Procedural Skills Workshop Megan Arnold PA-C Jenilea Thomas CP/NP AC/PC Faith Kinnear PNP-AC Fatima Westry PA-C Nicole Riccioni MSN, MPH, RN, CPNP-PC Baylor College of Medicine Texas Childrens Hospital Pediatric Critical Care Pediatrics Course Objectives
Provide education on procedural skills required in an ICU setting Review high risk scenarios and work through possible complications while performing procedural skills Provide a method to increase competency and performance in procedural skills Pediatrics Page 2 xxx00.#####.ppt 1/30/20 01:03:36 PM Disclosures We have no disclosures Pediatrics
Page 3 xxx00.#####.ppt 1/30/20 01:03:36 PM Procedures Arterial Line Placement Central Venous Line Placement PICC Line Placement Lumbar Puncture Pediatrics Page 4 xxx00.#####.ppt 1/30/20 01:03:36 PM Arterial Line Placement
Indications Blood samples for oxygenation and ventilation Frequent blood draws Continuous blood pressure monitoring Contraindications No collateral flow Infection Trauma/injury to the site Pediatrics Page 5 xxx00.#####.ppt 1/30/20 01:03:36 PM
Arterial Line Placement Complications Arterial spasms Thrombus Emboli Bleeding Hematoma Infection Necrosis Pediatrics Page 6 xxx00.#####.ppt 1/30/20 01:03:36 PM
Arterial Line Placement Preparation Equipment Positioning Confirmation of successful placement Pediatrics Page 7 xxx00.#####.ppt 1/30/20 01:03:36 PM Equipment: Armboard
Tape Towel (towel roll) Antiseptic PPE Arterial line kit T-connector Suturing kit Tegaderm Pediatrics Page 8 xxx00.#####.ppt 1/30/20 01:03:36 PM Positioning:
Secure wrist to arm board Dorsiflex 45-60 degrees Slightly abduct thumb Brings radial artery to the skin surface, and parallel to the long surface of the forearm to facilitate insertion Puncture skin with needle at about 30 degree angle Pediatrics Page 9 xxx00.#####.ppt 1/30/20 01:03:36 PM Confirmation of successful placement
Transduce to assess waveform Blood gas Pediatrics Page 10 xxx00.#####.ppt 1/30/20 01:03:36 PM Central Line Placement Indications No peripheral access Medications/fluid administration Emergencies CVP monitoring Nutrition
Frequent blood draws Contraindications Coagulopathy Thrombus Infection Distorted anatomy Pediatrics Page 11 xxx00.#####.ppt 1/30/20 01:03:36 PM Central Line Placement Complications
Infection Thrombus Arterial puncture Bladder puncture Bleeding Air embolism Arrthymia Pediatrics Page 12 xxx00.#####.ppt 1/30/20 01:03:36 PM Central Line Placement
Preparation Equipment Positioning Confirmation of successful placement Pediatrics Page 13 xxx00.#####.ppt 1/30/20 01:03:36 PM Equipment: PPE and sterile drapes/towels Ultrasound machine Suture kit
Central line dressing Heparin flushes CVL Kit Sizes: 6 months or less: 4-5 french >1 year to pre-teen: 5 french Teen and greater: 7 french Pediatrics Page 14 xxx00.#####.ppt 1/30/20 01:03:36 PM Positioning: Place towel under selected leg/buttock area
Externally rotate hip (frog leg position) Refer to picture on next slide. NERVE< ARTERY
KUB Blood gas Pediatrics Page 17 xxx00.#####.ppt 1/30/20 01:03:36 PM PICC Placement PICC Peripherally Inserted Central Catheter Silicone or polyurethane Inserted into a large vein in the peripheral circulation and threaded into central
circulation Catheter tip placed in the superior vena cava in upper extremity lines or inferior vena cava in lower extremity lines Pediatrics Page 18 xxx00.#####.ppt 1/30/20 01:03:36 PM PICC Placement Benefits Extended dwell time Parenteral nutrition
Chemical irritants, vesicants, pH > 8, pH < 6 Stable access for continuous infusions Blood draws Preserves peripheral venous system Decreased pain/stress associated with IV restarts Inserted with light to no sedation Pediatrics Page 19 xxx00.#####.ppt 1/30/20 01:03:36 PM
PICC Placement Complications/Risks Catheter damage/breakage/leaking Occlusion Thrombus, fibrin sheath Malposition Infection Catheter-related venous thrombosis Dysrhythmias Embolization of catheter fragment Pediatrics
Page 20 xxx00.#####.ppt 1/30/20 01:03:36 PM PICC Placement Equipment Ultrasound with sterile sleeve and jelly PPE (sterile gown, gloves); Sterile drape and towels Lidocaine Antiseptic skin prep (Chloraprep, Betadine) PICC placement kit (needle, peel-away dilator, PICC, wire) Use smallest French size possible to avoid damage to the vessel Sterile saline and heparin for flushing Suturing kit versus adhesive securement device Cavilon no sting barrier film StatSeal versus BioPatch
Sterile dressing Pediatrics Page 21 xxx00.#####.ppt 1/30/20 01:03:36 PM PICC Placement Positioning Upper extremity: Supine, abduct arm 90 degrees from trunk; turn head toward insertion site to prevent catheter from traveling cephalad through IJ Lower extremity: Externally rotate hips (frog leg position) with towel under selected leg/buttocks Under direct ultrasound guidance, cannulate the vein, holding
the needle at a 45 degree angle Pediatrics Page 22 xxx00.#####.ppt 1/30/20 01:03:36 PM PICC Placement Measurement Upper extremity: From planned insertion site, along venous pathway, to suprasternal notch, to third right intercostal space Lower extremity: From planned insertion site, along venous pathway to xiphoid process Confirmation of successful placement
Upper extremity: Chest x-ray Lower extremity: KUB Pediatrics Page 23 xxx00.#####.ppt 1/30/20 01:03:36 PM Lumbar Puncture Indications CSF cell count with diff, gram stain, culture for infection CSF glucose and protein CSF antibodies CSF cytospin for abnormal cells CSF pressure
Intrathecal medication administration Contraindications Hydrocephalus Unstable airway or hemodynamics Unstable spine Trauma/injury to the site Skin infection overlying puncture site Pediatrics Page 24 xxx00.#####.ppt 1/30/20 01:03:36 PM Lumbar Puncture Complications
Headache Pain at site Bleeding/Hematoma Spinal leak Infection Herniation Unable to obtain fluid Prevent/treat side effects: Lay flat for 30-60 minutes Hydrate Caffeine Blood patch Oral analgesics
Pediatrics Page 25 xxx00.#####.ppt 1/30/20 01:03:36 PM Lumbar Puncture Preparation Equipment Physical Exam POSITIONING Pediatrics Page 26 xxx00.#####.ppt 1/30/20 01:03:36 PM
Lumbar Puncture Equipment LP tray (sterile tubes, needle, lidocaine, cleanser, drapes, gauze, bandaid) Infant/toddler needle: 1.5 Child to teen: 2.5 Obese pt, adult 3.5-6 Sterile gloves HOLDER Pediatrics Page 27 xxx00.#####.ppt 1/30/20 01:03:36 PM
Lumbar Puncture Positioning Lateral or sitting position Ensure hips, shoulders in alignment to keep spine straight, knees should be in alignment with each other C-Shape Pediatrics Page 28 xxx00.#####.ppt 1/30/20 01:03:36 PM Lumbar Puncture Positioning Adults Pediatrics
Page 29 xxx00.#####.ppt 1/30/20 01:03:36 PM Lumbar Puncture Procedure Obtain consent/apply EMLA or topical anesthetic Wash hands, open tray, sterile gown, glove, hat and mask if required by institution When resistance gives (POP) remove stylet and check for CSF Obtain opening pressure first, CSF sample, medication to be injected Cleanse the site
Reinsert stylet Drape the site Apply gentle pressure to skin and remove needle Feel for iliac crest and spinal process in line with that Hold pressure with gauze Inject lidocaine near insertion site Apply bandaid Insert needle bevel toward the head, midline in spine
Return pt to supine position Document your procedure Pediatrics Page 30 xxx00.#####.ppt 1/30/20 01:03:43 PM Confirmation of successful placement Clear CSF with flow Pediatrics Page 31
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