repeated and frequent blood sampling; shorter hbf red cell half-life; Presentation \200 i \200 \200 \200 Pallor and tachycardia. O2 requirement or apnoea. (cid:1). Poor feeding Growth failure (cid:1). Treatment \200 \200 Start iron supplement at 4wks old for 12mths if <35wks gestation. Further research is requi red to establish appropriate blood transfusion thresholds for preterm infants. Transfuse if clinically indicated. Volume to transfuse (mL) = desired rise in Hb (g/dL) x weight (kg) x [4 (packed cells) or 6 (whole blood)]. Alternatively, give 20mL/kg over 4hrs. Blood should be CMV \200\223ve and irradiated. Erythropoietin is useful, but not cost-effective for ro utine use and may increase the risk of retinopathy of prematurity. Use is limited to infant s from Jehovah \200\231s witness families. Polycythaemia See also b p.630. De \201 ned as arterial or venous packed cell volume (PCV) >65%. More common if placental insuf \201 ciency, maternal diabetes mellitus, Down \200 \231s syndrome, or after twin to twin transfusion. Risk of complications due to thrombosis and or microvascular sludging. Treatment If \200 symptomatic: (lethargy, seizures, respiratory distress, poor feeding, th rombocytopenia, stroke, renal failure, NEC) perform dilutional exchange transfusion with 20 \200\22330mL/kg of normal saline over 30 \200\22360min. If asymptomatic: it is probably wise to perform dilutional exchange transfusion if PCV >70% to prevent complications. 06_McClure_06.indd 192 11/14/2012 11:22:51 PM NEONATAL hematology 193 Thrombocytopenia See also b p.642. Common neonatal causes include: \200 \200 \200 \200 Sepsis, including congenital infection. NEC. IUGR. Maternal idiopathic thrombocytopenic pur pura (ITP) (due to passive transfer of autoimmune IgG antiplatelet antibodies). Neonatal al loimmune thrombocytopenia (NAIT) resulting from transplacental passage of maternal speci \201 c IgG antiplatelet antibodies sensitized to differing fetal human platelet antigen (HP A). In 85% antibody is to HPA1 antigen. Placental dysfunction. Pre-eclampsia. DIC. \200 \200 Presentation \200 Petechiae. \200 Thrombocytopenia. \200 Intracranial hemorrhage (10 \200\22320%) particularly with NAIT. Treatment Platelet transfusion 10 \200\22315mL/kg if platelet count is <50 and active bleed - ing or <30 plus additional haemorrhagic risk factor or <20 in a well baby. NAIT-speci \201 c treatment \200 \200 fetal platelet transfusion. Maternal IV immunoglobulin. Antenatal: observe if platelets >40 x 109/L. If platelets less or infant Postnatal: symptomatic, give platelet transfusion (HP A1-negative if relevant) and consider corticosteroids, IV immunoglobulin, or even exchange transfusion (liaise with blood transfusion/hematology). Coagulation disorders See also b pp.632 \200\223640. The most common neonatal cause is DIC. Rarely, there is a speci \201 c coagulation defect, e.g. hemophilia, or haemorrhagic dise ase of newborn. Haemorrhagic disease of newborn Bleeding is due to de \201 ciency of vitamin K dependent f actors resulting from: \200 \200 \200 \200 Poor transplacental supply. Lack of enteric bacteria. Maternal anticonvulsants. Low vitamin K levels in breast milk. Typical presentation: is at age 2 \200\2237 days with bruising and spontaneous bleeding, e. g. from umbilicus, GI tract, or intracranial. Investigation: shows i prothrombin time (PT) and partial thromboplastin time (PTT), whilst platelet count is normal. Prevention: vitamin K1 at birth (see b p.140). Treatment: immediate IV vitamin K1 1mg and fresh frozen plasma 10mL/kg. 06_McClure_06.indd 193 11/14/2012 11:22:51 PM CHAPTER 6 Neonatology 194 Rh disease (rhesus haemolytic disease) Hemorrhage of fetal blood of differing rhesus group into the maternal circulation leads to maternal anti-D IgG production (usually fetus RhD +v e, mother RhD \200\223ve). Transplacental passage of this antibody leads to fetal RBC haem olysis. The condition is usually asymptomatic or only mild in the \201 rst affected pregn ancy. Severity usually increases with subsequent pregnancies. Maternal blood group and rhes us antibody status are routine- ly checked in early pregnancy. Elevated or rising titres in dicate that further fetal investigation is warranted, e.g. serial anti-Rh titres, fetal US, fetal blood sampling. The risk of disease is predicted by maternal anti-Rh titre: \200 \200 \200 Unlikely when maternal anti-Rh titre <4u/mL. 10% when titre is 10 \200\223100u/mL. 70% when fetal Hb <7g/dL or titre >100u/mL. Iso-immunization may also occur with other blood group incompatibilities, (e.g. ABO \200 \224usually baby A or B and mother O), other rhesus groups (e.g. c, C, e, E), Kell, Kidd, D uffy. Clinical presentation is usually milder than with RhD (particularly ABO). Presentation \200 fetal anemia, hydrops foetalis. Antenatal: \200 Postnatal: hydrops fo etalis, early jaundice, kernicterus (b p.195), cutaneous haemopoietic lesions ( \200\230blu eberry muf \201 n \200\231), hepatosplenomegaly, coagulopathy, thrombocytopenia, leucopeni a. Late: anemia, inspissated bile syndrome. Investigations \200 \200 group (usually RhD \200\223ve), i anti-Rh titre. Maternal blood for: Initially, cord or neonatal blood for: DCT +ve, group (usually RhD +ve) , i SBR. After diagnosis monitor SBR 4-hourly (until rate of rise known), blood glucose, ra te of Hb fall. Check coagulation screen. d Hb, i reticulocytes, d platelets, Treatment See also hydrops foetalis, b p.138. \200 \200 Close antenatal supervision +/ \200\223 intrauterine blood transfusion. After birth check c ord SBR and Hb, start high risk infants on intensive phototherapy whilst awaiting results. If SBR>100 mol/L then prepare infant for exchange transfusion, consider IVIG (see b pp.130 , 646). Supportive treatment as required, e.g. correct any coagulopathy. If treatment requi red, oral folic acid 250mcg/kg/day for 6mths. Check Hb every 1 \200\2232wks to detect anemi a for up to 12wks. Transfuse if symptomatic or Hb <7g/dL. Perform audiology screening if ex change transfusion required. Prophylaxis: +ve fetus or possible foeto-maternal hemorrhage. \200 \200 \200 Rh anti-D IgG given to RhD \200\223ve mothers after birth of Rh Prognosis Mortality <20% even if hydropic. Risk of late onset anemia. 06_McClure_06.indd 194 11/14/2012 11:22:51 PM BILIRUBIN ENCEPHALOPATHY (KERNICTERUS) 195 Bilirubin encephalopathy (kernicterus) A clinical syndrome resulting from the development o f excessive neuro- toxic unconjugated bilirubin levels. Toxic levels lead to selective dama ge of the cerebellum, basal ganglia, and brainstem auditory pathways. It may occur in the h ealthy neonate if serum bilirubin is >360 mol/L , but usually only occurs at signi \201 c antly higher serum levels (>430 mol/L after 48hr of life) unless: \200 \200 \200 \200 \200 \200 Infant is <24hr old. Infant is preterm. Infant is severely ill (any cause). Infant is acido tic. Caused by iso-immunization haemolytic disease. Reduced albumin binding caused by drugs or hypoalbuminanaemia. Presentation \200 \200 \200 \200 \200 \200 Lethargy progressing to hypertonia then hypotonia. Poor feeding. Fever. High-pitched cry. O pisthotonos. Seizures and coma. Main differential diagnosis is meningoencephalitis/sepsis. Neonatal tetany may also present with opisthotonos. Treatment \200 \200 Supportive (likely to require full intensive care). Urgent reduction of serum bilirubin by intensive phototherapy and exchange transfusion. Give IV immunoglobulin. Treat underlying c ause. \200 Prognosis Majority survives, but there is a high risk of athetoid cerebral palsy, deaf- nes s, and low IQ. 06_McClure_06.indd 195 11/14/2012 11:22:52 PM CHAPTER 6 Neonatology 196 Neonatal dermatology Neonatal skin is covered with vernix at birth and is poorly keratinize d. There is reduced resistance to bacterial infection, increased water loss, increased abso rption of drugs (all more pronounced with prematurity.) The following conditions are all benign and resolve without treatment, often within a few weeks of birth. \200 <2mm yellowish-white spots, usually on the face, secondary to Milia: blocked sebaceous/sweat glands. Erythema papular discrete lesions, often with a whit e center, mostly present over the knees, elbows, trunk, and face. Very common particularly in post-mature infants. Harlequin or quadrants, of body. s to vasomotor immaturity. Cutis b aby, secondary to vasomotor immaturity. Sucking Super \201 cial erythematous vascular mark s common on eyelids, face midline, and posterior scalp, particularly over the nape of neck (tends to persist at latter site). Mongolian region, common in non-Caucasians. May last sev eral years. toxicum (erythema neonatorum): erythematous macular \200\223 color change: marked erythema or pallor in different halves, marmorata (livedo reticularis): marble-like color change in well \200 blisters: common on hand, wrist, or upper lip. capillary haemangioma (salmon-patches, stork marks): blue spots: bluish-black macules, most often in lumbar \200\223sacral Nappy rash Usually a contact dermatitis from ammonia released by bacterial break- down of u rine. Treatment Includes: \200 \200 \200 Frequent nappy changes. Barrier cream, e.g. zinc and castor oil cream; expose to air. Suspe ct secondary Candida infection if worse in \202 exures or satellite lesions present. Trea t with topical antifungal, e.g. nystatin ointment 6-hourly (if severe may bene \201 t from oral antifungal simultaneously). Infantile seborrhoeic eczema Very common. Usually appears after a few weeks. Erythema and s caling rash affects face, neck, behind ears, axillae, scalp (cradle cap), upper trunk, napk in area, and \202 exures. Majority spontaneously resolve within weeks. Minority will go o n to develop atopic eczema, particularly if there is a family history. Treatment \200 \200 \200 Avoid detergents (i.e. soap). Use topical emollients. Mild topical steroid/antifungal prepa ration (e.g. 1% hydrocortisone cream). 06_McClure_06.indd 196 11/14/2012 11:22:52 PM NEONATAL DERMATOLOGY 197 06_McClure_06.indd 197 11/14/2012 11:22:52 PM CHAPTER 6 Neonatology 198 Perinatal death Causes \200 \200 \200 \200 \200 \200 \200 Extreme prematurity (40%). Congenital abnormalities (30%). RDS. Sepsis. Perinatal asphyxia. Pulmonary hypoplasia. Miscellaneous. After death \200 Take photographs and mementos, e.g. footprints, according to parents \200\231 wishes. Infor m all relevant professionals, (e.g. GP, obstetrician). Refer to coroner (Procurator Fiscal in Scotland) if required. UK criteria are: \200 \200 \200 \200 Explain and offer po st-mortem to parents. Possible bene \201 ts include: \200 \200 \200 \200 \200 \200 Unexpected/unexplained death. As soon as possible consider (with consent!): \200 \200 \200 \200 Currently, no neonatal organ or tissue is harvested for transplantation in UK. If able, issue completed death certi \201 cate to parent/guardian who is then resp onsible for registering the death. In the UK there is a speci \201 c certi \201 cate requ ired for a neonatal death (i.e. <28 days old). Offer follow-up appointment with senior doct or at 4 \200\2236wks to discuss issues surrounding death, post-mortem \201 ndings, bereav ement. \200 cause of death unknown; no medical practitioner attended illness leading to death; intraope rative death or prior to recovering from anesthetic; suspicious circumstances. determines cause of death; identi \201 es unknown comorbidities; determines degree of norm ality; audits clinical care; research; medical education. blood for culture \200\224save serum for possible later testing (iem); throat, eye, ear sur face swabs for bacterial and viral culture; suprapubic aspiration (spa) of urine to be save d (iem); axilla skin biopsy for \201 broblast culture (send in sterile saline). Withholding or withdrawal of life support Up to 70% of deaths on UK neonatal units follow w ithholding or elec- tive withdrawal of life-sustaining treatment. In UK the Royal College o f Pediatrics and Child Health states that there are 5 situations when with- holding or with drawal of life sustaining treatment may be appropriate. Three are relevant to newborns and are summarized here: 06_McClure_06.indd 198 11/14/2012 11:22:52 PM PERINATAL DEATH 199 \200\230No chance \200\231: life-sustaining treatment simply delays death without signi \201 cant alleviation of suffering, e.g. spinal muscular atrophy type 1. \200\230No purpos e \200\231: although the baby may be able to survive with treatment, the degree of physical or mental impairment will be so great that there is no quality of life, e.g. severe perman ent brain injury after perinatal hypoxia. \200\230An unbearable situation \200\231: treatm ent is more than can be borne by the baby and/or family when the illness is progressive and irreversible, e.g. recurrent cardiopulmonary resuscitation in an infant with irreversible and progressive cor pulmonale. The other two situations relating to \200\230brain death \200\231 and \200\230permanent vegetative state \200\231 cannot currently be diagnosed in the newborn. Withholding or withdrawing life-sustaining treatment must be \201 rst dis- cussed with th e parents. Almost always a joint decision can be made in the child \200\231s best interests . Time, rather than court proceedings, is usually the best approach, the latter being best reserved for extreme situations. Procedure for withdrawal of life-supporting treatment Remember, withdrawal of life-sustaini ng treatment does not equal with- drawing care: \200 If possible, allow parents and family to say their good-byes, spend time alone with baby, h ave appropriate religious services conducted. Parents may wish to be present at the time of withdrawal. Offer options of being present or holding the child in a private quiet room du ring withdrawal or afterwards. Stop all non-palliative infusions and remove all peripheral vascular lines and gastric tubes. Clamp central lines and chest drains. Switch off all alar ms/monitors. If ventilated, disconnect and remove ETT. Dress or swaddle infant and then all ow parents to cuddle infant. Give parents/family space and privacy. After death undertake r elevant tasks as outlined in above. \200 \200 \200 \200 b \200\230After death \200\231, 06_McClure_06.indd 199 11/14/2012 11:22:52 PM This page intentionally left blank 201 Chapter 7 Practical procedures Capillary blood sampling 202 Venepuncture 203 Intravenous cannulation 204 Peripheral arteri al blood sampling 205 Peripheral arterial cannulation 205 Umbilical arterial catheter 206 U mbilical venous catheter 208 Central venous catheterization via a peripheral vein 209 Airwa y management 210 Mask ventilation 211 Endotracheal intubation 212 Insertion of a chest drai n 214 Intraosseous infusion 216 Intracardiac injection 216 Pericardiocentesis 217 Abdominal paracentesis 217 Urethral bladder catheterization 218 Suprapubic aspiration of urine 219 L umbar puncture 220 Cerebral ventricular tap 221 Exchange transfusion 222 Note: All practical procedures should be performed whilst observing appropriate practices t o minimize the risk of infection for both the patient and the operator, including aseptic t echnique, wearing protective clothing, such as gloves, and safe disposable of all contamina ted sharp equip- ment, e.g. needles. 07_McClure_07.indd 201 11/14/2012 2:31:43 PM CHAPTER 7 Practical procedures 202 Capillary blood sampling Capillary blood sampling is used when small volumes of blood are n eces- sary for analysis, e.g. FBC, blood gas, blood glucose. An automated device to pierce the skin is preferred over a lancet, as it causes less pain and punctures to a predetermine d depth, thereby reducing the risk of underly- ing bone damage or infection. Equipment \200 \200 \200 \200 Alcohol impregnated swab. Automated device or sterile lancet. Appropriate sample bottles or capillary tubes. Cotton wool or gauze swab. Site \200 Plantar heel surface outside the medial and lateral limits of calcaneous bone in the young infant (Fig. 7.1). Finger site in the older child. Procedure \200 \200 \200 \200 Warm the heel or \201 nger. In the case of foot, hold dorsi \202 exed. Clean with an alc ohol impregnated swab. Gently massage area to improve blood \202 ow and use your hand as a tourniquet. Puncture skin with an automated device or sterile lancet. \200\230Scoop \200 \231 droplets of blood into an appropriate sample container or on to blood glucose-measurin g strip. Note that excessive squeezing leads to falsely high serum potassium and haematocri t levels, and bruising. Once sample has been collected stop any residual bleeding by local pressure with a cotton wool ball or gauze swab. \200 Fig. 7.1 Site for capillary blood sampling on plantar surface of foot. Sampling area is ind icated by shaded area. 07_McClure_07.indd 202 11/14/2012 2:31:43 PM VENEPUNCTURE 203 Venepuncture Venepuncture is preferable to capillary blood sampling when a signi \201 cant volume of blood is needed for testing, e.g. coagulation studies, or when sterility of samp le is important, e.g. blood culture. Equipment \200 In older child, as in adults, a 21 \200\22323G needle and syringe or vacuum tube should be used. In infants and small children use either a 23G butter \202 y needle and syringe or 2 1 \200\22323G butter \202 y needle without the normal tubing. An alcohol impregnated swab. Appropriate sample bottles or capillary tubes. Cotton wool or an occlusive plaster. \200 \200 Procedure \200 Suitable sites include the antecubital fossa, dorsum of the hand, and dorsum of the foot. S ometimes, necessity demands that other sites such as the scalp are used, particularly in in fants. Identify suitable vein and warm limb if necessary. Topical local anesthetic cream ca n be applied under an occlusive dressing for 30 \200\22360min reduces pain and may be appro priate in young children. Apply a tourniquet proximal to the intended venepuncture site. In infants this is often best done using your own gloved \201 ngers or asking an assistant to squeeze the limb. Also use your \201 ngers to stretch the overlying skin to stabilize the vein. In young children an assistant may be required to keep the child \200\231s limb s teady. Clean overlying skin with an alcohol impregnated swab. Along the line of the vein an d in a proximal direction, insert needle through overlying skin at 20 \200\22330 into the vein until blood \202 ashes back into the needle. Stabilize needle/butter \202 y with y our \201 ngers and then aspirate into syringe or, if using a butter \202 y with no tubin g, allow blood to drip into sample bottles. Repeated gentle release and retightening of tou rniquet often increases blood \202 ow. Once blood has been collected, release the tourniq uet, remove needle and then apply gentle pressure to puncture site for a few minutes with c otton wool. Once bleeding has stopped, an occlusive plaster is optional, but is often appre ciated! \200 \200 07_McClure_07.indd 203 11/14/2012 2:31:44 PM CHAPTER 7 Practical procedures 204 Intravenous cannulation IV cannulation is required for the infusion of \202 uids or drugs . Any blood sampling necessary may also be done at the time of insertion. This \200\230com - bined \200\231 technique will save puncturing the child twice. Equipment \200 \200 \200 \200 \200 An alcohol impregnated swab. IV cannula: IV extension set and 3-way tap with Luer lock \202 ushed with 0.9% saline. Tourniquet (older children). Fixing tape or transparent occlus ive dressing to \201 x cannula in site. 24G in newborns, 21G in older children. Procedure \200 Carefully identify a suitable vein. The dorsum of the hand or foot or antecubital fossa is ideal. Other suitable sites include the anatomical snuff box, volar aspect of forearm, grea t saphenous vein at the medial malleolus or knee. Whilst not ideal, scalp veins can be used , but the hair usually needs to be shaved. If possible, avoid larger veins if a percutaneou s central line insertion is likely to be needed later. Tip: transillumination of hand or fo ot with a \200\230cold \200\231 light source can be very useful for locating \200\230hidd en \200\231 veins, particularly in the newborn. In an emergency, or if one or more normal s ites have been used, scour the whole body and use whatever vein you can \201 nd! Consider at least 45min of local anesthetic cream applied under an occlusive dressing over the inte nded vein before starting. Remove the cream before starting. Ensure good vein perfusion, e. g. warm extremity before cannulation. If needed, ask an assistant to help with keeping the child \200\231s limb steady. This may require wrapping a young child in a towel or sheet. I n older children, apply a tourniquet proximal to the vein. In infants, if attempting the ha nd dorsum, apply compression and immobilization by \202 exing the wrist, then grasping wi th the index and middle \201 ngers over the dorsum, whilst the thumb is placed over the c hild \200\231s \201 ngers. Clean site with an alcohol impregnated swab. Insert cannula at an angle of 10 \200\22315 to the skin with the bevel upright, just distal and along the line of the vein. When the stylet tip penetrates into the vein lumen blood will \202 ash back (not always if the vein is small!). Once vein lumen is entered advance 1 \200\2232mm, to ensure the cannula is also in vein, and then advance the cannula over stylet up into the vein. Remove stylet, and collect any blood required from the cannula hub. Flush cannula wi th 0.9% saline to con \201 rm IV placement ( \202 uid should infuse without resistance) a nd to prevent clotting, then connect IV line. Secure cannula with appropriate adhesive tape or dressing leaving the skin over the cannula tip visible so that extravasation can be obs erved. Splint extremity to prevent the cannula kinking. This is a dif \201 cult procedure to master, particularly in the newborn. not be afraid to ask for senior help if unsuccessfu l after 2 or 3 attempts. \200 \200 \200 \200 Do 07_McClure_07.indd 204 11/14/2012 2:31:44 PM PERIPHERAL ARTERIAL BLOOD SAMPLING 205 Peripheral arterial blood sampling Used for determination of blood gasses, acid \200\223bas e status, or when large volumes of blood are required and venous access is dif \201 cult. Equipment \200 \200 As for venepuncture. Heparinized arterial blood syringe, if blood gas analysis intended. Procedure \200 In descending order of appropriateness, the suitable sites are: radial artery, posterior ti bial artery (in newborns), dorsalis pedis artery (newborns) and ulna artery (only if Allen \200\231s test con \201 rms patent adjacent radial artery). If the femoral artery is to be used in the older child, cannulation is preferable before sampling. Brachial artery should rarely, if ever, be used because of its \200\230end arterial \200\231 distribution. Ident ify artery by pulse or \200\230cold \200\231 light. Partially extend limb, (e.g. extend wr ist for radial artery sampling), and with a \201 nger slightly stretch skin over artery t o stabilize its position. Clean overlying skin using an alcohol impregnated swab. Insert ne edle through overlying skin at 15 \200\22330 angle into artery until blood \202 ashes b ack; if after inserting needle there is still no \202 ash back withdraw slowly as often b lood will then appear. Collect blood by aspirating into the syringe. Remove needle and appl y pressure with cotton wool or gauze swab to puncture wound for at least 5min and bleeding has stopped. \200 \200 \200 Peripheral arterial cannulation This procedure is indicated when repeated arterial blood sa mpling or arte- rial pressure monitoring is required. The most common arteries used are tho se described for peripheral arterial blood sampling. Equipment As for IV cannula (see b p.2 04). Procedure \200 Identify selected artery by method described above and follow the procedure described, but use a cannula instead of a needle. When blood \202 ashes back into the hub, advance the c annula smoothly over the stylet and into the artery. Remove the stylet and immediately stop the bleeding by applying pressure over the artery and the tip of the catheter with your \201 nger. Connect a 3-way tap that has been previously \202 ushed with heparinized salin e. Samples can be obtained from the unused ports. Flush the arterial line with heparinized saline (1U/mL) and connect the saline infusion line at 1 \200\2232mL/h (1U heparin/mL). A p ressure transducer may be attached to continuously monitor arterial BP. 07_McClure_07.indd 205 11/14/2012 2:31:44 PM CHAPTER 7 Practical procedures 206 Umbilical arterial catheter An umbilical arterial catheter (UAC) can be used in newborns up to 48hr old for invasive BP monitoring, continuous blood gas monitoring, blood sampling, \202 uid infusion, and/or exchange transfusion. Site To avoid the origins of the coeliac, mesenteric, and renal arteries, the tip of the ca theter should be positioned in the aorta above the diaphragm at the T8 \200\223T10 vertebra l level or in the distal aorta at the L3 \200\223L4 level. Equipment \200 \200 Antiseptic solution, e.g. 0.5% chlorhexidine. Sterile surgical instruments including \201 ne forceps, blunt-ended dilator probe, scalpel, artery forceps, scissors, suture forceps, sutures. Sterile drapes, gown, gauze swabs, and gloves. Umbilical catheters: (cid:2)1500g. Catheters with a terminal electrode can be used for continuous measurement of arterial O2 a nd CO2 concentrations. 3-way taps, IV extension sets, syringes, cord ligature. 5 \200\22310 mL syringes, one containing heparinized saline (1Ut/mL). BP transducer if monitoring is int ended. \200 3.5Fr if birth weight <1500g; 5.0Fr for newborns \200 \200 Procedure \200 \200 \200 Monitor baby closely during procedure, e.g. O 2 saturation monitoring. An assistant should hold the baby \200\231s legs down with the infant supine. Calculate the distance (cm) to in sert the catheter from the the aorta at T8 \200\22310 level using the formula: umbilicus to Insertion distance = 3 \227 weight (kg) + 9 + umbilicus stump length. To control bleeding, tie a cord ligature around the umbilicus stump. Catheter insertion should be performed usi ng strict aseptic technique. Wash hands and put on sterile gloves, gown, +/ \200\223 surgic al mask. Connect a 3-way tap to catheter and prime with heparinized 0.9% saline (do not use heparinized saline if coagulation testing is required). Clean cord and periumbilical area with antiseptic solution. Surround periumbilical area with sterile towels to create sterile \201 eld. Clamp the umbilical cord horizontally with artery forceps 0.5 \200\2231cm abov e umbilical skin. Using the artery forceps as a guide, cut the umbilical cord horizontally and immediately below with the scalpel. Identify the two umbilical arteries and umbilical v ein (see Fig. 7.2). Dilate the end of one of the arteries with \201 ne forceps or a probe until wide enough for the catheter tip to be easily introduced. Gently advance catheter th e calculated distance (see formula). If resistance is met put gentle traction on the umbili cus using artery forceps as this often eases insertion down the spiral umbilical artery. As pirate blood to con \201 rm position and take required samples. Note: arterial blood shoul d pulsate and still bleed if catheter hub is held above infant (unlike blood from the umbil ical vein). \200 \200 \200 \200 \200 \200 07_McClure_07.indd 206 11/14/2012 2:31:44 PM UMBILICAL ARTERIAL CATHETER 207 Secure catheter by \201 xing a zinc oxide \202 ag around the catheter and then suture i t to the stump (see Fig. 7.2). Ligate remaining vessels with a separate purse string suture . Remove cord ligature and check for bleeding. Connect catheter to 3-way tap and IV infusio n set. BP monitoring can be performed by connecting appropriate pressure transducer. Con \201 rm correct placement with a combined CXR/AXR. Catheter should loop initially downwards to the pelvis as it traverses the iliac arteries before ascending up the aorta. Check perf usion of the perineum and lower limbs. If ischaemia occurs, this usually may be corrected b y an IV bolus of 0.9% saline or albumin. If ischaemia remains, remove the catheter immediat ely. Following insertion, the abdomen should remain exposed to allow immediate observation of any hemorrhage, e.g. from accidental removal of catheter. As soon as the catheter is no longer required, it should be removed. Cut the surrounding suture, then slowly withdraw it, taking several minutes to remove the \201 nal few centimeters from the artery. Then appl y pressure or suture to limit any bleeding. Umbilical catheter Zinc oxide tape Suture from tape to skin Vein Umbilical artery p Umbilical stum Fig. 7.2 One method of umbilical catheter \201 xation. 07_McClure_07.indd 207 11/14/2012 2:31:44 PM CHAPTER 7 Practical procedures 208 Umbilical venous catheter A UVC is indicated in newborns up to 5 days of age for: emergency vascu- lar access during resuscitation; vascular access when it is dif \201 cult to obtai n otherwise; prolonged \202 uid or drug infusion; exchange transfusion; central venous pr essure (CVP) measurement. Equipment \200 \200 5 or 6 Fr umbilical venous catheter. Remaining equipment as for umbilical arterial catheter ( b p.206). Procedure \200 Measure distance from umbilicus to mid-sternum (= insertion distance). Catheter insertion s hould be performed using strict aseptic technique. Wash hands and put on sterile gloves, go wn, +/ \200\223 surgical mask. Clean and prepare umbilical stump and create sterile \201 eld as detailed on b p.206. Identify umbilical vein (see Fig. 7.2) and then dilate opening with \201 ne forceps or a dilating probe. Insert catheter the measured distance (see Proc edure, \201 rst bullet point). Aspirate blood to con \201 rm insertion. Blood from the u mbilical vein should not pulsate and, when the catheter hub is held open to the air above t he infant, blood will slowly fall back to the infant. Do not do this for long or an air emb olus will result! If blood will not aspirate or resistance is felt before the catheter is i nserted the measured distance, it is likely that the catheter tip has lodged in the hepatic portal veins or sinus. Withdraw the catheter and then reinsert as far as it will go while still allowing blood aspiration. Flush umbilical catheter with heparinized saline (1Ut/Ml). Secure catheter and ligate unused other umbilical vessels using method described for umbil ical arterial catheter (b p.206). Remove cord ligature and check for bleeding. Con \201 rm correct position by a combined CXR/AXR. UVC should only follow a direct course proximally through the liver (unlike a UAC) Ideally, tip should lie in the inferior vena cava (IVC) ju st above diaphragm. The catheter can then be used for blood sampling, \202 uid or drug ad ministration, or CVP monitoring (the later only if the catheter tip is above the diaphragm) . As soon as the catheter is not needed, remove it slowly and then gently compress umbilica l stump until bleeding stops. In an emergency (e.g. resuscitation at birth) the procedure i s simpli \201 ed. Simply, cut the umbilical cord with a scalpel blade 1 \200\2232cm distal to the umbilical skin and rapidly insert the umbilical catheter until blood can be aspirat ed. Resuscitation drugs and \202 uids can then be given safely. Don \200\231t worry about hemorrhage as cardiac output will be minimal or absent in such an emergency! Besides, any bleeding can be easily controlled by squeezing the base of the umbilicus between the thumb and index \201 nger. Note: Caution is needed as air embolism will occur if an umbilical c atheter is left open to the air for any signi \201 cant time. \200 \200 \200 \200 \200 07_McClure_07.indd 208 11/14/2012 2:31:44 PM CENTRAL VENOUS CATHETERIZATION VIA A PERIPHERAL VEIN 209 Central venous catheterization via a peripheral vein For administration of prolonged or con centrated IV \202 uids or drugs. Sites Suitable sites include the veins of the antecubital fossa, or long saphenous vein ant erior to the medial malleolus or inferior \200\223medial to the knee. Less preferred sites include the axillary or scalp veins. Equipment \200 \200 \200 \200 Sterile surgical instruments including \201 ne forceps and scissors. Sterile gloves, gauz e swabs, gown, and drapes. Antiseptic solution, e.g. 0.5% chlorhexidine. 23 or 27G silastic long line catheter. 27G should only be used when a 23G line cannot be inserted. 2 \200\223 5mL syringe and heparinized (1U/mL) saline solution. Introducer, e.g. 19G butter \202 y ne edle, 20G IV cannula. Sterile adhesive tape and transparent occlusive dressing. \200 \200 Procedure \200 Measure distance from insertion site to just above the right atrium. Placing the catheter t ip in the right atrium risks pericardial tamponade. Catheter insertion should be performed using strict aseptic technique. Wash hands and put on sterile gloves, gown, +/ \200\223 sur gical mask. Set out equipment and prime catheter with sterile heparinized saline. Apply tou rniquet proximal to selected insertion point. Immobilize relevant limb, then clean insertio n site with antiseptic. Place sterile drapes around insertion point to create sterile \201 eld. Insert introducer needle into the vein until blood \202 ashes back. If using a cannula, remove stylet. With \201 ne forceps advance catheter through introducer needle/c annula. Continue to advance catheter into vein until the desired distance is reached. Tip: often the catheter will meet resistance as it becomes wedged against a kinked vein or valve . Milking in a proximal direction with a \201 nger over the catheter tip may facilitate f urther advancement. Remove tourniquet and then \202 ush catheter with heparinized saline. Once fully inserted, withdraw introducer needle/cannula. Remove from line after unscrewing catheter hub. Reconnect hub to catheter. Ensure haemostasis at puncture site by applying g entle pressure with sterile gauze swab. This may take some considerable time! Secure line i n place by using thin strips of sterile adhesive tape and sterile transparent occlusive dre ssing. Start infusion of heparinized saline (1U/mL) to keep line patent. Con \201 rm cathe ter tip placement with CXR. This may be aided by the injection into the line of 0.5mL of co ntrast solution immediately before X-ray. Ideally, the catheter tip should lie just proxima l to the right atrium. Withdraw the catheter before use if it is in the right atrium. \200 \200 \200 \200 \200 \200 \200 \200 \200 07_McClure_07.indd 209 11/14/2012 2:31:44 PM CHAPTER 7 Practical procedures 210 Airway management Before effective ventilation can take place, the airway must be patent. T his can be ensured in various ways, alone or in combination. \200 Head tilt: slightly extended in older children. Chin lift: chin to pull the tongue forward. Jaw thrust: jaw to pull the tongue forward. Guedel oro-pharyngeal airway: \202 ange reac hes the lips. Be careful not to push the tongue back. To determine the correct size, hold t he airway along the line of the jaw with the \202 ange in the middle of the lips. The end of the correctly sized airway should be level with the angle of the jaw. Endotracheal intu bation: Suction: However, if the methods described above are not successful in obtaining an adequate airway, check that the airway is not obstructed by secretions, vomitus, blood, me conium, etc. If there is obstruction on inspection, or it is obvious from the start, suctio n should be performed using an appropriate suction catheter connected to a suction source. Tracheotomy: nasal endotracheal intubation fails or is contraindicated. Perform only if alr eady trained by a senior doctor. The description of this technique is beyond the scope of t his book. tilt the head back gently to a neutral position in newborns, using 1 or 2 \201 ngers apply forward pressure to just under the apply forward pressure behind one or both angles of the slip the airway over the tongue until the \200 see b p.212. not routinely required, especially in newborn resuscitation. bypasses upper airway obstruction and when oral oro- 07_McClure_07.indd 210 11/14/2012 2:31:44 PM MASK VENTILATION 211 Mask ventilation This procedure is useful during resuscitation or for short periods of as- sisted ventilation. It can be performed using a self-in \202 ating bag and face mask with an appropriately-sized reservoir bag; alternatively, use a mask connected to a \200\230T \200\231 piece and a continuous supply of gas, as well as a pressure-limiting device. In th e latter, a breath is given by occluding the open aperture of the \200\230T \200\231 piece . Procedure \200 \200 b p.210). Ensure patent airway (see Select appropriate size mask. It should be big enough to be able to cover the face from the bridge of the nose to below the mouth, but not extend over the e dge of the chin or over the orbits. In infants a round mask, e.g. Laerdal or Bennett \200 \231s mask, is most appropriate. In older children the Laerdal molded mask is more suitab le. Connect face mask to an appropriate self-in \202 ating bag or tubing with a \200\230T \200\231 piece and then to an oxygen or air supply at an adequate \202 ow rate, e.g. 5 \200\2238L/min in the newborn. In newborns, a pressure-limiting valve should used and initi ally be set at 725 \200\22330cmH2O. Apply mask to face over mouth and nose, and apply enoug h downward pressure to make an effective seal. Give in \202 ation breaths by either compre ssing self-in \202 ating bag or occluding open aperture of \200\230T \200\231 piece. Obse rve and ausculate chest wall for adequate in \202 ation. Note whether condition of child i s improving or deteriorating. If in \202 ation is poor or child deteriorating, check airwa y is not obstructed and use one or more techniques described on b p.210 to ensure patent ai rway. Prolonged mask ventilation is likely to lead to a distended stomach. Insert an oro-gastric tube on free drainage to decompress the stomach and pre- vent diaphragmatic splinting. 07_McClure_07.indd 211 11/14/2012 2:31:44 PM CHAPTER 7 Practical procedures 212 Endotracheal intubation Indications This procedure is used as part of advanced resuscitatio n and care. Equipment \200 Appropriately-sized laryngoscope: blade size starts at 0 (7.5cm long) for use in preterm in fants. Use size 1 (10cm) in term infants. In older children use curved blade laryngoscopes (Macintosh). ETT 1000 \200\2233000g; 3.5mm when >3000g. The appropriate size then increases as child size increases up to male adult size of 8 \200\2239mm. Cole (shouldered) ETTs are suitable for oral intubation in newborns. Straight (non-shouldered) tubes can be used for oral or nasal intubation. Appropriately-sized introducer if required. Lubricating jelly if attempting nasal intubation. Magill forceps if attempting nasal intubation. Suction cathete r and tubing connected to suction source. Appropriate ETT connection adaptors, tubing, and O Fixation device and tape. neonatal laryngoscopes are straight; size: 2 \200\2232.5mm (internal diameter) in infant <1000g; 3mm when \200 \200 \200 \200 \200 2 source. Procedure \200 