Advanced neonatal procedures
- 1. WELCOME
- 2. SEMINAR ON ADVANCED NEONATAL PROCEDURES SUBMITTED TO DR. Mrs. S.Kamala PROF. OF NSG RMCON , AU SUBMITTED BY T.Senthil Vadivu II YEAR M.Sc NSG RMCON, AU
- 3. ADVANCED NEONATAL PROCEDURES • Endo tracheal tube (ET) intubation • Respirator or mechanical ventilation • Extra corporeal membrane oxygenation • Incubator care • Photo theraphy • Gastric gavage • Gastric lavage • Blood transfusion
- 4. NEWER IMAGING MODALITIES IN THE NEONATE • Ultra sono graphy (USG) • X-ray • Computed tomography (CT) scan • Magnetic resonance imaging (MRI) • Neuro imaging Structural • Ultra sono graphy (USG) • Computed tomography (CT) scan • Magnetic resonance imaging (MRI) Physiological • Positron emission tomography • Single photon emission computerized tomography Study of cerebral blood flow • Doppler studies •
- 5. ENDO TRACHEAL INTUBATION INTUBATION Intubation is refers to the placement of a tube into external orifice of the body. TRACHEAL INTUBATION Tracheal intubation is the placement of a flexible plastic tube in to the trachea to protect the patients airway and provide a means of mechanical ventilation.
- 6. ORO TRACHEAL INTUBATION This is the most common tracheal intubation Where with the assist of a laryngoscope, an endo tracheal tube is passed through the mouth, larynx and vocal cords in to the trachea. NASO TRACHEAL INTUBATION Naso tracheal intubation where a tube is passed through the nose, larynx, vocal cords and trachea.
- 7. INDICATIONS IN NEONATAL ASPHYXIA • Bag and mask ventilation fails to improve cardiac status. • Apparently still born baby after adequate suctioning of upper airway. • Infants with diaphragmatic hernia. • Thick meconium stained baby. • Babies requiring prolonged positive pressure ventilation • As a pre requisite for artificial ventilation.
- 8. Circulatory • Cardio pulmonary arrest • Refractory or unresuscitate shock. • Sepsis CNS depression • Head injury • Diabetic coma • Barbiturate poisoning etc. Disease of theperipheral nervous system • Polio mylitis • Tetanus • Organ phosphorus poisoning Administration of general anesthesia
- 9. Airway support • Diminished mental status • Compromised airway anatomy (eg. edema) • Diminished airway reflexes( general anesthesia , drug over dose) • Requirement for sedation in circumstances (eg. CT, MRI) • Pharyngeal instability (eg. Facial fractures) Pulmonary diseases • Acute hypoxic respiratory failure • Hypo ventilation • Lung disease
- 10. RECOGNITION OF A DIFFIUCULT AIRWAY History • Difficult intubation • Upper airway obstruction • Anatomic features Mid face hypoplasia Gross macrocephaly Small mouth Glossoptosis • Severe obesity • Facial trauma • Oro pharyngeal mass • Limited temporo mandibular joint mobility • Midline clefts • Micro canthia • Limited neck mobility
- 11. EQUIPMENT FOR AIRWAY MANAGEMENT Emergency ventilation • Ventilation with AMBU bag • Oral or nasal airways • Laryngeal mask airway • Trans tracheal jet ventilation
- 12. EMERGENCY INTUBATION • Laryngoscope • Endotracheal tube of different sizes • Stylet • Flexible fibroptic bronchoscope • Intubating laryngeal mask • Blind nasal tube • Magill forceps • Tapes • Syringes • Suction • Stethoscope • Fibroptic intubating airway • Bronchoscopy
- 14. SELECTION OF TRACHEAL TUBE Uncuffed tracheal tube fo children < 8 years old Formula for the selection of uncuffed tracheal tube size (mm ID) = Age (Years)+ 4 4 Cuffed tube size (mm ID) Weight/ age ET tube size in diameter in mm <1000 gm 2.5 1000 – 2000gm 3.0 2000 – 3000gm 3.5 >3000gm 4.0 1 -5 years 4.0 – 5.0 5 – 12 years 5.0 – 6.5
- 15. PREPARATION FOR INTUBATION • Assemble all the equipment • Administer oxygen before intubation • Laryngoscope and suction equipment should be checked. Position of the patient • Child more than 2 years – a folded sheet or towel to be placed under the occiput align the pharyngeal and tracheal axis. So that external ear canal is anterior to shoulder. • child < 2 years – a folde sheet to be placed under shoulder to align airway • The patient is placed in supine position. The operator stands beyond the patients head. Patient’s neck is slightly extented with the head in midline.
- 16. Position of the patient
- 17. TECHNIQUE • Clear the oropharynx with • Gentle suctioning. • Empty the stomach. • Orotracheal intubation is preferred during resuscitation. • Hold laryngoscope handle in left hand and insert the blade in to the mouth in midline, following the natural contour of the pharynx to the base of the tongue.
- 18. Technique
- 19. • Once the tip of the blade is at the base of the tongue and the epiglottis is seen, move the proximal end of the blade to the right side of the mouth and then sweep the tongue toward the middle to achive control of the tongue to insert the blade along the right side of the mouth to the base of the tongue. • This movement provides a channel in the right third of the mouth to pass the tracheal tube while maintaining direct visualization of the laryngeal structures.
- 20. • After the tube is properly positioned , traction is exerted upward in the direction of the long axis of the handle to displace the base of the tongue and the epiglottis anteriorly exposing glottis. • Insert the tracheal tube from the base laryngoscope blade. • In addition, application of cricoid pressure by an assistant may facilitated visualisation of the glottic opening.
- 21. • The black glottic marker of the tube is placed at the level of the vocal cords. Precautions • Risk of laryngeal trauma is increased if the blade is initially inserted in to the esophagus and then slowly withdrawn to visualize the glottis. • The handle and blade must not be used for prying or levering, nor should the upper gums or teeth be used as a fulcrum. These practices may damage to the teeth and reduce the ability to visualize the larynx.
- 22. CONFIRMATION OF TRACHEAL TUBE PLACEMENT • Symmetric bilateral chest movement. • Look for water vapor in the tracheal tube during exhalation. • Listen for breath sounds over upper abdomen. • Look for the evidence of exhalation of carbon dioxide by capnography or mass spectrometer. • Fibroptic identification of trcheal rings via endotracheal tube lumen. • Chest roentgenogram.
- 23. Fixation of the tube • Cut 3 pieces of adhesive plaster approximatly 7cm X 1.5 cm size. • Two of these cut across the middle along the length to resemble pantaloons. • Apply tincture benzoin along the upper lip. • Fix the uncut rectangular piece here. • Fix the pantaloons on both cheeks encircling the tube.
- 24. CHANGING ET TUBE Tube needs to be changed if its cuff develops leak A standard NG tube with in it can be used as a guide. The patient is hyper ventilated. The guide is passed through a ET tube. Maintaining cricoid pressure, the tube is withdrawn over the guide and another ET tube is passed over it in to the trachea. The guide is then withdrawn.
- 25. ET route for administration of drugs • Epinephrine • Nalaxone • Atropine • Lidocaine • Surfactant in preterm babies
- 26. COMPLICATIONS • Hypoxia • Bradycardia • Apnea • Pneumothorax • Contusions or laceration of the tongue, gums, pharynx, epiglottis, trachea, vocal cords or esophagus. • Infections • Post- extubation stridor
- 27. RAPID SEQUENCE INTUBATION Rapid sequence in refers to the rapid uninterrupted injection of preselected dosage of an induction agent and a muscle relaxant. INDICATIONS • Head injury • Combativeness • Prolonged seizure activity • Drug over dosage • Respiratory failure • Near drowning • Burns • Sepsis • Pneumonia
- 28. Contra indications • Facial trauma , edema or fractures. • Distorted laryngotracheal anatomy or airway anatomy.
- 29. STEPS OF RSI • Brief history and anatomic assessment. • Preparation of equipment and medications. • Pre oxygenation. • Pre medications with adjunctive agents (atropine, lignogaine etc). • Sedation and induction of unconsciousness. • Cricoid pressure. • Muscle relaxation. • Intubation. • Verification of ET tube placement. • ET tube is secured, appropriate mechanical ventilation is begun. Chest x-ray ordered.. • Medical record documentation.
- 32. Oxygenation Partial pressure of oxygen in alveolar (PaO2) is the driving pressure for gas exchange across the alveolar – capillary barrier determining oxygenation. PaO2 = ({Atomspheric pressure – water vapour}x FiO2) – PaCO2 / RQ RQ = respiratory quotient Adequate perfusion to alveoli that are well – ventilated improves oxygenation. Hemoglobin is fully saturated 1/3 of the way through the capillary.
- 33. Gas exchange • Hypoventilation and V/Q (ventilation / perfusion) mismatch are the most common causes of abnormal gas exchange. • Hypoventilation can be corrected by increasing minute ventilation. • V/Q mismatch can be corrected by increasing the amount of lung that is ventilated or improving perfusion.
- 34. Time constant is the time required to fill an alveolar space. It takes three times constants (0.3 – 0.45 sec) to achieve greater than 90% capacity of the alveolar unit filled. Time constant = Resistance (pressure x time/volume) x Compliance (volume/pressure)
- 36. • A mechanical ventilator is a machine that generates a controlled flow of gas into a patient’s airways. • Oxygen and air are received from cylinders or wall outlets, the gas is pressure reduced and blended according to the prescribed inspired oxygen tension (FiO2), accumulated in a receptacle within the machine and delivered to the patient using one of many available modes of ventilation. • The central premise of positive pressure ventilation is that gas flows along a pressure gradient between the upper airway and the alveoli. • The magnitude, rate and duration of flow are determined by operator.
- 37. • Flow is either volume targeted and pressure variable, or pressure limited and volume variable. • The pattern of flow may be either sinusoidal (which is normal), decelerating or constant. Flow is controlled by an array of sensors and micro processors. • Conventionally, inspiration is active and expiration is passive. • There are two phases in the respiratory cycle, high lung volume and lower lung volume (inhalation and exhalation). Gas exchange occurs in both phases.
- 38. • Inhalation serves to replenish alveolar gas. • Prolonging the duration of the higher volume cycle enhances oxygen uptake, while increasing intrathoracic pressure and reducing time available for CO2 removal.
- 40. Three main expectations from the ventilator: 1.Ventilator must recognize patient’s respiratory efforts (trigger). 2.Ventilator must be able to meet patient’s demands (response). 3.Ventilator must not interfere with patient’s demands (synchrony).
- 44. • A setting of greater than 0 makes it too sensitive (meaning the triggered breath from the ventilator will be too frequent). • A negative setting (negative 1 or negative 2) setting is usually acceptable. • Too negative setting will increase the work of the patient (to generate a negative pressure) to trigger a ventilator breath.
- 45. INDICATIONS FOR MECHANICAL VENTILATION Following are clinical signs indicating acute respiratory failure: Air hunger or slow ineffective ventilation Cyanosis Marked brady cardia or tachycardia Hypotension Restlessness, irritability or lethargy Convulsions and unconsciousness The arterial PCO2 of >60 mmHg and PO2 of < 60 mmHg while receiving 100% O2 indicated acute respiratory failure.
- 47. • Neonates – Congestive cardiac failure – Shock – Congenital heart disease like PDA, large VSD and other complex cardiac malformations. – Cardiac arrest • Children – Intractable congestive cardiac failure – Shock – Cardiac arrest
- 48. • Neonates – Birth asphyxia – Recurrent apnoea – Intraventricular haemorrhage – Heavy maternal sedation • Children – Guillain – Barre syndrome – Meningitis – Encephalitis – Status epilepticus – Head injury – Tetanus – Accidental poisoning – Acute poliomyelitis
- 49. • RR >70 • Moderate to severe retractions • Intractable apneic spells • Impending or established shock • Cyanosis in FiO2 > 0.4 • PaO2 < 50 mm Hg in FiO2 > 0.8 with sufficient trial of CPAP • PaCO2 > 70 mmHg • pH < 7.25
- 51. Advantages: • The continuous flow of fresh gas allows the patient to make spontaneous respiratory efforts between ventilator breaths with intermittent mandatory ventilation (IMV) • Good control is maintained over respiratory pressures. • Inspiratory and expiratory time can be controlled independently. • The device is relatively simple.
- 52. Disadvantages: • Tidal volume is poorly controlled • The system does not respond to changes in respiratory system compliance. • Spontaneously breathing patients who breathe out of phase with too many IMV breaths may receive inadequate ventilation and are at increased risk for air leak. Indications: • This type of ventilator is useful in any form of lung diseases in children
- 53. Synchronized and patient triggered (assist/ control or pressure support) ventilators • These ventilators combine the features of pressure limited, time cycled, continues flow ventilators with an airway pressure, airflow or respiratory movement sensor. • By measuring inspiratory flow or movement, these ventilators deliver intermittent positive pressure breaths at a fixed rate in synchrony with the baby’s inspiratory efforts. It is called synchronized IMV or SIMV.
- 54. Advantages • Synchronizing the delivery of positive pressure breaths with the infant’s inspiratory effort reduces the phenomenon of breathing out of phase with IMV breaths. • Pronounced asynchrony ventilator has been associated with airleak and intra ventricular hemorrhage. Use of SIMV reduces this complications. Disadvantages • Inappropriate to trigger a breath or fail to trigger because of problems with sensor. • It is more expensive and complicated to use.
- 55. Indications • SIMV can be used when a conventional pressure limited is indicated. • It is used for infants who are breathing spontaneously while on IMV. Volume cycled ventilators Volume cycled ventilators deliver a preset tidal volume to the patient. Positive pressure breaths delivered in the IMV mode are synchronized with the patient’s inspiratory efforts (SIMV mode) controls are also provided or adjusting inspiratory pressure pause and for delivering continuous or decelerating inspiratory flow patterns
- 56. Advantages • These ventilators capable of many different modes of ventilation. • Asynchrony between spontaneous breath and positive pressure breaths are discouraged, thus avoids the risk of barotrauma. Disadvantages • The absence of continuous flow circuitry requires that patient must open the inspiratory demand valve during spontaneous breathing. • It is more expensive.
- 57. High frequency ventilators This can achieve adequate and it is an important adjunct to conventional mechanical ventilation in the newborns. Types • High frequency oscillatory ventilator • High frequency jet ventilator • High frequency flow ventilator These ventilators apply continuous distending pressure to maintain an elevated lung volume, small tidal volumes are super imposed at a rapid rate.
- 58. Advantages • It can be achieve adequate ventilation while avoiding the large swings in lung volume required by conventional ventilators and associated with lung injury, it is useful in pulmonary air leak syndrome. • They allow the use o high MAP for alveolar recruitment and improvement in ventilation perfusion matching. Disadvantages • Despite theoretical advantages on high frequency ventilators, no significant benefit of this method has bee demonstrated.
- 59. Conventional modes of mechanical ventilation • Control mode ventilation(CMV) • Assist control mode ventilation (AMV) • Intermittent mandatory ventilation(IMV) • Pressure support ventilation(PSV) • Mandatory minute ventilation(MMV)
- 60. Ventilator controls • FiO2 :- 0.21 – 1.0 • PIP :- 0 – 80 cm of H2O • PEEP :- 0 – 20 cm of H2O • RR :- 0 -120 breath/ min • Ti :- 0 -3 seconds • Te :- 0- 60 seconds Alarms • FiO2 • PIP, PEEP, MAP fall • Loss of gas supply or leakage in the system • Humidity • Inspired gas temperature • Power loss
- 61. Continuous positive airway pressure(CPAP) mode • CPAP mode providing continuous distending airway pressure to the patient who is breathing spontaneously. • The ventilator generates a constant positive pressure through out the respirratory cycle with out any ventilatory breath. • It is commonly used to provide intern=mittent positive pressure ventilation(IPPV) or intermittent mandatory ventilation(IMV).
- 62. Positive end expiratory pressure • PEEP maintains lung volumes and prevents alveolar collapse during expiration. • PEEP is the most effective mode that increases MAP. • Both extremely high and low PEEPs are associated with retention of CO2. • PEEP between 4 and 8 of H2O is effective and safe. • High PEEP may cause air leaks, and impede venous return to the heart and increase pulmonary vascular resistance ad intracranial tension.
- 63. Initial settings for establishment of assisted ventilation • The patient should be kept on an open care system with servo control mode to provide thermo neutral environment. • Proper suctioning and stabilize with 100% 0f oxygen. • Attached vital signs monitor and pulse oxymeter. • Intubate the patient. • Check the ventilator.
- 64. Initial settings FiO2 :- 0.5 PIP :- 18 -20 cm of H2O PEEP :- 4 -5 cm of H2O RR :- 40 -50 breath/ min Ti :- 0.4 – 0.5 seconds • Observe the patient for cyanosis, retractions, chest wall movements, breath sounds ad capillary perfusion. • Perform arterial gas analysis.
- 65. Monitoring adequacy of ventilation Clinical parameters • No cyanosis – pink color • Absence of retractions • Adequate expansion of chest • Adequate air entry • Prompt capillary filling • Normal BP Pulse oximetry • Oxygen saturation 90-95% Blood gasses • Pa O2 – 60-90 mm Hg • Pa CO2 – Acute case; 40-45 mmHg • Chronic case; up to 60 mmHg • Ph ; 7.35- 7.45
- 66. Respiratory care during ventilation • Chest physiotherapy Changing the position of the patient Postural drainage Percussion and vibration • Endo tracheal suctioning • Humidification • Aerosal therapy • Sedatives and other drugs • Eye care
- 67. Weaning from mechanical ventilation Condition for weaning • Improving general conditions • Decreasing FiO2 requirement • Improving breath sounds • Decreasing endotracheal secretions • Improving chest x-rays • Decreased chest tube drainage • Improved fluid and electrolyte staus • Improving neurological status
- 68. WEANING METHOD • Decrease FiO2 to keep SpO2> 94 • Decrease the PEEP to 4-5 and gradually by decrements of 1-2 cm H2O • Decrease the SIMV rate to 5 (by 3-4 breath / min) • Decrease the PIP (to 20 cm H2O by reducing 2cm H2O each time tidal volume <5ml/ kg )
- 69. Extubation criteria • Control of airway • Patent upper airway • Good breath sounds • Minimal oxygen requirement(<0.3 with SpO2 > 94) • Minimal pressure support(5-10 above PEEP) • ‘awake’ patient
- 70. Supportive care during ventilation • Infusion of appropriate fluid • Administration of sodium bicorbonate • Inotropic agents • Appropriate antibiotics • Nasogastric feeding • X-ray chest
- 71. Complications • Soft tissue trauma • Atelectasis of lung • Perforation of trachea or esophagus • Avulsion of vocal cords • Supglottic stenosis • Infections • Acute parotrauma • Broncho pulmonary dysplasia • Hyperoxia • High PEEP leads to reduced venous return and cardiac output and increased cerebral pressure
- 72. GASTRIC GAVAGE Tube feeding or gastric gavage Gastric gavage is the term applied to the process of feeding the patient by means of a tube introduced directly in to the stomach by way of either mouth or the nose. The word “gavage” comes from the french “ gaver” meaning to “ force feeding of poultry”.
- 73. INDICATIONS FOR NG TUBE INSERTION Diagnostic • Gastric aspirate test for diagnosis of neonatal septicemia. • Shake test for lung maturity. • Examination of gastric contents. • Assessment of upper GI bleeding. • Measurement of gastric volume. • Determination of gastric acid content. • Drug analysis on stomach content. • Passage of intrinsic factor.
- 74. Therapeutic • Paralytic ileus • Acute gastric dilatation • Intestinal obstruction • Gastric haemorrhage • Enteral feeding • Administration of therapeutic substances. Contra indications of tube insertion • Nasal fractures • Head and neck injury • Esophageal stricture • Ingesion of alkali
- 75. INDICATIONS FOR GASTRIC GAVAGE • Preterm babies • Certain sick babies like • Severe neurological problems • Severe medical problems • Unconsciousness • RDS • Viral hepatitis • For at risk babies requiring continuing care • Viral encephalitis • Meningitis • Babies with palatal paralysis • Tetanus • Tube feeding are used to supplement the breast feed . •
- 76. Contra indications of tube feeding • Absence of bowel sounds • Respiratory distress • Intestinal obstruction • Convulsions • Upper gastro intestinal bleeding • Paralytic ileus • Nasal fracture • Head and neck injury
- 77. TECHNIQUE Preliminary assessment • Recognize the patient by his identification • Check the doctor’s order • Get the instruction from the senior sister • Check the consciousness of the child • See the required feed is ready • Check the articles available in the ward • Assess the reaction of the patient to the tube feeding
- 78. EQUIPEMENT A clean tray containing • Nasal tube,(catheter no. 7 or 8), funnel, glass connection and tubing. • Levin tube or ryle’s tube • Required amount of fluid in a bowl • ( bolus feeding- 300 to 500 ml/day, intermittent feeding- formula is placed in to gravity bag dripped in over 30 – 60 mins, continues feeding- administer via infusion pump usually 50 – 150 ml) • Lubricant such as water soluble jelly • Clean water in a container
- 79. • Swab stick • Rag pieces • Kidney basin • Mackintosh and towel • Adhesive tapes and scissors
- 80. PROCEDURE • The head is raised in semi upright position • The distance from the nose to ear lobe and from the ear lobe to xiphoid process is determined to measure the length of the tube is to be passed. The spot is marked on the tube . • The patent nostril is selected and cleaned with swab sticks.
- 81. • The terminal end of the tube is lubricated with lubricant. • The tube is passed in to the nostril downward along the floor of the nose. • With swallowing of the saliva tube is advanced in to the esophagus and passed up to the mark as measured.
- 82. Confirmation of the tube placement • Aspiration of the stomach content • Air is injected in to the tube while the epigastric area is palpated • Placing the tube in a glass of water and escape of air bubbles • Radio opaque tube can be assessed by radiography.
- 83. • The tube is fixed with a tape. • Check the bowel sounds prior to each feeding. • Elevate the head of the bed before each feeding. • Connect the syringe or funnel and pinch the tube and hold the syringe upward and pour some plain water in to it. • Pour the feed before the funnel is empty. After feeding also pour some water to clear the tube. • Make the patient in comfort. • Replace the articles. • Record the procedure.
- 84. When are tube feeding stopped? • When they no longer needed; the baby must have ; Developed a gag reflux No respiratory problems Normal vital signs, color and activity • When they are not tolerated; The baby is so sick
- 85. Complications of tube feeding • Inability to pass the tube may be due to gagging, uncooperative patient esophageal stricture, creation of false passage, esophageal atresia etc. • Pulmonary aspiration • Esophageal perforation • Gastric perforation • Nasal necrosis
- 86. GASTRIC LAVAGE Gastric lavage also commonly called stomach pumping or gastric irrigation is the process of cleaning out the contents of the stomach.
- 87. INDICATIONS • Oral poisons • GI bleeding • Meconium aspiration syndrome • Suspected congenital TB
- 88. CONTRA INDICATIONS • Ingestion of corrosive poisons • Ingestion of hydrocorbons • Presence of neurological symptoms • Tetanus
- 89. EQUIPMENT • Stomach tube • Suction machine, syringe or aspirating bulbs • Liquid paraffin • Mouth gag • Normal saline
- 90. TECHNIQUE • Measure the distance on the tube • Keep the child in supine position • Smear the tube with lubricant • Pass the tube gently through the nose or mouth in to the stomach • Confirm the presence of tube in stomach • Secure the tube • Remove the gastric contents by gentle suction or syringe or aspirating bulb • After removing gastric contents, perform gastric lavage by normal saline • Repeat the introduction and with drawl of fluid
- 91. COMPLICATIONS • Aspiration pneumonia • Laryngospasm • Esophageal perforation • Trauma
- 92. EXCHANGE TRANSFUSION INTRODUCTION: Exchange transfusion is a potentially life-saving procedure that is done to counteract the effects of serious jaundice or changes in the blood due to diseases such as sickle cell anemia. DEFINITION: Exchange transfusion involves slowly removing the patient's blood and replacing it with fresh donor blood or plasma.
- 93. INDICATIONS: • Neonatal polycythemia (dangerously high red blood cell count in a newborn) • Rh-induced hemolytic disease of the newborn • Severe disturbances in body chemistry • Severe newborn jaundice that does not respond to phototherapy with bili lights • Severe sickle cell crisis • Toxic effects of certain drugs
- 94. TECHNIQUE • Exchange transfusions are performed using a one catheter or two catheter push-pull method. • The exchange equipment is set up by nursing staff, but the specialist responsible for the exchange must check the set-up prior to commencing the exchange. This set-up is a joint responsibility between medical and nursing staff, but the specialist doing the exchange has overall responsibility for the procedure.
- 95. 1. Two Catheter Push-pull Technique • Blood is removed from the artery while infusing fresh blood through a vein at the same rate. • InOutUmbilical vein Peripheral artery orUmbilical vein Umbilical artery or Peripheral vein Peripheral artery2orPeripheral vein Umbilical artery In Out Umbilical vein Peripheral artery or Umbilical vein Umbilical artery or Peripheral vein Peripheral artery2 or Peripheral vein Umbilical artery
- 96. 2. One Catheter Push-pull Technique • This can be done through an umbilical venous catheter. Exceptionally, an umbilical artery catheter can be used. • Ideally, the tip of the UVC should be in the IVC/right atrium (at or just above the diaphragm) but can be used if it is in the portal sinus. For ‘high’ UVC placement, position should be checked by an X-ray. This is not always necessary for a low position. A low positioned catheter is usually removed after each exchange. • Withdraw blood over 2 minutes, infuse slightly faster.
- 97. VOLUME • N.B: Blood Volume = 70-90 ml/kg for term and 85- 110 ml/kg for preterm infants • One blood volume removes 65% of baby’s red cells. • Two blood volumes removes 88% • Thereafter the gain is small. <1000gms Use 5ml aliquots 1000-2000gm 10ml >2000gm 3 15ml
- 98. PRINCIPLES • There must be at least one doctor/ns-anp and one nurse exclusively involved in the exchange throughout its progress. • The doctor/ns-anp must be present throughout the exchange. He/she may leave the room briefly to get blood results, but if called away, the exchange is stopped and the lines flushed. • It may be necessary for another doctor/ns-anp to cover the rest of the unit during the exchange. • Meticulous care must be taken throughout, especially with volume balance, the rate of the exchange, the vital signs and any signs of air in the lines.
- 99. PRINCIPLES (contd..) • All exchanges are to be conducted in nicu level 3. • The nurse must be at least a level four nurse, who is trained and up to date with the procedure, if there are not two nurses who are trained and up to date on shift, one who is should be called in (placed on call) • If there are any doubts about the set-up or the method of doing the exchange transfusion, they must be immediately referred to senior medical or nursing staff and the exchange interrupted until they are answered satisfactorily.
- 100. PROCEDURE A. If an exchange transfusion is necessary, compatible blood must be ordered. If a severely affected ( i.e. hydropic) infant with Rh hemolytic disease is anticipated at birth, it may be necessary to have blood available in the nursery prior to the delivery. The request should be for O negative packed red blood cells of the specific volume needed and of the appropriate CMV status.
- 101. This blood may be utilized in any one of the following ways: 1. The RBC's may be given as a simple transfusion (with or without additional Plasmanate) while stabilization of the infant is accomplished. 2. The RBC's may be used for a partial exchange transfusion to acutely elevate the hematocrit without changing the blood volume in a severely anemic baby. B. When the need for an emergency, complete exchange transfusion is virtually certain, arrangements can be made in advance for O negative whole blood or O negative PRBC's resuspended in fresh frozen plasma.
- 102. C. For double-volume exchange transfusions for hemolytic disease of the newborn or for hyperbilirubinemia without hemolysis, the blood used will be packed cells (type O, Rh specific for the infant) resuspended to the desired hematocrit in compatible fresh frozen plasma. D. A partial exchange transfusion is often done for polycythemia (see section on polycythemia). II. Although the standard anticoagulant (CPD) is acidic, the blood need not be buffered. If the infant is severely acidemic, consult the staff neonatologist. III. If possible, the infant should be NPO and the stomach contents aspirated prior to the procedure.
- 103. IV. The exchange transfusion should be done under a radiant warmer using sterile technique. V. The donor blood should be warmed using the blood warmer to a temperature not exceeding 37oC. VI. The infants blood pressure, respiratory rate, heart rate and general condition should be monitored during the exchange transfusion according to standard nursing protocol. VII. If the serum bilirubin concentration is at a dangerous level and the blood for exchange transfusion is not yet ready, consider priming the infant with 1 gram/kg (4 ml/kg) of a 25% solution of salt-poor albumin to bind additional bilirubin and keep it in the circulation until the exchange can be accomplished..
- 104. VIII. The umbilical vein catheter should be inserted until there is free flow of blood immediately prior to starting the exchange transfusion. See section on placement of umbilical catheters for technique. The exchange transfusion should not be done through an umbilical artery line unless the UAC is used only for blood withdrawal with simultaneous replacement through the umbilical vein or peripheral IV. At the beginning of the exchange transfusion, the first blood sample withdrawn should be sent for for 1)total and direct bilirubin; 2) hemoglobin and hematocrit; 3) glucose; and 4) calcium.
- 105. IX. Use the "exchange transfusion kit", which contains catheters, stopcocks, waste bag, and calcium gluconate.
- 106. • X. Ideally, blood (or colloid in the event of a partial volume exchange) should be infused through a peripheral vein at a rate equal to blood withdrawal from the UVC. If the "push-pull" (single catheter) technique is utilized, no more than 5 ml/kg body weight should be withdrawn at any one time.
- 107. • XI. The exchange volume is generally twice the infant's blood volume, (generally estimated to be 80 ml/kg). The total volume exchange should not exceed one adult unit of blood (450-500 ml). A standard two- volume exchange will remove approximately 85% of the red cells in circulation before the exchange and reduce the serum indirect bilirubin level by one-half. The exchange of blood should require a minimum of 45 minutes. • XII. The need for giving supplemental calcium is controversial. If used give 0.5 to 1.0 ml of 10% calcium gluconate IV, after each 100 ml of exchange blood. Monitor heart rate for bradycardia.
- 108. • XIII. At the end of an exchange transfusion blood should be sent for sodium, glucose, calcium, total and direct bilirubin, and hemoglobin and hematocrit. • XIV. At the end of an exchange transfusion, the umbilical vein catheter is usually removed. In the event of a subsequent exchange, a new catheter can be inserted. • XV. Hypoglycemia often occurs in the first or second hour following an exchange transfusion. It is therefore necessary to monitor blood glucose levels for the first several hours after exchange.
- 109. • XVI. The serum bilirubin concentration rebounds to a value approximately halfway between the pre- and post- exchange levels by two hours after completing the exchange transfusion. Therefore, the serum bilirubin concentration should be monitored at two to four hours after exchange and subsequently every three to four hours. • XVII. Feedings may be attempted two to four hours after the exchange transfusion.
- 110. COMPLICATIONS: • Blood clots • Changes in blood chemistry (high or low potassium, low calcium, low glucose, change in acid-base balance in the blood ) • Heart and lung problems • Infection (very low risk due to careful screening of blood) • Shock due to inadequate replacement of blood
- 111. UMBILICAL VEIN CATHETERIZATION INTRODUCTION Umbilical vein catheters (UVC), are used for exchange transfusions, monitoring of central venous pressure, and infusion of fluids (when passed through the ductus venosus and near the right atrium); and for emergency vascular access for infusions of fluid, blood products or medications. MEANING Umbilical vein catheterization should be considered as a potential intravenous access stein infants up to 2 weeks old. The procedure is indicated for neonates with shock or cardiopulmonary failure.
- 112. INDICATIONS: Emergent access to newborn circulation – Exchange Transfusion – Very ill infants – Very low birth weight (<750g) EQUIPMENT • 5 or 8 French catheter, or a 5 French feeding tube • 10-mL syringe • Umbilical cord tape or suture to tie the base of the cord • Flush solution
- 113. PROCEDURE: 1. Place the infant beneath a radiant warmer and restrain the extremities. 2. Prepare the abdomen and umbilicus with antiseptic solution (surgical prep). 3. Drape the umbilical area in a sterile manner. Expose the infant’s head for observation. 4. To anchor the line after placement, place a constricting loop of umbilical tape at the base of the cord. Using a scalpel blade, trim the umbilical cord to1 to 2 cm above the skin surface
- 115. 5. Identify the umbilical vessels. The umbilical vein is a single, thin-walled, large-diameter lumen, usually located at12 o’clock. The arteries are paired and have thicker walls with a small-diameter lumen 6. Obtain an umbilical vascular catheter(5 Fr). Flush the catheter with heparinized saline (1 unit per mL) andattach it to a 3-way stopcock. 7. Measure and mark 5 cm from the tip of the catheter. 8. Close the ends of a pair of smooth forceps, then insert the end into the lumen of the umbilical vein. Dilate the opening by allowing the ends of the forceps to separate, then insert the catheter into the lumen of the umbilical vein and advance it gently toward the liver for 4 to 5 cm or until blood return is noted.
- 116. 9. If resistance to advancement of the catheter is encountered, the tip might be in the portal vein or the ductus venosus. The catheter should be pulled back until blood can be withdrawn smoothly. 10. Remove the catheter when resuscitations complete and peripheral vascular access has been obtained.
- 117. COMPLICATIONS AND PITFALLS Central venous catheterization is an invasive form of vascular access, and many potential complications are associated with this technique. Some of these potential complications are common to all sites of insertion, while others are site specific. The complications common to all insertion sites are as follows: Arterial injury: • The most common complication of this technique is accidental puncture and/or cannulation of the adjacent artery.
- 118. In most cases, this results in a minor injury to the artery that can be easily managed with direct pressure at the insertion site or by application of a pressure dressing. • Obviously, it is much harder to control significant bleeding of one of the carotid arteries, but fingertip pressure applied directly to the site might be sufficient. • Use of the vein dilator or a mishap with the scalpel can result in more serious injury to the artery, necessitating the involvement of a vascular surgeon. • If possible, it is best to avoid injuring the artery. •
- 119. Infection: • Central venous catheters are foreign bodies and can, like any such object, become colonized by bacteria. Central venous catheter infections can have devastating consequences, particularly in critically ill children. • Furthermore, the emergence of multiple resistant bacteria in many hospitals increases the risks substantially. Attention to sterile technique is critical. • When time permits, those involved in the placement should don sterile gowns and wear masks and hats. Large sterile drapes can prevent inadvertent contamination of the guide wire and catheter prior to insertion. •
- 120. Thrombosis: • Just as any foreign object can become infected, almost any foreign object can become a nidus for thrombus formation. • The risk is highest with polyvinylchloride catheters and when the rate of infusion through the catheter is lessthan 3 mL/hr. • Flushing the catheter with heparin when it is not in use and using • heparinized fluid when the rate of infusion is less than 3 mL/hr might prevent thrombus formation. • Catheters made of Teflon have surface characteristics that are not conducive to thrombus formation.
- 121. • Unfortunately, these catheters are also quite stiff and can injure vascular structures. Likewise, catheters that are impregnated with heparin are less often associated with thrombus formation. Guide wire misplacement: • In rare instances, the guide wire enters the central venous circulation and must be retrieved by an angiographer or a surgeon. • This complication can be avoided by ensuring that one hand remains in firm contact with the wire at all times.
- 122. Air embolus: • Allowing a bolus of air to enter the catheter can result in an air embolus when the end of the needle or catheter is open to the air and the venous pressure is low. • This complication is most likely to occur when the catheter is placed into the internal jugular vein or the subclavian vein. An air embolus can be avoided by covering the open end of the catheter with the thumb after the guide wire has been removed, before connecting the intravenous fluids, and by positioning the patient with the insertion site slightly dependent.
- 123. • Such positioning has the added benefit of aiding catheter placement because it dilates the veins. • Aspirating the catheter before flushing will remove air within the catheter. • Older patients can be asked to perform a Valsalva maneuver during internal jugular and subclavian cannulation to avoid negative pressure • within the vein.
- 124. Site-Specific Complications • Umbilical vein catheterization should be used for temporary vascular access only, and the catheter should be removed once the patient is stable and vascular access has been secured via other sites. Umbilical vein catheterization can cause hepatic thrombosis, infection, and hemorrhage due to vessel perforation.
- 125. THANK YOU