Clinical Guidance - · PDF fileClinical Guidance . Neonatal Manual Chapter 15: Practical...

Clinical Guidance

Neonatal Manual Chapter 15: Practical procedures

Summary This manual contains clinical guidelines developed by the Neonatal Unit multidisciplinary team over recent years. This chapter contains guidelines on various aspects of medical management, particularly to do with practical procedures, on the Neonatal Unit. It is linked to and should be used in conjunction with the completed neonatal manual details of which are contained in the introductory chapters.

Document Detail Document Type Clinical Guideline Document name Neonatal Manual Chapter 15: Practical procedures Document location GTi Clinical Guidance Database Version 2.0 Effective from February 2012 Review date February 2015 Owner Timothy Watts, Clinical Lead, Neonatal Unit Author Karen Turnock, Consultant Neonatologist Approved by, date Neonatal Clinical Governance Group, February 2012 Superseded documents Neonatal Manual Chapter 15: Practical procedures v1.0 Related documents Neonatal Manual Chapters 1-15; Initial management of the

preterm newborn <30 weeks gestation; Neonatal nursing guidelines

Keywords Neonatal, Neonatology, Neonatal Unit, Newborn, NNU, NICU, SCBU, peripheral line, arterial line, umbilical line, PICC, exchange transfusion, intubation, chest drain, tracheostomy, broncho-alveolar lavage, supra-pubic aspirate, naso-jejunal tube, lumbar puncture, ventricular tap

Relevant external law, regulation, standards

Change History Date Change details, since approval Approved by

Neonatal Manual Chapter 15 – Practical Procedures v2.0 Effective from February 2012 to February 2015 Page 2 of 26

15 Practical Procedure Page

15.1 Insertion of peripheral venous lines 3 15.2 Sampling from arterial lines 4 15.3 Arterial stab (Radial arterial stab) 5 15.4 Insertion and maintenance of peripheral arterial lines 6 15.5 Insertion and maintenance of umbilical arterial lines 7 15.6 Insertion and maintenance of peripheral venous lines 9 15.7 Insertion and maintenance of percutaneous central lines (long

lines) and surgical placed central lines 11

15.8 Best practice for central line insertion 14 15.9 Exchange transfusion 15 15.10 Endotracheal intubation 17 15.11 Insertion and care of chest drains 18 15.12 Tracheostomy care guidelines for the neonatal unit 20 15.13 Non-directional brocho-alveolar lavage (BAL) 22 15.14 Suprapubic aspiration of urine (SPA) 22 15.15 Insertion of naso-jejunal feeding tube 23 15.16 Lumbar puncture 23 15.17 Ventricular tap and removal of cerebrospinal fluid (CSF) from

reservoirs 24

15 PRACTICAL PROCEDURES

These guidelines do not take the place of supervised experience, always ask a more senior

colleague to teach and supervise if you are inexperienced.

Care should be taken when performing practical procedures in neonates:

• Aseptic precautions and awareness of best practice to avoid nosocomial infection are

crucial

• The skin of preterm babies is particularly fragile in the first week of life

• The bones of chronically ill preterm babies may develop rickets and are vulnerable to

fractures 15.1 INSERTION OF PERIPHERAL VENOUS LINES

Cannulation of the peripheral veins provides access for infusion of crystalloid and colloid

solutions, medications and short term access for infusion of total parenteral nutrition (TPN)

where no central access is available.

Equipment needed

• Red tray

• Gloves

• 24G yellow cannula (26G cannula available for very small difficult to cannulate babies)

• 2mL syringe

• Luer-lock extension set or T piece

• Alcohol swabs

• 0.9% sodium chloride

• Steri-strips

• Tegaderm or similar bio-occlusive dressing

• Splint

Procedure

1. Before starting, choose a suitable vein. Avoid using potential “long line sites” initially

such as the antecubital fossa and long saphenous veins. If a scalp vein is to be used,

you may want to remove hair from the area first.

2. Clean procedure: wash hands

3. Clean red tray with Clinell wipes and place all equipment into tray as it is opened.

4. Before starting the procedure – adjust the height of the incubator and ensure you have

adequate lighting.

5. Consider sucrose analgesia and swaddling where appropriate.


6. Wash hands and wear gloves

7. Prepare equipment. Draw up 0.9% sodium chloride to flush and prime extension T-

piece. Clean site with an alcohol swab and leave to dry for approximately 30 seconds.

8. Firmly grip the limb using your fingers as a tourniquet whilst stretching the skin to

stabilise the vein. Cleaning the skin again with the alcohol swab can help make the vein

easier to see. It may be helpful if an assistant holds the limb.

9. With the cannula bevel facing upwards, puncture the skin and vein together at an angle

of approximately 35º. Carefully advance the cannula until blood appears in the hub.

10. Withdraw the needle holding it with your thumb and middle finger, while simultaneously

advancing the cannula into the vein with your forefinger.

11. Attach the T-piece and tighten the luer lock. Flush the cannula through with 0.9%

sodium chloride to check patency.

12. Secure the cannula using steri-strips then cover with Tegaderm. Avoid dressings and

strapping that obscure the entry site of the line as this can make detection of

extravasation difficult. Ensure dressing is not circumferential to the limb.

13. If necessary secure the limb with a splint making sure it is placed correctly, the tapes

are not too tight and joints are well supported.

14. Document site date and time of insertion –use a peripheral vascular access sticker in

the continuation notes.

Remember the rule: Three strikes and you’re out! Ask for help after your third attempt. 15.2 SAMPLING FROM ARTERIAL LINES

Equipment needed:

• Red tray

• Gloves

• 3 syringes, one containing 2mL 0.9% sodium chloride

• Large Clinell wipe (2% chlorhexidine 70% alcohol)

Procedure

1. Clean red tray with Clinell wipes and drop rest of equipment in tray.


adequate lighting.

3. Clean procedure: wash hands and wear gloves; use ‘aseptic non-touch technique’

(ANTT)

4. Clean Bionector hub with Clinell wipe and allow to dry (ANTT)

5. Attach syringe to Bionector and close line to transducer.


6. Slowly withdraw 2mL blood to clear dead space. Keep this.

7. Slowly withdraw sample using 1mL syringe (for blood gas only 0.1mL is sufficient)

8. Slowly re-transfuse previously withdrawn dead space fluid.

9. Flush with 1mL 0.9% sodium chloride, ensuring catheter is clear of blood.

10. Turn 3-way tap to reopen line to transducer.

15.3 ARTERIAL STAB (RADIAL ARTERIAL STAB)

Arterial puncture is usually performed to obtain blood for blood gas analysis or other

haematological investigations when venepuncture or capillary sampling is unsuitable.

Equipment needed

• Red Tray

• 26G needle or butterfly

• Syringe

• Alcohol swab

• Gloves

• Cotton wool

• Capillary tube or relevant blood bottles

Procedure



adequate lighting.


4. Clean procedure: wash hands and wear gloves

5. First locate the radial artery. A cold light to transilluminate the wrist may be useful in

preterm babies.

6. Confirm the presence of collateral circulation by performing an Allen’s test as described

in peripheral arterial line guideline.

7. Extend the wrist. Palpate the artery. Marking the site with a gentle fingernail imprint

may be helpful.

8. Clean the site with the alcohol swab.

9. With the wrist extended slightly, puncture the skin with the needle at an angle of

approximately 30º. The bevel should be facing upwards.

10. Advance the needle until blood appears in the hub.

11. Either gently aspirate the sample with a syringe or drip the blood into the specimen

bottle. Collect the least amount of blood needed.

12. Withdraw the needle and apply firm pressure until bleeding has stopped.


15.4 INSERTION AND MAINTENANCE OF PERIPHERAL ARTERIAL LINES

Cannulation of the peripheral arteries may be necessary for infants receiving intensive care for

invasive blood pressure monitoring and frequent blood sampling when an umbilical line cannot

be placed, there are clinical reasons to avoid using the umbilical vessels, or when it is no

longer possible to access the umbilical vessels.

Equipment needed

• Red tray

• 24G cannula

• 2ml syringe

• Luer lock extension set


• Alcohol swab

• Steri-strips


• Splint

• Gloves

• Cotton wool

Procedure



adequate lighting.



5. Find an artery. A cold light to transilluminate the artery may be useful in preterm babies.

The radial artery (a third in from the radial side of the wrist) is most commonly used.

Alternatively the posterior tibial artery may be used (just behind the medial malleolus).

6. Confirm the presence of collateral circulation in the hand by performing an Allen’s test.

To do this, elevate the arm and simultaneously occlude the radial and ulnar arteries at

the wrist to drain blood from the hand. Release pressure on the ulnar artery. If normal

colour returns to the hand within 10 seconds adequate collateral circulation from the

ulnar artery is present. If normal colour does not return for 15 seconds or more,

collateral circulation is poor and it is best not to use the radial artery in that arm.

7. Hyperextend the wrist. Palpate the artery. Marking the site with a gentle fingernail

imprint may be helpful.

8. Clean site with an alcohol swab and leave to dry for approximately 30 seconds.


9. With the wrist extended slightly, the cannula bevel upwards, insert the needle at an

angle of 20-30º through the anterior wall and into the lumen of the artery until blood is

seen.

10. Advance the cannula while simultaneously withdrawing the needle. Blood should flow

back freely.

11. Attach the syringe with primed T piece and flush the cannula

12. Secure the line as in venous cannulation. Do not attempt to do it single handed.

13. Attach heparinised sodium chloride infusion with pressure transducer. Infusion rate

generally 0.5mL/hr, can run at 1mL/hr in larger babies (see UAC guideline for making

up infusions).

14. Label the line as ‘arterial’.

15. Document insertion of the line on a peripheral vascular access sticker in the notes; in

addition document performance of Allen’s test and comment on perfusion distal to the

site of insertion.

16. Other more central arteries can be cannulated: the axillary and femoral arteries are less

likely to cause problems than the brachial. Always discuss insertion of arterial lines into

vessels other than those around the wrist and ankle with the consultant responsible.

17. For all arterial lines, have a low threshold for removing the line if local circulation

appears compromised. If there is any evidence of ischaemic injury, complete an

incident form.

18. A GTN patch can help maintain circulation if there is evidence of compromise: it needs

to be applied immediately proximal to the point of insertion plus over the compromised

area.

19. If the decision is taken to apply a GTN patch without removing the arterial line,

accepting the risk of ischaemia and loss of digits, this needs to be clearly documented

in the notes along with documentation that this risk has been discussed with the

parents. 15.5 INSERTION AND MAINTENANCE OF UMBILICAL ARTERIAL LINES

Cannulation of the umbilical artery provides secure long-term access for invasive monitoring of

blood pressure, arterial oxygenation, blood sampling and exchange transfusion.

Equipment needed (prepacked UAC/UVC sets are available on NICU)

• Cut down set

• Umbilical catheter size 3.5 or 4 depending on the size of the baby

• Cleaning solutions (0.5% chlorhexidine and sterile 0.9% sodium chloride)


• Umbilical cord tie


• Three way tap

• Sterile gloves

• Gown and mask

• 2mL syringe

• Needle to draw up 0.9% sodium chloride flush

• Suture

• Steri-strips

Procedure

1. Inspect toes and feet for bruising and cyanosis

2. Before starting establish length of insertion using the following formula for a high

position line:

3. (Birth weight in kg x 3 + 9 + stump) = length in cm

4. Observe best practice for central line insertion (see 15.8)

5. Sterile procedure: wash hands with Hibiscrub, wear sterile gown and gloves; wear

mask if baby in open cot, observe strict sterile technique

6. Prepare equipment and prime catheter and 3-way tap with 0.9% saline. Clean stump

and abdomen with chlorhexidine, allow 30 seconds to dry. Avoid using excessive

amounts of chlorhexidine and ensure there is no pooling behind the baby. For

extremely preterm infants (less than 27 weeks) wash off chlorhexidine with 0.9% saline

(assistant holds cord by clamp). Drape with sterile towels, securing with artery forceps if

necessary.

7. Loosely fix cord tie around base of stump (can be tightened if bleeding occurs), cut off

and discard “dirty” end of stump. (A clean cut is essential if the end is to be used for

insertion of catheter.) The catheter can be inserted into either the cut end or the side of

one of the two umbilical arteries. If using the cut end, stabilise the cord with artery

forceps, then proceed to step 9.

8. If using the ‘side on’ method, clamp the cord with artery forceps. Apply traction. Identify

artery. With scalpel, cut half way through leaving posterior wall of artery intact.

Approach the artery at a right angle.

9. The artery can be gently dilated with an umbilical dilator, non-toothed forceps or the

catheter itself.

10. Advance the catheter gently but firmly to desired length. Pulling the catheter towards

the head will help the catheter negotiate the initial caudal curve. If the catheter cannot

easily be advanced catheterisation of the other artery should not be attempted, get

help.

11. Secure the suture to the Wharton’s jelly, tie firmly round the catheter several times and

fix with Steri-strips.


12. Attach heparinised saline infusion with pressure transducer. Infusion rate 0.5mL/hr in

small baby or 1mL/hr in larger babies. Remove the sterile field and cord tie and check

perfusion of the lower limbs.

13. Document the procedure on the Neonatal Unit central vascular device record, including

the size of line, length of insertion, and comment on peripheral perfusion.

14. X-ray chest and abdomen. For high position, catheter tip should be between T6 -T10. If

catheter below T10 withdraw to L3/4 for low position. Do not advance the catheter once

it has been sutured in position due to infection risk. Document the X ray appearances

on the central vascular device record, include details of any adjustment to line position.

15. For all arterial lines, have a low threshold for removing the line if peripheral circulation is

compromised. If there is any evidence of ischaemic injury, complete an incident form.

Arterial line infusions:

Arterial lines are maintained with heparinised solutions, 1 unit of heparin per mL, run at 0.5 or

1.0 mL/hr.

50 mls 0.45% saline with 50 units of heparin is most commonly used to minimise sodium load

in the first few days, older infants can have 50mls 0.9% saline with 50 units of heparin.

The only other solution that can be run through arterial lines is dilute bicarbonate: 1.5mls 8.4%

sodium bicarbonate made up to 20 mls with water for injections, with 20 units of heparin. This

can be used for infants with persistent metabolic acidosis, and the bicarbonate concentration

can be titrated against the pH response.

15.6 INSERTION AND MAINTENANCE OF UMBILICAL VENOUS LINES

Cannulation of the umbilical vein provides secure access for administration of drugs and IV

fluids including TPN. This procedure can be carried out during an emergency resuscitation at

birth but is usually performed at the same time as insertion of the umbilical arterial line.

Equipment needed (pre-packed UAC/UVC sets are available on NICU)

• Cut down set

• Umbilical catheter 4 or 5 depending on size of baby, double lumen for extreme preterm

infants

• Cleaning solutions (0.5% chlorhexidine and sterile 0.9% sodium chloride)

• 0.9% sodium chloride flush

• Needle to aspirate flush

• 2mL syringe

• Umbilical cord tie

• 3-way tap

• Sterile gloves


• Gown and mask

• Suture

• Steri-strips

Procedure

1. Before starting establish length of insertion using the following formula:

(Birth weight in kg x 3 + 9 + stump)/2 + 1 = length in cm


3. Sterile procedure: wash hands with Hibiscrub, wear sterile gown and sterile gloves,

mask if baby in an open cot; observe strict sterile technique

4. Prepare equipment and prime catheter and 3-way tap with 0.9% saline. Clean stump

and abdomen with chlorhexidine, allow 30 seconds to dry. Avoid using excessive

amounts of chlorhexidine and ensure there is no pooling behind the baby. For

extremely preterm infants (less than 27 weeks) wash off chlorhexidine with 0.9% saline

(assistant holds cord by clamp). Drape with sterile towels, securing with artery forceps if

necessary.

5. Loosely tie cord tie around base of stump (can be tightened if bleeding occurs), cut off

and discard “dirty” end of stump. (A clean cut is essential if the end is to be used for

insertion of catheter). The catheter can be inserted into either the cut end or the side of

the umbilical vein. If using the cut end, stabilise the cord with artery forceps, then

proceed to step 87.

6. If using the ‘side on’ method, clamp the cord with artery forceps. Apply traction. Identify

vein. With scalpel, cut half way through leaving posterior wall of vein intact. Approach

the vein at a right angle.

7. The vein can be gently dilated if necessary with an umbilical dilator, non-toothed

forceps or the catheter itself.

8. Advance the catheter gently but firmly to desired length. Pulling the catheter caudally

may help insertion. If you cannot withdraw blood from the line it is probably in the liver.

Withdraw the catheter slightly until blood can be withdrawn.

9. Secure the suture to the Wharton’s jelly, tie round the catheter several times and place

Steri-strips around catheter and suture.

10. Commence infusion of 10% dextrose, remove the sterile field and the cord tie.

11. Document the procedure on a Neonatal Unit central vascular device record, including

size of line, length of insertion, and if it is possible to aspirate blood.

12. X-ray chest and abdomen. The tip of the catheter should be just above the level of the

diaphragm. If the catheter is inadvertently placed in the liver it should be removed and

replaced: it can be helpful to insert a second line over the first before removing it. Do


not attempt to advance the catheter once it has been sutured in position due to infection

risk.

13. Once position has been confirmed, it is safe to infuse concentrated dextrose solutions,

TPN and drugs, including inotropes.

14. Document X ray findings on the central vascular device record, including details of any

adjustments to line position.

15. The site of insertion should be visible at all times and the security of attachment

checked frequently.

NB. Umbilical venous and arterial lines are central lines and should therefore be handled using

aseptic technique (ANTT) at all times.

Relevant anatomical reference points are given in the table below:

Structure Vertebral Level

Ductus arteriosus T4/5

Coeliac axis T12

Superior mesenteric artery T12/L1

Renal artery L1

Inferior mesenteric artery L3

Aortic bifurcation L4/5

15.7 INSERTION AND MAINTENANCE OF PERCUTANEOUS CENTRAL LINES (LONG

LINES) AND SURGICALLY PLACED CENTRAL LINES

Long lines provide long term access for parenteral nutrition and drug infusions. Veins in the

antecubital fossa, the long saphenous at the medial side of the ankle or knee and scalp are

commonly used. Strict aseptic technique is essential. They can be used for several weeks

provided strict aseptic technique is used and the circuit is broken as little as possible.

Equipment needed for long line insertion

• Tape measure

• Sterile forceps

• Long line set:

o Vygon Nutriline Pic Line– 24G 50cm, peelable cannula

o Vygon Epicutaneo 2 - 24G 30cm and 50cm, split cannula

o Vygon Nutriline Twinflo (double lumen) – 24G 30cm, peelable cannula

o Vygon Premicath – 28G (baby <1000g) 20cm: splitting needle or 24G cannula

• Dressing pack

• Cleaning solution (0.5% chlorhexidine)

• 0.9% sodium chloride flush

• 2 10mL syringes


• 2 needles to draw up flush and omnipaque

• Sterile gloves

• Gown and mask

• Sterile drapes

• Steri-strips

• New pack of Duoderm

• Sterile scissors


• 20mL syringe containing 0.9% sodium chloride, giving set and two way octopus

• Omnipaque

Procedure for long line insertion

1. Choose a suitable vein and carefully measure the length of catheter to be inserted. The

line tip should end in the superior vena cava (SVC) or inferior vena cava (IVC), just

adjacent to the right atrium.

2. If the procedure is routine (not in an emergency) agree with the nurse looking after the

baby a suitable time for the procedure to take place.

3. Set up equipment on trolley and identify assistant


5. Sterile procedure: wash hands with Hibiscrub, wear gown and sterile gloves plus a

mask if the baby is in an open cot; observe strict sterile technique.

6. Prepare equipment and prime the line with 0.9% sodium chloride flush from 10mL

syringe.

7. Clean skin and adjacent area with 0.5% chlorhexidine, allow to dry for 30 seconds.

(Assistant holds limb until cleaned). Drape with sterile towels and secure with artery

forceps if necessary.

8. Place the sterile non-toothed forceps, the long line and some spare gauze on the sterile

field.

9. To enter the vein, use the needle provided or, for 28G lines, a yellow 24G cannula can

be used.

10. Apply tourniquet if necessary. Insert the needle or cannula into the vein. A good blood

flow should appear. Release the tourniquet.

11. Using the forceps, advance the long line through the needle/cannula and thread it to the

desired length. Be patient. If threading the catheter is difficult, abducting or gently

massaging the limb may help. It should be possible to aspirate blood from the line: if the

line is ‘wedged’ at a shorter length than that measured, withdraw the line a short

distance until it is possible to aspirate blood.


12. Remove the introducer without dislodging the long line. As bleeding often occurs at this

stage, apply gentle pressure to stem the flow of blood.

13. It is not possible to remove the yellow cannula from the line when used to insert a

Premicath. It needs to be removed from the skin and secured with the line; pad under

the cannula with Duoderm to avoid pressure sores.

14. Curl the excess line without kinking and secure with Steri-strips. Use Duoderm under

the connector to avoid pressure sores.

15. Cover with Tegaderm.

16. Never allow the dressing Tegaderm to wrap all the way around the limb, this can

impede venous return.

17. Commence an infusion of 0.9% sodium chloride at 0.5mL/hr to avoid the line clotting

whilst waiting for X-ray. The infusion pump needs to have been purged before it is

connected and a bolus of 0.5ml should be given once connected to avoid the line

occluding.

18. Draw up 0.5mL Omnipaque into the second 10ml syringe and attach to the second arm

of the octopus. Leave this sidearm clamped off ready for the X ray to be taken.

19. Take down the sterile field.

20. Document the procedure on the Neonatal Unit central vascular device record, including

details of the line used (use the sticker supplied with the long line), length of insertion,

desired length of insertion, and if it possible to aspirate blood.

21. X-ray: contrast medium should be used to pin point the line tip:

o stop the infusion

o inject 0.3-0.5mls of contrast, dependent on size of line

o wait 15 seconds before taking x-ray

o flush well with 0.9% saline afterwards and restart the infusion with a bolus of

0.5mls

22. When the line position is confirmed, it must be withdrawn if it has curled up or is in the

right atrium. Follow dressing change guidance and strict aseptic technique; apply a

second dressing to cover any remaining exposed areas. A further x-ray may be

necessary if the line position has been altered significantly.

23. Always document X-ray findings and any adjustments made to the line on the central

vascular device record: if there is any uncertainty about line position discuss with the

consultant.

Potential complications

Line occlusion: should be preventable by ensuring line is well flushed on insertion; pump is

purged and primed before connecting; bolus of 0.5mL is given as soon as line connected to

pump; and line has at least 0.5mL/hr infusion running at all times; using pulsing action whilst


flushing. Before considering line removal: flush with 0.9% saline sodium chloride using 10mL

syringe ; and redress the line (following dressing change guidance and full aseptic technique)

to ensure it is not kinked.

Withdrawal occlusion: occurs when line flushes, but blood cannot be withdrawn. May be

caused by catheter tip position, fibrin clot.

Infection at insertion site (see ‘Infection’ guidelines)

Infection from line colonisation (see ‘Infection’ guidelines)

Extravasation: may be caused by thrombosis, catheter tip displacement, damage to catheter.

Refer to separate guideline for advice on how to manage.

Catheter rupture: prevention is by never flushing with excessive force, always use 10mL

syringe for flushing

Thrombosis: may cause significant vena cava obstruction; may need anticoagulation

Line complications must always be reported on an incident form.

Surgical central venous lines

When securing lines it is essential that the insertion site is visible through the occlusive

dressing.

Broviac line dressings need to be changed weekly, more often if dirty or oozing from insertion

site.

Broviac lines must be curled around and taped to the skin with steri-strips before applying the

occlusive dressing.

Flush at least once daily with 0.9% sodium chloride 1-2ml if continuous IV infusion not attached

to line.

15.8 BEST PRACTICE FOR CENTRAL LINE INSERTION

Strict aseptic technique is essential and requires an assistant

All involved should be familiar with this best practice guidance

Timing of insertion should be agreed between practitioner and assistant

Personnel

Practitioner:

• For unstable babies, especially <30 weeks gestation, the practitioner needs to be

independently competent in insertion.

• In stable babies a less skilled individual can perform the procedure with direct

supervision by an independently competent practitioner. This level of supervision

should be tailored; the learning practitioner and supervisor need to define time limits

and numbers of attempts.

Assistant:

• Helps provides practical help with equipment, sterile preparation and insertion


• Assists in ensuring the sterile field is maintained, including making practitioner aware of

any breach in sterile technique

• Monitors time and attempts: 1 hour or 3 attempts in one limb during any attempt (unless

emergency procedure)

Process

• Hand decontamination with Hibiscrub NOT simple hand soap.

- Remove jewellery, wash hands and forearms for 15 seconds with soap under

running water

- Clean under nails

- Use Hibiscrub to hands and forearms, rub vigorously for at least 2 minutes ensuring

friction to all areas of hands, fingers and forearms

- Rinse thoroughly keeping hands held higher than elbows and away from scrubs

• Dry hands with sterile towel

• Sterile gown and gloves should always be worn, plus mask when baby is on open cot

• The assistant should hold the limb or cord until the area is cleaned and draped

• Skin preparation

• 0.5% chlorhexidine (aqueous)

• Site of insertion and adjacent skin should be cleaned thoroughly and chlorhexidine

solution left to air dry

• Wash chlorhexidine solution off the skin with sterile 0.9% sodium chloride

• Use sterile drapes to ensure only the sterilised area is accessible to the practitioner:

• Take to care to avoid the drapes touching non-sterile areas.

• Secure drapes to avoid the sterile field becoming compromised.

• If sterile field compromised in any way re-establish before continuing e.g. re-clean the

area, put on new sterile gloves

• Sterile field should be removed as soon as procedure complete. Use new sterile

dressing pack and gloves for any manipulation.

Documentation

Always complete the Neonatal Unit Central Vascular Device Record immediately after

successful insertion and after any manipulation.

All boxes should be completed.

15.9 EXCHANGE TRANSFUSION

Indications


Unconjugated hyperbilirubinaemia (e.g. Rhesus haemolytic disease): intravenous

immunoglobulin may be considered to reduce the likelihood of exchange transfusion in

haemolytic disease of the newborn (see ‘Management of hyperbilirubinaemia’ guidelines)

Severe anaemia complicated by cardiac failure

Sepsis or disseminated intravascular coagulation (DIC) – only rarely indicated

Inborn errors of metabolism

Equipment

• Either a venous line for replacement and a central venous or arterial line for withdrawal

of blood or an umbilical venous catheter for both withdrawal and replacement of blood:

umbilical line positions must be confirmed on X-ray

• Blood giving set with a warming coil

• High flow infusion pump

• 3-way tap or 4-way tap

• Gloves

• Gown and mask

• Several empty syringes

• Container to discard blood.

Preparation

• Contact Blood Bank and request “blood for exchange transfusion” - not packed cells.

Inform them of the volume needed.

• Calculate the total volume for a double volume exchange:

• 2 x 85 x weight (kg) = volume in mL

• If the indication is severe anaemia a single volume exchange is sufficient

• **Order blood early as it can take several hours to be issued**

• The blood is ordered from National Blood Service (NBS) in Tooting. It is ‘partially

packed’ with a haematocrit of 0.50-0.55 and should be O RhD negative, Kell negative,

CMV-negative, leuco-depleted and 5 days old or less. It is not appropriate to use whole

blood as this may have a haematocrit as low as 0.35. It is also very important to inform

Blood Bank of a history of intra-uterine transfusions, as this leads to a risk of associated

graft-versus-host disease in the baby, which persists postnatally. The blood will then

also need to be irradiated (as will all red cell and platelet transfusions).

• NBS have a number of routine transports per day, but if the blood is required outside of

those times, a ‘blue light’ transport should be requested

• As only nursing staff are trained to administer blood transfusions, ensure close nurse

involvement before and during the procedure


Procedure

1. If the indication for exchange transfusion is jaundice, continue maximum phototherapy

and ensure adequate hydration whilst setting up exchange transfusion

2. The exchange should take place over 2 hours (no less) – calculate how frequently the

aliquots of blood need to be removed – blood is withdrawn in 5-20ml aliquots

depending on the size of the baby

3. Check a blood gas, SBR and glucose prior to the exchange and at least once during

the procedure

4. Sterile procedure: wash hands with Hibiscrub, wear sterile gown and gloves (and mask

if baby in an open cot); observe strict sterile technique

5. If using two separate lines, place the 3-way tap in the arterial line or UVC and begin

removing aliquots of blood. Start the transfusion blood at the calculated rate of infusion.

It is important to keep checking with the assistant that the volume of blood going in and

the volume coming out are the same. Slow down the rate of removal and infusion if the

infant is unstable.

6. For a single UVC exchange, a 4-way tap is required. Remove an aliquot of blood,

discard, and then infuse an identical size aliquot of transfusion blood.

7. It is important for an assistant to record the volumes of blood that have gone in and out,

and also to monitor the heart rate, blood pressure and blood glucose as significant

morbidity (apnoea, bradycardia, vasospasm and thrombosis) has been reported in 6%

of exchange transfusions in sick preterm infants

8. Check serum electrolytes, including Ca, glucose, FBC, blood gas and SBR after the

exchange

9. Leave all the catheters in situ – a second exchange is often required

15.10 ENDOTRACHEAL INTUBATION

Equipment

• suitable laryngoscope and blade - check the light source

• appropriate size ET tubes according to baby’s weight

o < 1000g 2.5 mm

o 1000 to 2500g 3.0 mm

o > 2500g 3.5 mm

• Keep a range of tubes available, including a size above and below the estimated size

• introducer

• Neopuff system connected to the air / oxygen source with appropriate face mask

attached

• ventilator set up appropriately


• range of suction catheters and working suction equipment

Procedure

1. Ensure that the baby has secure intravenous access

2. Ensure heart rate, respiration and oxygen saturation are continuously monitored


4. Position the baby with neck slightly extended (i.e. neutral position) and ventilate the

baby with Neopuff and mask until vital signs are stable

5. Unless there are specific contraindications or intubation is being performed as part of

cardiopulmonary resuscitation, administer the pre-medications intravenously in the

following order:

a. Fentanyl 5 micrograms per kg

b. Atropine 20 micrograms per kg

c. Suxamethonium 2mg per kg

6. Continue to ventilate the baby while drugs are being administered ensuring vital signs

are satisfactory

7. Intubate the baby inserting ET tube approximately 1-2cm beyond vocal cords

(depending on size of baby)

8. Attach the Neopuff system to ET tube and ventilate using PIP which produces adequate

chest wall expansion

9. Confirm correct placement by observing chest movement and listening for equal air

entry on both sides of the chest. A rule of thumb for length of ET tube at lips (in cm) =

weight of the baby in kg + 6; but always confirm correct placement by clinical

examination

10. Secure the ET tube and record the length at lips

11. Commence appropriate mechanical ventilation after reconnecting ETT to ventilator

12. Confirm correct placement by CXR

13. Document the procedure in baby’s notes giving details - size of ET tube, length at lips,

any adjustments made after CXR and any problems encountered during the procedure

15.11 INSERTION AND CARE OF CHEST DRAINS

Emergency Needling of Chest for Tension Pneumothorax

Equipment

• Alcowipe and gloves

• Blue/green butterfly with 3 way tap and 10mL syringe attached

• Jar of sterile water

Procedure



2. Clean area with an alcowipe

3. Insert butterfly in to 2nd intercostal space midclavicular line of affected side, moving

needle slightly laterally once through the skin to reduce the likelihood of an open track

once it is removed.

4. Place 3-way tap under water, below level of baby and open, or remove air slowly by

aspirating syringe.

5. Prepare for chest drain insertion.

Chest Drain Insertion

Equipment

• Tape measure

• Cut-down pack

• Gown, mask and gloves

• Cleaning solution (0.5% chlorhexidine )

• Scalpel with straight blade, artery forceps, suture

• Intercostal drain (8-10F for small babies 12-14F for large)

• Underwater seal and suction (5-10cmH2O)

• Steri-strips


• 1% lignocaine, syringe, needle

Procedure

1. Measure insertion length as distance from incision site to mid clavicular line

2. Position baby affected side up 30-45° for pneumothorax (use a towel) or supine for

effusions.

3. Sterile procedure: wash hands with Hibiscrub, wear sterile gown and gloves, mask if

baby is in an open cot; observe strict sterile technique

4. Clean skin with Chlorhexidine, allow at least 30 seconds to air dry.

5. Infiltrate insertion site with 1% lignocaine: maximum 0.3ml/kg of 1% solution

6. Make small incision just above the rib in the 4th or 5th intercostal space mid axillary line

(only large enough to admit drain), making sure you are well clear of the breast bud.

7. Use forceps for blunt dissection down to the pleura

8. Remove trochar from drain and apply forceps to clamp drain

9. Advance drain 2-3cm or premeasured length into the pleural space aiming:

• anteriorly and upwards for pneumothorax

• posteriorly and downwards for effusions


10. Connect drain to underwater seal and apply suction (Heimlich valves are available for

retrievals). Check that the drain is bubbling / swinging.

11. Anchor the drain. Do not use purse string sutures (unsightly scar). Instead, insert suture

through edge of incision, using each end to wrap and tie around the drain. Cover this

with a Steri-strip and apply a dressing over entire drain site.

12. Repeat CXR (AP +/- lateral) to check drain position and lung inflation. Tip should not be

in as deep as the paravertebral gutter.

NB: When repositioning a drain, ensure the side port proximal to the tip remains in the

pleural cavity

Removal of chest drain

1. Leave drain in situ until 24 hours after bubbling has stopped

2. Clamp the drain for 6 hours and then re-x-ray. If there is no reaccumulation then

remove.

3. Use a sterile pack, gloves, Steri-strips, Tegaderm, Zoff

4. Clean the area, gently removing the Tegaderm with a Zoff square

5. Remove the stitch and drain, immediately occluding the incision site (send tip for M,C

and S)

6. Close incision site with Steri-strips, applying Tegaderm over this.

7. Re-X-ray after 2 hours unless clinical deterioration before

Complications of chest drains

• Haemorrhage from vascular bundle in groove below each rib

• Tip can damage pericardium, thoracic duct and phrenic nerve(s)

• Scarring particularly around breast bud

15.12 TRACHEOSTOMY CARE GUIDELINES FOR THE NEONATAL UNIT

Questions regarding tracheostomy care can be directed to Paediatric ENT Nurse Specialists,

bleep 2348

Equipment required for care of babies with tracheostomy

Keep equipment at baby’s cot side

• tracheostomy tubes and introducers x2 of correct size and size below (sizes available -

3.0 NEO, 3.0 PAED, 3.5 NEO, 3.5 PAED)

• tracheal dilators

• airway filters

• scissors

• tracheostomy tape


• 1 mL syringe and a vial of saline for clearance of difficult secretions

• box of appropriate sized catheters

Post-op care

First week

• Check tapes twice daily, observing for swelling of neck, tightness of tapes, security of

tapes. Clean under tapes and loosen if necessary but do not change. Suction as

necessary; see below for procedure for suctioning. Ensure sutures are kept secured to

tape on chest. Do not cut or disturb.

• For emergency recannulation, pull sutures forward and down to open stoma and re-

insert new tracheostomy tube.

• The first routine tracheostomy change is usually done one week post-op under the

supervision of the ENT team. Subsequent tracheostomy tube changes are usually once

weekly (see below)

General tracheostomy care

• Suctioning of the tracheostomy tube should be carried out only as necessary

• For the correct suction catheter size, use tracheostomy size x 2. e.g. 3.5 TT would

require size 7 suction catheter

• Measure the length of the tracheostomy tube and record. Only suction to a depth equal

to the length of the tracheostomy tube

• Use suction pressure of 8-10cmH2O

• Change air filter/humidifier as necessary

• Change tapes daily as a two-person procedure - one person holding the tracheostomy

tube and a second changing the tapes. Observe the neck for redness etc. Ensure new

tapes are tight - i.e. one finger only can be placed under tape.

• Tracheostomy tube changes (after the first – see above) are usually done once weekly.

o this is a two-person procedure

o ensure all equipment needed is available at the baby’s cotside

o ensure infant wrapped in a sheet to swaddle, leaving neck exposed

o place a roll under the shoulders to extend the neck.

o prepare new tracheostomy tube with introducer. Use aqua gel as necessary

o suction prior to tube change.

o remove old tapes

o remove old tube and immediately replace new tube with introducer.

o remove introducer immediately.

o secure with new tapes

o re-attach to ventilator or oxygen supply as necessary


15.13 NON-DIRECTIONAL BRONCHO-ALVEOLAR LAVAGE (BAL)

Indication:

Persistent atelectasis on CXR despite routine suction and positioning.

Equipment

• Nasogastric (NG) tube - appropriate size for endotracheal tube length

• Syringes (5 & 10ml)

• 0.9% Sodium chloride - 1 ml/kg

• Sterile gloves

• Universal specimen container

Technique:

1. This should only be performed in the presence of a paediatric physiotherapist or a

senior doctor.

2. Carefully monitor heart rate and oxygen saturation throughout the procedure.

3. Very clean procedure: wash hands and wear sterile gloves

4. Clear large airway secretions by pre-oxygenation (via ventilator or Neopuff) and

suction.

5. Pre-oxygenate with FiO2 1.0, using ventilator or Neopuff, avoiding prolonged hyperoxia

if <32 weeks gestation.

6. Fill syringe with calculated amount of normal saline and prime appropriate size NG tube

(see above).

7. Using sterile gloves attach syringe of normal saline to NG tube.

8. Disconnect patient from ventilator and advance the NG tube until resistance is felt (the

tube is now in the wedged position).

9. Instil the saline slowly to limit the amount of reflux up the airway and immediately

aspirate the saline back up using the syringe, withdraw the NG tube and reconnect the

patient to the ventilator.

10. Place the contents of the syringe into the specimen pot labelled BAL and send for

analysis.

11. The patient may need further suctioning to remove any saline left after the BAL.

12. Return the FiO2 to its original level as tolerated.

15.14 SUPRAPUBIC ASPIRATION OF URINE (SPA)

This is a definitive method of diagnosing or excluding UTI

1. Check with ultrasound that urinary bladder is full (about 1 hour after a feed) to avoid a

dry tap



3. Keep a container ready for clean catch if baby passes urine during the procedure

4. Ask an assistant to hold the baby steady

5. Very clean procedure: wash hands and wear sterile gloves

6. Use 2 or 5mL syringe with size 23G (blue) needle

7. Puncture the skin in mid abdominal line 0.5-1cm above the pubic symphysis

8. Push the needle down slowly with continuous suction with the syringe

9. Keep needle vertical. N.B. Urinary bladder is an abdominal organ as opposed to pelvic

in older children and adults

10. Take as large a urine sample as possible

11. Do stick urinanalysis (record results in notes / chart) and send sample for M, C & S

12. Keep the sample in the fridge while awaiting transport

15.15 INSERTION OF NASO-JEJUNAL FEEDING TUBE

If naso-jejunal feeds are indicated, the NJ tube should be passed as follows:

1. With infant supine, measure from the nasal bridge to the ankle. (This is the length of the

tube to be inserted. Nasal bridge to umbilicus shows the length of the tube to reach the

stomach). Mark these positions.

2. Lie the baby on the right side and advance the tube to the first marked position so that

the tube is in the stomach.

3. Inject 2ml of sterile water through the tube then advance it. Peristaltic activity should

carry the tube through the pylorus. When the marker reaches the nostril the tube should

be in the jejunum. The tube should be secured to the cheek. Insert orogastric tube and

then check position of both tubes with an x-ray.

4. Once NJ feeding has been started, if milk is aspirated from the orogastric tube it

indicates that the NJ tube has slipped back into the stomach. Fluid can rarely be

aspirated from the NJ tube.

15.16 LUMBAR PUNCTURE

Indications

To screen for central nervous system infection

To drain cerebrospinal fluid (CSF) in communicating hydrocephalus

To screen for inborn errors of metabolism

Contraindications

Cardiorespiratory instability when the procedure may cause added compromise

Bleeding diathesis – coagulopathy should be corrected before doing LP


Skin infection over lower back

Very high intra-cranial pressure (non-communicating) – although coning is very rare in

neonates

Equipment

• Dressing pack, sterile gown and sterile gloves

• 0.5% chlorhexidine and sterile saline

• spinal needle: 25G (0.5mm) for preterm, 22G (0.7mm) for term

• 3 sterile containers and one glucose bottle

• adhesive plaster or permeable spray dressing

Procedure

1. Sterile procedure: wash hands with Hibiscrub, wear sterile gown and gloves; observe

strict sterile technique

2. Ask an assistant to hold the baby in a lateral decubitus position

3. Identify the correct interspace i.e. L3-L4 – the space that falls immediately above or

below a line drawn between the iliac crests

4. Clean the lumbar area with chlorhexidine, allow at least 30 seconds to air dry. and

wash it off with saline

5. Drape with sterile towels

6. Ask the assistant to curl the baby up so that the interspinous spaces open up, keeping

the spine horizontal and the shoulders and iliac crests in a vertical line

7. Insert the needle perpendicular to the skin in the midline and point it towards the

umbilicus

8. Advance the needle carefully – usually about 1cm in a term baby and 5-7mm in a

preterm baby

9. You may feel it “give” as the needle enters the subarachnoid space

10. Remove the stylet and collect the CSF – usually 5-10 drops in each bottle

11. If no CSF is obtained, try one interspace above or below L3-L4

12. Remove the needle and apply an adhesive plaster or spray

13. Document the procedure in the notes

15.17 VENTRICULAR TAP AND REMOVAL OF CEREBROSPINAL FLUID (CSF) FROM

RESERVOIRS

Indications

To screen for CSF infection in babies with a reservoir

Removal of CSF in non-communicating hydrocephalus (see separate protocol)


Equipment

• as for lumbar puncture

• electronic transducer for pressure measurement, 3-way tap and t-piece primed with

0.9% saline.

• for reservoir tap, 21G (green) butterfly and syringe

Procedure

Ventricular tap

1. Perform cranial u/s scan to determine size of ventricles – do tap on side worse affected

by ventricular dilatation or parenchymal damage if present. In symmetrical cases tap

right side (usually the non-dominant side)

2. Sterile procedure: wash hands with Hibiscrub, wear sterile gown and gloves; observe

strict sterile technique

3. Position the baby on his/her back, facing up to the ceiling

4. Place yourself at the head of the baby ie facing towards his/her toes. An assistant must

hold the head absolutely still. Sedate if necessary

5. Prepare a sterile area over the lateral aspect of the anterior fontanelle on the chosen

side (shave any hair). Clean the area with chlorhexidine, allow at least 30 seconds to

air dry and wash it off with saline.

6. Insert the spinal needle approximately 1cm lateral to the midline, level with the widest

point of the fontanelle, perpendicular to the scalp

7. Advance the needle until you are in the ventricle (usually feel a “give”). Usually this is 4-

5cm in term babies. Withdraw the trochar to establish CSF flow. In most cases this is

easy as the underlying pathology is massive ventriculomegaly related to obstruction of

CSF flow.

8. If the first attempt is unsuccessful, reinsert the trochar and advance the needle by 1cm

more.

9. If the first attempt is unsuccessful, reinsert the trochar and advance the needle by 1cm

more.

10. Connect the needle to one port of the 3-way tap and the t-piece to another port. The

other end of the t-piece is then connected to the pressure transducer. Allow CSF to flow

to end of t-piece and and then depress blue switch at end distal to patient. Zero the

transducer while it is held level with the baby’s right atrium and then read pressure on

monitor. The baby should be completely still and settled whilst measuring the pressure

and the head should not be held. The 3rd port of the 3-way tap is opened to allow CSF

to drip out as below.

11. Collect samples for investigation by dripping 5-10 drops of CSF into each bottle – 3 for

microscopy and culture, 1 for protein and 1 for glucose


12. Always measure the CSF pressure (upper limit of normal 6mmHg � 8cmH20) and then

remove 10-15ml/kg CSF if raised, preferably letting it drip, but slow aspiration is

permissible if ventricles huge. Recheck CSF pressure after removal of CSF.

13. Skin dressing as for LP

Removal of CSF from a reservoir

The reservoir has a metal base plate therefore there is no risk of inserting the needle too far

1. Sterile procedure: wash hands with Hibiscrub, wear sterile gown and gloves

2. Clean the area overlying the reservoir as described before

3. Stabilise the reservoir with one hand

4. Insert the butterfly needle into the middle of the reservoir – initially it feels a bit stiff and

then it “gives” as the tip of the needle enters the cavity of the reservoir

5. Draw off the desired amount of CSF, as above.


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