The document provides information about an advanced neonatal procedures seminar. It discusses various neonatal procedures like endotracheal intubation, mechanical ventilation, imaging modalities, and complications of intubation. It also covers rapid sequence intubation and different types of mechanical ventilators used for neonates including indications, advantages, and disadvantages.
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
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
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.
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.
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.
30.
31.
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)
35.
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.
39.
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).
41.
42.
43.
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.
46.
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
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
50.
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.
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
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
114.
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.
