Practical Procedures.pptx

गर्भोदक वमन
 ततोऽस्यानन्तरनम सैन्धवोपहितेन सर्पिषा कायि ्रच्छर्िनम।
गर्ािम्र्ः सैन्धववचा सर्पिषा वामयेततः॥अ.ि.उ१ १०
when new born takes garbhodak into his/her mouth , then vaman karma
should be done using saindhav and sarpi.
In Ashtang Hridya vacha is also mentioned along with saindhava sarpi

STOMACH WASH
 It is the power of cleaning out the contents of the stomach.
 Stomach wash is done in babies born with meconium stained
amnoniatic fluid.
 Because meconium is an irritant and it’s presence in the
stomach cause gastritis and vomiting.
 It is also used for eliminating poison from the stomach in older
children.
 Sometime it is used to confirm level of bleeding from the upper
GIT.
 It can also be used for cooling technique for hyperthermic
patients
 Stomach wash is done with the help of nasogastric tube.

Nasogastric Tube Insertion
 It is the process in which a tube from nose to stomach insert for
different purpose.
Indications:
• Feeding sick and premature infants.
• Feeding an unconscious child.
• For gastritis decompression in cases of intestinal obstruction,
paralytic ileus
• To administer medications.
• Gastric lavage in case of poisoning
• Gastric lavage in newborn in case of meconium stained liquor.
• For diagnosis of TOF.

CONTI….
CONTRAINDICATIONS
• facial trauma
• Base of skull fracture.
• Recent oesophageal perforation/repair.
Size of Nasogastric Tube
Age NG tube(FR)
<1month 6-8
1-6month 8-10
1-3yr 10-12
3-6yrs 12
6-8yrs 12-14
>8yrs 14-16

Method of NG tube Insertion
 Child should be lying supine with head end elevated.
 Measures the length of tube to be inserted from the tip of nose to the
tragus and then to the xiphoid process.
 Apply lubricant at distal end of the tube
 With the neck slightly hyperextended . Pass the tube into the nose
along the floor of nose straight backwards.
 Insert the tube till mark is reached and check its position by pushing
air into the tube and simultaneously auscultating over the abdomen to
listen for the rush of air.
 Secure the tube to the nose with adhesive tap.
Precautions:
 Stop the insertion immediately if the child has bouts of cough or
develops respiratory distress.
 While removing the N.G. tube always pinch the outer end to avoid
emptying the contents in to phyranx.

Umbilical Vein Cathaterization
 Umbilical vein catheterization utilizes the exposed
umbilical stump in a neonate as site for emergency
control venous acess up to
Indications:
• I.V medications at the time of recussitation
• Exchange blood transfusion
• Rapid replacement of blood or fluid .
• Rarely for setting up infusion when other sites fail.
Contraindications:
• Patient with gastro
• Omphalitis
• Omphalocele
• Peritonitis , necrotizing enterocolitis

Technique
 Restrain the infants by using a padded cccc splint for fixing all four
limbs.
 The infants should be placed under a RHW
 Site is prepared aseptically using alchol providine solution.
 Drap the abdomen using sterile towel
 Cut the umbilical stump with the scalpel blade about 2cm from the
skin.
 The umbilical stump is held with toothed forceps and opening of vein
is identified .
 Clot or debris is removed with forceps and its opening dilated with the
closed point of a small artery forcep
 the catheter (5fr for <3.5kg and 8fr > 3.5kg) is marked with a thread
for the appropriate distance to be inserted (20 % of crown heel length)
 The catheter is filled with N.S gently pushed in to the vein.

 If is sticks at a distance of 2 cm gently suction should be applied to
suck out any additional clot following by injection of herparinized
saline.
 The umpbilical stump is pulled downward and catheter gently pushed
forwards with occasional rotatory movements till a free flow of blood it
obtained.
 The desired length of the catheter to be inserted can be calculated by
measuring shoulder umbilical distance.
 For resuscitation and exchange blood transfusion catheter tip is kept
just underneath the skin from where a good flow of blood is obtained
 The venous catheter should never be kept open to air for fear of air
embolism.
 The catheter should be secured in place with a purse string suture.
 The free end of the catheter should be stapped to the abdominal wall
well away from the perinium to avoid contaminations.

Lumbar Puncture
 It is a procedure of taking fluid from the spine in the lower back
through a hallow needle usually done for diagnostic purposes.
Indications :
1. To diagnose CNS infection ( meningitis, encephalitis)
2. To monitor the efficacy of treatment in the CNS infection.
3. To diagnose subarchnoid haemorrhage .
4. To diagnose CNS involvement in leukemia
5. Evaluation of demylenating degeneration and collagen vascular
diseases.
6. To inject chemotherapeutic agent (methotrexate cytarabine) and
immunoglobulins.
7. To instill contrast material for myelography.

contraindications
1. Uncorrected bleeding diathesis.
2. Raised intracranial pressure.
3. Patient with cardiovascular instability.
4. Gross lumbosacral anomaly.
5. Infection in the skin or underlying tissue at the puncture site.
Procedure :
1. Postioning ;
The child should be placed in a lateral reccurent posture with the
neck flexed knees drawn upward towards the abdomen (fetal
posture) and the back placed to the edge of the table.
Alternative position is with child level of L3- L4 or L4-L5 interspace.

 Procedure:
1. Identify the desired site of lumbar puncture.
2. Clean the area with spirit, povidine iodine followed by spirit
3. Drap the area with sterile linen.
4. Skin and underlying tissue may be anesthetized with a local
anesthesia.
5. The spinal needle (22G needle , 1-2 inch long with stylet) introduced
gently perpendicular to back aimed towards umbilicus and directed
slightly cephalad
6. A sudden loss of resistance or give in will be felt as the needle
penetrates the duramater.
7. Stylet is removed frequently as the needle is advanced slowly to
determine whether CSF is present.
8. Measure the opening pressure with a manometer.
9. Collect 5-10 ml of CSF for estimation of protein, sugar, cell count ,
gram staining culture and other investigations.
10. Instruct the parents to keep the child in horizontal position to avoid
post lumbar puncture headache.

Thoracocentesis
 The procedure include needle thoracocentesis ( closed chest
needle aspiration) to remove air or fluid from the pleural space
thereby improving ventilatory function.
 Emergency closed chest needle aspiration in the child may be
required for relief of symptoms sue to tension pneumothorax .
Indications:
1. Therapeutic aspiration in massive pleural effusion.
2. Diagnostic aspiration in case of pleural effusion of unknown
cause.
3. Emergency management of tension pneumothorax.

 Contraindications:
1. Bleeding diathesis
2. Thrombocytopenia
Positioning:
 Patient sits comfortably in a chair leaning forward
with arms and head supported on an adjustable
table
 In small infants and very sick children who cannot sit
the child can lie supine with the lateral chest wall of
the affected side brought to the edge of the table.
 Supine posture is preferred for decompression of
tension pneumothorax

 Site of Aspiration:
1.Pleural effusion: 7th-9th intercostal space.
2.Pneumothorax : 2nd and 3rd intercostal space.
 Procedure :
1.Confirm the site of aspiration.
2. Monitor the vital sign.
3. Clean the area with spirit, providine iodine solution followed by spirit.
4.Drape the site with sterile linen.
5. Anesthetize the skin, subcutaneous tissue and parietal pleura with
1% lignocaine.
6.Use a 18G to 20G needle attached to a 3 way stop cock with one end
attached to a 30ml syringe and other end attached to tubing for
collection case of therapeutic drainage of massive pleural effusion.

7. The needle is introduced gently at right angle to the chest wall in the
marked interspace just above the rib. Slowly advance the needle and
gently aspirate.
8.Withdraw the pleural fluid by gentle suction.
9.Stop the aspiration immediately if the child complaint of severe
tightness in chest & intractable cough with thin frothy blood stained
sputum or if the child develops cardio-respiratory compromise.
10.Do not aspirate >1500ml fluid at one time.
11.Collect the pleural fluid for estimation of protein, LDH, glucose, cell
count, gram strain and other investigation.
12.Emergency decompression of tension pneumothorax require the
needle to be attached to a underwater seal drainage .
13.The needle is inserted slowly perpendicular to the chest wall till a
gush of air is appreciated in the un

Exchange Blood Transfusion
 Administration of blood or blood products via transfusion is called
blood transfusion.
Indications of blood transfusion:
 Acute blood loss more than 20-30% of the total blood volume
 Severe anaemia
 Septic shock
 To provide platelets and plasma for clotting factors.

Process of B.T:
1. Identify the blood bag and compare the following with the requisiton slip
2. Child’ name, age, sex, and hospital reg.no.
3. Blood bag No.
4. Blood group and RH type of blood
5. Date of collection and expiry
6. Check the blood bag for any bubbles dark areas or sediments
7. Ask the child family for any history of previous transfusions and any
documented allergic/transfusions reaction.
8. Estimate the volume to be transfused and determine the rate of infusion.
9. Take the baseline vital signs.
10. Connect the tubing to the bag and flush line completely with blood
ensuring no air is present in the line.

11. flush the IV cannula with saline and ensure the patency.
12. Connect the tubing to the cannula and slow start open the clamp on
switch and adjust the flow with the roller.
13.Initial flow rate is low and later increased if no reaction occurs.
14.Vital should be taken every 15 minute
Collection of blood sample:
 Collection of blood sample is done for investigation
 The blood can be withdrawn from vein , artery or capillary.
 The universal precautions apply to all sampling procedure.
 The sample withdrawn must labelled and sent to laboratory with
complete patient details.

Vein Puncture
Indications
 To withdraw blood sample for laboratory studies.
 For administration of drugs.
Contraindications
 Venesection of deep veins in known cases of coagulation disorders.
 Local infection/gangrene at the site of venesection.
Precaution
 Avoid femoral vein for sampling. Femoral venesection can result in
reflex femoral arterial spasm resulting in gangrene of extremities,
septic arthritis of hip and penetration of peritoneal cavity.

 Avoid internal jugular vein for the fear of laceration of adjacent
carotid artery and risk of pneumothorax/subcutaneous emphysema
 Avoid neck veins in infant with intracranial bleed/raised intracranial
pressure.
Procedure:
1. Select veins so as to spare larger veins for I.V cannulation or failed
attempts at venesection.
2. The following choice of veins is suggesting in the order of preference
: dorsum of hand, antecubital fossa, dorsum of feet , great
saphenous vein at ankle, vein in the center of ventral aspect of wrist,
scalp , proximal great saphenous vein.
Then finally neck veins if all of the above fail to withdraw blood sample.

3. Locate the desired vein, warm the extremity, apply local anesthetic
cream if available and prepare the area with antiseptics.
4. Apply a tourniquet proximal to the vein to enhance the visualization of
the vein.
5.A 23 gauze needle is considered best as 24-26 gauze needles
(smaller bore) might result in clotting and 21-22 gauze needle(wide
bore) might result in prolonged bleed following sampling.
6. The needle is inserted at 25-40degree angle with berel turned
upward. The needle must be inserted along the direction of blood flow.
7.Sample can be collected by the drip method i.e collecting drops of
blood flowing through the needle in desired vial.
8.Remove the torniquate before removing the needle after the sampling
is done to avoid massive bleeding from the site.
9.Always apply local pressure with dry gauze to achieve haemostasis.

Capillary Puncture
 Capillary puncture is a convenient method for collection of small
amount of blood for estimation of glucose, HB, PCV, bilirubin and for
making a peripheral blood smear.
Sites of Capillary puncture;
Infants: plantar surface (lateral and medial border ) of the foot.
Older children: great toe or pulp of 3rd or 4th finger.
Procedure:
1. Warm the heel or pulp of fingers prior to puncture to improve the
local circulation.
2. Clean the desired area (heel of the foot/finger pulp) with antiseptic.
Allow the area to dry prior to pucture.

3. Blood lancet is used for capillary puncture. The depth of puncture
should not exceed 2mm to avoid injury to underlying bone.
4. The first drop of the blood is wiped off
5. Gently squeeze the lower leg and ankle/finger for collection of
sample.
6. Apply firm pressure bandage to achieve haemostasis.

Intravenous canulization
Procedure:
1. Wash the hands and wear gloves.
2. Position child and limb, place tourniquet
3. Select appropriate site (dorsal venous network in hands and feet,
veins in arms or legs, scalp veins)
4. Swab with alcohol first, using an outward circular motion and let it
dry.
5. Swab with alcohol again and let it dry.
6. Puncture the skin with the bevel of the needle facing upward and the
needlle at 30 degree angle to the skin surface. The point of entry
should be 0.5 cm distal to the vein eith needle aimed at the course
of the vein in its direction of blood flow.

7. As soon as the skin is punctured, reduce the angle to alost skin level
and advance needle slowly till the needle is advance needle slowly
till the needle is felt to have pierced the vessel wall
8. Backflow of blood into the set may be seen if not gently withdrawn
the stylet.
9. As blood appears advance the cannula into the vein while removing
the stylet.
10. If no bleed return seen draw cannula back and keeping it under the
skin advance again slowly to attempt re-insertion.
11. Flush the inserted cannula with N.S to confirm patency of vein and
cannula.

Uretheral Catheterization
 Indications:
1. Drainage of bladder in case of retention of urine secondary to
obstruction.
2. Drainage of bladder following major pelvis or rectal surgeries.
3. To document urinary output in critically children.
4. To obtain urine sample for culture examination.
Procedure:
1. Prepare the instrument, foley’s catheter, lignocaine jelly, gloves,
syringe with water to inflate the balloon and urinary bag for collection

2. Under aseptic precautions, clean the genitalia with providine iodine .
3. Lubricate the end of urinary catheter with lignocaine jelly to facilitate
entry
4. Locate the urethral meatus and insert the lubricate end of the
catheter up to half junction.
5. Urine starts flowing out of the catheter outlet which should be
connected to urinary outlet which should be connected to urinary
drainage bag.
6. Inflate the balloon of the catheter with 2-5 ml of N.S. and gently pull
the bulb till the bladder neck . Ensure that the balloon is not inflated
when the catheter is in urethra it might result in urethral rupture .
7. Secure the catheter and maintain local asepsis by soap and water or
by providine iodine

8. Empty the drainage bay regularly at least every 24 hrs.
9. Replace the catheter if visibly dirty or clogged or there is peritubal
leakage.
10. While removing the catheter deflate the balloon and then gently
remove the catheter to avoid any urethral injury.
Appropriate size of urinary catheter:
Age group males Females
<1yrs 8-10Fr 5-8Fr
1-3 yrs 10-12Fr 8-10Fr
3-12yrs 12-14Fr 10-12Fr

Bone Marrow Aspiration
 It is a procedure that involve taking a sample of the liquid part of the
soft tissue inside your bone.
 Bone marrow is the spongy tissue found inside bones.
Indications :
1. Evaluation of hematological disorders like severe anemia,
pancytopenia, megaloblastic anemia, refracting anemia or
suspected leukemia .
2. Severe neutropenia( <500IUL). Persisting for >3 days or
unresponsive to G- csf

3. Staging of lymphoma and other solid tumors.
4. Evaluation of PUO
5. Unexplained spleenomegaly
Contraindications:
1. Severe bleeding diathesis/coagulopathy disorder.
2. Local skin infection or underlying osteomylitic
Positioning:
Postion of the patient depends on the site of aspiration. The infants is
placed supine for tibial aspiration and for aspiration from posterior
superior iliac spine the child is placed in prone posture.

 Site of Aspiration:
Infants (<1yrs) preferred site is a triangular area at the proximal and of
medial surface of tibia just distal to the tibial tuberosity.
Other sites of aspiration include sternum anterior superior iliac spine
and greater trochanter.
Procedure:
1. Position the child prone and examine the site for any evidence of
infection and mark the area.
2. Clean the desired atea with spirit, povidine iodine followed by spirit.
Drape the area with sterile linen.
3. Prepare the bone marrow aspiration needle and arrange clean glass
slides for making smear of the aspirate.
4. Anesthetize the skin subcutaneous tissue till periosteum with 1-2%
lignocaine. Using a 23 gauze needle and wait for 2-3 min

6. Make a small incision of 3-5mm in the skin to facilitate the entry of
needle especially when a biopsy is planned along with aspiration.
7. Stablize and restrain the child for proper positioning.
8. Ensure the trocar is completely inserted inside the needle.
9. Hold the bone marrow needle between the thumb and forefinger
and introduce the needle at 90 degree angle and advance into
marrow cavity with a slow twisting motion.
10. Remove the trocar from the needle and attach a 10-20 ml syringe to
the needle and aspirate forcefully until a small drop of marrow
appears in the syringe hub. Suction should be stopped as soon as
2-3ml of marrow is obtained.
11. Remove the syringe immediately from the needle and place the
dropped marrow in 5-6 slide.

12. remove the needle using twisting motion and apply pressure,
dressing over the site to avoid bleeding.

Practical Procedures.pptx

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Practical Procedures.pptx