Neonates 60 – 80 mmhg
Infants 80 – 100 mmhg
Children 100 – 120 mmhg
Adults 100 – 150 mmhg

100. How do I measure for
NP suctioning?

101. • Measure from the
tip of the nose to
the bottom of the
earlobe
• Note on catheter
how many mm this
is
amount of water with the tube. This will check the suction. It will
tube e
thick mucous.
suction depth. Put the tube
the tip of the nose to the tip of the ear lobe with the tube.
n this spot so you do not suction too
he tube into the nostril.
e straight back toward the ear, not up
than the length you measured.
put in the tube.
If the tube does not go in easy,
st your angle and try again.
Measure
tip of nose
to ear lobe
Measurement

102. • Matierals needed:
• Clean gloves
• Suction catheter
• Facemask with
shield
• Surgi-lube
• Saline drops
• Place 2-3 saline drops in each
nostril
• Lubricate tip of catheter with
surgi-lube
• Insert the catheter down to your
measurement
• Initiate suction by putting thumb
over suction port
• Pull back slowly while moving
the catheter in a circular motion
Technique

103. Oropharyngeal suction:
• measurement: from centre of incisor to
angle of jaw and insert approximately
3 cm further.
Tips for suctioning:
Apply suction and rotate the catheter to
suction the secretion. Do not push the
catheter in and out against the wall
of the throat as this may injure the
mucus membrane.
For suctioning the mouth a firm metallic suction
tip may be used like yankauer catheter.
Care must be taken to avoid injury to
oral mucosa.

104. Complications:
• 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.

105. METERED DOSE
INHALER

106. Metered dose Inhaler

107. Step1:Shake the inhaler
well.
Step 2: Breathe out gently, place the
mouthpiece in the mouth with lips curled
around it.
Step 3: Begin breathing in slowly but at
the same time, press down on the inhaler
canister.
Step 4: Continue breathing in slowly and
steadily until the lungs are full.
Step 5: Hold your breath
for 10 seconds or for as
long as comfortable.
Breathe out slowly.
Fig: Use of MDI

108. SPACER

109. • Spacers are bottle-shaped plastic devices
which have a mouth piece at one end
and other end has an opening which the
MDI can be attached.

110. • Requires perfect co-ordination between
inspiration and activation of device.
• Not possible in small children
• To eliminate this problem spacer is
adviced.
DISADVANTAGE OF MDI

111. • Remove the cap of MDI shake it and
insert in to spacer device.
• Place mouth piece of spacer in mouth or
attach to face mask in case of infants
and younger children
• Start breathing in and
out gently and observe
movements of valve.
How to use MDI with spacer device

112. THORACOCENTESIS

113. Indications
• To diagnose pleural
effusion or empyema.
• Therapeutically when
large collection of fluid
compromise ventilatory
function.
Thoracocentesis
contraindication
 Uncontrolled
Coagulation disorder
 Active skin infection
 Only one functioning
lung
 Severe cough or
hiccup
 Atelectesis
 Uncooperative patient.

114. 114

115. Procedure:
Consent is taken from the patient

116.  Arms folded in
front
 Patient sitting on
edge of bed

117. 117

118. 118

120.  A wide gauze aspiration needle (blood
transfusion needle can be used) having
tubing attached with it is introduced
perpendicular to the skin. Fluid my be
withdrawn by a sterile 50ml syringe. It
is safe to use a stopcock between the
needle and syringe to avoid the risk of
pneumothorax.
 After removal of fluid sterile dressing is
applied over the puncture site.
Procedure:

121. • Infection
• Pneumothorax
• bleeding
complications:

122. PARACENTESIS

123. Indication:
• Determine etiology of ascites; diagnose peritonitis.
• To remove large volume of ascetic fluid when causing respiratory
compromise.
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

125. 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

126. • Proper consent
• 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
Procedure:

127. • 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.

128. • 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.

129. • Ascitic fluid leakage
• Bleeding from injury to inferior epigastric
artey.
• Bowel perforation .
• Infection.
complications

130. BONE MARROW ASPIRATION

131. INDICATIONS :
DIAGNOSTICITP
Aplastic
Anemia
Leukemia
Lymphoma
LD bodies in
kala-azar
Storage
disorders- PUO
Myelofibrosis

132. CONTRAINDICATIONS :
• Coagulation factor deficiencies
(hemophilia)
• DIC
• Concomitant use of Anticoagulants.
HEMORRHAGIC
DISORDERS
• Infection.SKIN
• Osteomyelitis
• Osteogenesis imperfecta.
BONE
DISORDERS

133.  Children below 2 years:
– Upper third of the medial aspect of the shaft of the tibia.
 Children above 2 years:
 Posterior superior iliac crest is the preferred site.
 Manubrium sterni may also be used – in the sternum the site is just
above or below the manubrio-sternal angle.
Common site for bone marrow aspiration

135. CONSENT
POSITION
STERILIZE
LOCAL
ANESTHESIA
INCISION
NEEDLE IN
MARROW
ASPIRATE
SAMPLE

136. 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.

137. 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 .

138. 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.

139. 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

140. What is an ABG:
• ABG sampling is a commonly performed procedure which
allows health professionals to quickly obtain information on a
patients respiratory status (blood oxygen and carbon dioxide
levels), as well as patients acid base status.
• It is an invasive procedure.
• Blood is drawn from an artery rather than a vein.
• Helps differentiating oxygen deficiencies from primay
ventilatory deficiencies from primary metabolic acid base
abnormalities.

141. Information obtained from an ABG:
• Acid base status
• Oxygenetion
• Dissolved oxygen (PO2 )
• Saturation of haemoglobin
• CO2 elimination
• Electrolyte status
• Levels of caboxyhaemoglobin and methemoglobin

142. Which artery to choose :
• The radial artery is superficial, has collaterals and is easily
compressed. It should almost always be the first choice.
• Other arteries like femoral, brachial, dorsalis pedis can be
used in emergencies.

143. Procedure

155. Complications :
 The commonest complication from an arterial puncture is
hematoma at the site.
 Less common but important complications are thrombus in
the artery and infection at the site.