CHAPTER 25: Procedures

INDICATIONS

• Apnea, respiratory depression, hypoxia, cardiac, respiratory or neurologic failure

EQUIPMENT

• Appropriate mask size: An appropriate mask completely covers the patient’s nose and mouth without mask edges hanging off the face or covering eyes

• Bag: Self-inflating or anesthesia (flow-inflating) bag

TECHNIQUE

• Position patient’s head by either chin lift (stable cervical spine) or jaw thrust (unstable cervical spine) to maximize upper airway diameter

• Place mask over patient’s mouth and nose and hold tight against face using C-E hold (see Figure 25-1). The thumb and 2nd finger form a “C” shape over the mask while the 3rd, 4th, and 5th fingers of the same hand form an “E” over the mandible, effectively pulling the patient’s jaw up to meet the mask. Be careful not to compress the soft tissues below the mandible

• Squeeze bag to push air into patient’s lungs

  • ✓ Self-inflating bag: Simple to use, pop-off valve limits amount of pressure delivered, no air reaches patient unless bag is squeezed, delivers room air unless attached to an oxygen reservoir

  • ✓ Anesthesia bag: Requires experienced operator, requires oxygen reservoir, can deliver blow-by oxygen, continuous positive-airway pressure (CPAP), or assisted breaths

• Goal rate of delivered breaths: 8–10 breaths per minute

  • ✓ Unsecure airway during one-person CPR: 2 breaths for every 30 compressions

  • ✓ Unsecure airway during two-person CPR: 2 breaths for every 15 compressions

  • ✓ Secure airway during CPR: 8–10 breaths per minute

• Chest wall rise indicates adequate delivery

• Listen for air leak around mask as each breath is delivered. If an air leak is heard, it can be due to hand position, wrong mask size, or fatigue. Try the following—reposition C-E hold, use two hands for C-E hold with a second provider squeezing the bag, or switch providers

INDICATIONS

• Upper airway obstruction in a patient with spontaneous respirations

• Used to stent tongue away from posterior pharynx

• Can be used in conscious patients

• Do not use in patients with severe head or facial injuries, or concern for basilar skull fracture

EQUIPMENT

• Appropriate sized NP airway: To estimate appropriate NP airway length, measure the distance from nare to tragus

• Lubrication jelly

TECHNIQUE

• Apply lubrication jelly to insertion end of NP airway

• Insert NP airway into patient’s nare with gentle posterior pressure until the flange rests upon the nare edge

• The NP airway should glide in easily. If resistance is encountered, check NP airway size, lubrication, or patency of nasal passage

INDICATIONS

• Upper airway obstruction in an unconscious patient with spontaneous respirations

• Upper airway obstruction in an unconscious patient receiving bag-assisted ventilations

• Used to stent tongue and pharyngeal soft tissues away from posterior pharynx

• Do not use in a conscious patient as it may stimulate the gag reflex, emesis, and aspiration

EQUIPMENT

• Appropriate sized oral airway: To estimate appropriate oral airway length, measure the distance from the corner of the mouth to angle of the mandible

• Wooden tongue depressor

TECHNIQUE

• Using tongue depressor, push tongue away from palate

• Insert the oral airway along the curve of the tongue so that the innermost edge of the oral airway rests just posterior to the tongue

• The flange of the oral airway should rest on the patient’s lips

• Be careful not to push tongue back and cause further upper airway obstruction

INDICATIONS

• Airway protection; existing or impending cardiac, respiratory or neurologic failure

EQUIPMENT

Mnemonic: “MSOAP”

• M-Meds: Intubation adjuncts, sedatives, paralytics, resuscitation meds, anticonvulsants

  • ✓ See inside back cover for rapid sequence intubation medications

• M-Monitors: Cardiorespiratory (CR) monitor, pulse-oximeter, blood pressure (BP), end-tidal CO₂ detector

• S-Suction: Yankauer (rigid catheter), flexible soft catheter

• O-Oxygen: Tank or “wall” supply, delivery tubing

• A-Airway Equipment: Endotracheal tubes, stylets, laryngoscope blades, masks, self-inflating bag or anesthesia bag, NP airway, oral airway, laryngeal mask airway, tape, benzoin, syringe for cuff inflation

• P-Personnel

Choosing an Endotracheal Tube

• Beyond the newborn period, cuffed tubes may be safely used

• Formula for uncuffed ETT diameter:

  $[Age(years)/4]+4$

• Formula for cuffed ETT diameter:

Calculate uncuffed tube size and subtract 0.5

Choosing a Laryngoscope Blade

• Straight (Miller) and curved (Macintosh) blades are available. Chose blade based on comfort level of laryngoscopist and size of child

• Some age-related suggestions:

  • ✓ Preemie: Miller 0

  • ✓ Zero–3 months: Miller 1

  • ✓ Three months–3 years: Miller 1, Miller 2, Wis-Hipple 1.5

  • ✓ Three–12 years: Miller 2, Macintosh 2

  • ✓ Older than 12 years: Miller 3, Macintosh 3

TECHNIQUE

• Check all equipment and monitors. Preoxygenate with 100% O₂. Administer selected pharmacologic agents (see inside cover)

• Adjust height of bed to accommodate the person performing the intubation

• Position patient’s head by either chin lift (stable cervical spine) or jaw thrust (unstable cervical spine) to maximize upper airway diameter. Depending on the age of the child, a towel roll under the head or shoulders may help to achieve the “sniffing” position

• If using stylet, tip should not extend beyond end of ETT

• Consider having an assistant apply gentle cricoid pressure (Sellick maneuver)

• Open mouth using scissor-finger technique with right hand (thumb on mandibular dental ridge, index or middle finger on maxillary dental ridge)

• Holding the laryngoscope in the left hand, insert blade on the right side of the patient’s mouth, and sweep tongue toward the midline. Gently but firmly pull up along the axis of the handle of the laryngoscope maintaining a straight wrist. Do not rock back or lever the laryngoscope on the teeth

• Suction and reposition as needed until the glottic opening (characteristic inverted V of vocal cords) is visualized

• While maintaining visualized glottis, introduce ETT with right hand from the right side of mouth and pass tip of tube through the vocal cords

• Depth of insertion: Internal diameter of the ETT × 3 (length to corner of mouth), or double lines on tube just past vocal cords

• Confirmation of proper placement: Presence of end-tidal CO₂, mist in ETT tube, bilateral chest rise, and equal breath sounds

• Temporarily secure ETT to patient with benzoin and tape. Obtain chest x-ray to confirm placement (ideal tip placement is between clavicles and carina). Definitively secure ETT by splitting tape lengthwise; secure one arm to upper lip and wrap second arm around ETT. Repeat with second piece of tape

INDICATIONS

• Airway protection; cardiac, respiratory, or neurologic failure; difficulty passing endotracheal tube

• Excellent rescue device since fairly easy to use for a variety of providers

• Can serve as a bridge to a more definitive airway

EQUIPMENT

• Appropriate sized LMA: Depends on the patient’s weight and the LMA manufacturer. Each LMA will be labeled with a weight range in kilograms that is acceptable for use. Also displayed will be the quantity of air in milliliters that is required to fill the LMA cuff

• Lubrication jelly

• Equipment as listed in MSOAP pneumonic under “Endotracheal Intubation”: Medications, monitors, suction, oxygen, airway equipment, personnel

• See inside back cover for rapid sequence intubation medications

• If LMA is being placed due to failed intubation, consider calling for additional airway personnel

TECHNIQUE

• Stand at the head of the bed as if performing intubation

• Check all equipment and monitors. Preoxygenate with 100% O₂. Administer selected pharmacologic agents

• Apply lubrication jelly to insertion end of LMA

• Position patient’s head by either chin lift (stable cervical spine) or jaw thrust (unstable cervical spine) to maximize upper airway diameter

• With nondominant hand, grasp the patient’s mandible and open the mouth

• With the dominant hand, hold the LMA as shown (see Figure 25-2) and insert LMA into mouth, skimming along the curve of the tongue into the pharynx until resistance is met

• Once resistance is met, inflate LMA cuff with appropriate amount of air

• In younger patients, consider the rotational approach where the LMA is first inserted with the opening facing the palate and then rotated 180° into position when resistance is felt

• Begin ventilating patient. Ensure appropriate LMA placement by checking for presence of end-tidal CO₂, bilateral chest rise, and equal breath sounds

INDICATIONS

• Immediate vascular access for cardiopulmonary arrest or shock; intravenous access difficult or not possible in critically ill patient

• May be used to administer fluids, blood products, medications

• Aspirated blood can be sent for diagnostic studies. Values such as WBC count, potassium, calcium, transaminases, and blood oxygen level are less reliable

EQUIPMENT

• Gloves, gauze; antiseptic solution (povidone-iodine or chloraprep); 1% lidocaine; syringe; 22- or 25-gauge needles; saline flush in 10-cc syringe; intraosseous (IO) needle

• If using the battery-powered driver: Device driver, appropriate IO needle, stabilizer dressing, extension tubing, 2% lidocaine

• If no IO needle is available, a bone marrow aspiration needle with trocar or 20-gauge spinal needle can be used

PLACEMENT SITES

1. Proximal tibia: Tibial plateau (anterior, medial flat surface of tibia), 1–2 cm below the tibial tuberosity. This is the preferred site

2. Distal femur: Midline on femoral plateau (lower third of femur), approximately 1–2 cm above the superior border of the patella. Alternative site for infants and young children

3. Distal tibia: 1–2 cm above the medial malleolus. Easier to use in children older than 3 years of age

4. Proximal humerus: Typically requires battery-powered driver device; greater tubercle of humerus appropriate in the older, skeletally mature child. To access the greater tubercle safely, place patient’s arm on their abdomen with elbow flexed. The greater tubercle prominence is about 1 cm above the surgical neck of the humerus or 2 cm below the acromion process

MANUAL INSERTION TECHNIQUE

• In awake patients, inject 1% lidocaine into skin and periosteum

• Prepare skin with antiseptic solution

• Stabilize extremity with nondominant hand (Keep hand away from opposite side of insertion site to avoid injury!). Identify landmarks for insertion, most commonly at the tibial plateau

• Hold IO needle with hub resting in the palm; stabilize needle with thumb and index finger placed 1–2 cm from the tip

• Insert needle perpendicular to the bony cortex or slightly angled (10–15 degrees) away from the growth plate. Use steady back and forth rotational motion while gradually increasing pressure until a sudden decrease in resistance is felt. Immediately release pressure to prevent piercing opposite end of bone

• Unscrew the needle cap and remove the trocar. If the needle is secure in the bone, it should stand without support

• Confirm intramedullary placement with aspiration of blood or bone marrow and/or easy infusion of fluids without extravasation

  • ✓ Flush the needle with 10 mL of normal saline and connect it to conventional IV tubing

• Secure needle with a dressing. Avoid bulky dressings that may make infiltration difficult to detect

BATTERY-POWERED DRIVER TECHNIQUE

• Battery-powered IO needle and driver sets have become more widely available in prehospital and hospital settings (EZ-IO^®, VidaCare Corporation)

• Needles come in three sizes:

  • ✓ Small (15 mm) = Pink for patients 3–39 kg

  • ✓ Medium (25 mm) = Blue for patient ≥40 kg

  • ✓ Large (45 mm) = Yellow for patients ≥40 kg with excessive subcutaneous tissues, often needle of choice for humerus site

• Identify appropriate location for insertion and anatomic landmarks. Cleanse insertion site

• Choose the appropriate needle based on the patient’s weight and amount of subcutaneous tissue

Note: Weights are rules of thumb; important thing is that one black line is still visible after the needle is through the skin. Due to amount of subcutaneous tissue, pink needle often only helpful in very young patients, blue needle used most widely. If in doubt, go with the longer needle to ensure that the marrow is penetrated!

• Place the needle into the battery-powered driver and remove the safety cap

• Position driver with the needle perpendicular to the bone surface and insert needle until you feel bone. Ensure that at least 5 mm of the needle is visible as indicated by the black line (if not, use a longer needle or alternative site)

• Press trigger to activate the driver applying gentle downward pressure. Release the trigger when you feel a sudden decrease in resistance

• Hold the catheter in place and remove the driver by pulling up. Remove the stylet from the catheter by rotating counterclockwise and safely dispose of the stylet

• Secure the site with the stabilizer dressing

• Connect primed connector and draw labs if necessary

• Flush the catheter quickly with 10 mL of NS (to displace marrow and provide room for infusion)

Note: In an awake or responsive patient, consider infusing 2% lidocaine without epinephrine into IO prior to this step—infusion into the marrow is quite painful

INDICATION

• Restore integrity and function of injured tissues while minimizing scar formation and infection

EQUIPMENT

1. Basics: Light, mask, sterile gloves, povidone-iodine solution

2. Irrigation: 20- to 60-mL syringes, sterile saline, splash guard

3. Suture tray: Needle holder, nontraumatic tissue forceps, tissue scissors, hemostats, sterile gauze, sterile drapes

4. Suture material:

   • ✓ Nonabsorbable: Monofilament nylon (Ethilon), polypropylene (Prolene)

   • ✓ Absorbable: Vicryl, fast-absorbing gut, chromic gut

     • ■ Nonabsorbable sutures have high tensile strength and are typically used on extremities

     • ■ Fast absorbing sutures (vicryl rapide, fast-absorbing gut) are frequently used for pediatric facial lacerations

     • ■ Chromic gut is useful for intra-oral laceration closure as well as for fingertip/nailbed lacerations

5. Size: Face: 6-0 or 5-0; scalp, trunk, extremities: 4–0; sole of foot, over large joints: 4–0 or 3–0

GENERAL TECHNIQUE

1. Local Anesthesia:

   • ✓ “LET” gel: Contains lidocaine, epinephrine, and tetracaine. Apply for 15–20 minutes up to three times or until skin blanches. Avoid areas where vasoconstriction is contraindicated

   • ✓ 1% Lidocaine (10 mg/mL): Infiltrative anesthetic; maximum dose: 4 mg/kg; onset: 2–5 minutes; duration: 30–120 minutes

   • ✓ 1% Lidocaine with epinephrine (1:200,000): Infiltrative anesthetic, reduces bleeding; maximum dose: 7 mg/kg; onset: 2–5 minutes; duration: 60–180 minutes; contraindicated in digits, penis, pinna, tip of nose

   • ✓ Sodium bicarbonate: Buffers local anesthetic to improve potency and reduce pain. Mix 1 part NaHCO₃ to 9 parts lidocaine or lidocaine with epinephrine

2. Wound Preparation:

   • ✓ Exploration: Provide hemostasis; explore for foreign body

   • ✓ Débridement: Remove devitalized or heavily contaminated tissue

   • ✓ Hair: May clip. Alternatively, use petroleum jelly to keep unwanted scalp hair away from wound. Do not shave eyebrows

   • ✓ Irrigation: Irrigate with normal saline using 20- to 60-mL syringe and splash-guard. Use 100–200 mL for average 2-cm laceration. Clean wound periphery using povidone-iodine solution

3. Apply Suture Using Needle Holder:

   • ✓ For better control, hold loaded needle holder near the tip. Do NOT keep fingers in rings of the needle holder while sewing

   • ✓ Enter skin with needle perpendicular to surface. Retrieve needle after each pass with needle holder or forceps

   • ✓ Place just enough sutures so that there are no gaps in the wound

4. Instrument Tie: Tighten knot so that skin edges just come together, making sure that wound edges are everted to minimize scar formation (Figure 25-3). Repeat single loop tie, in an over and under manner, for a total of four throws. Cut both ends of suture allowing adequate length (at least 1 cm) to retrieve suture at time of removal

5. Suture Removal: Neck: 3–4 days; face: 5 days, scalp: 7–10 days; upper extremities, trunk: 7 days; lower extremities: 8–10 days; joint surface: 10–14 days

SUTURE TECHNIQUES

1. Simple Interrupted Sutures: Most common suture used for uncomplicated wounds. Enter skin with needle directed downward or angled slightly away from wound edge (see Figure 25-3)

2. Inverted (“Buried”) Subcutaneous Sutures: Used to counteract tension on wound. Insert needle from within wound at fat–dermal junction (Figure 25-4)

3. Vertical Mattress Sutures: Combines a deep and superficial stitch into one suture (Figure 25-5). Used in wounds of high tension or where difficult to tie an inverted subcutaneous suture

4. Horizontal Mattress Sutures: Reinforces subcutaneous tissue and relieves tension from wound edges. Useful as deep layer in relatively shallow lacerations and in areas with minimal subcutaneous tissue (Figure 25-6)

5. Half-buried or Corner Suture: Useful in flap closure. Enter skin below and just lateral to the point of V-shaped flap (Figure 25-7)

6. Simple (Continuous) Running Suture: Limited to linear, clean, low tension wounds. Saves time but breakage unravels entire stitch (Figure 25-8)

ALTERNATIVES TO SUTURES

Tape (“Steri-Strips”)

• Indications: Linear lacerations under minimal tension; useful for reinforcing or refining other repairs; not useful for wounds requiring meticulous approximation or for moist or hairy areas

• Technique: Clean and dry skin surrounding laceration. Apply adhesive (benzoin) to surrounding skin, and wait 90 seconds for it to become “tacky.” Place tape strips perpendicularly across wound leaving some space for oozing. Place extra tape strips across ends of previous strips and parallel to wound

Staples

• Best for scalp wounds. Requires staple remover

• Technique: Prepare wound in same manner as for sutures. Have assistant evert wound edges with tissue forceps or finger pressure. Line up arrow on stapler with center of wound. Place staples by applying steady firm pressure to stapling device. Place staples about 0.5 cm apart

Tissue Adhesives (“Dermabond”)

• Best for linear wounds with minimal tension

• Allows rapid, painless closure of wounds. No removal needed

• Do not use in hairy areas, in the mouth, or near the eyes of young children. Do not use on wounds at high risk for infection

• Technique: Irrigate wound in same manner as for suture repair. Position patient so that adhesive cannot leak into adjacent structures (particularly important for wounds near the eye). The wound must be completely dry. An assistant should hold the wound edges together with forceps or gloved fingers. Activate tissue adhesive applicator (vials often require crushing to start polymerization process and to soak the foam applicator tip). Apply adhesive along surface of wound creating a thin film. Allow this to dry for a few seconds before applying 2–3 subsequent layers in concentric ovals around the wound (avoid applying adhesive to inside of wound). Hold wound until dry

• In the event that the tissue adhesive needs to be removed, apply petroleum jelly or antibiotic ointment for about 30 minutes

• Wears off in 5–10 days

POST-LACERATION REPAIR MANAGEMENT

• In general, cover the wound for the first 24 hours and apply topical antibiotic ointment to wounds. In wounds closed with tissue adhesive, however, no cover is necessary and antibiotic ointments should be avoided

• Antibiotics—Not indicated for majority of lacerations. Antibiotics may be indicated for “high-risk wounds.” Consider first-generation cephalosporin (e.g., cephalexin). Consider erythromycin if penicillin/cephalosporin allergic. Consider amoxicillin/clavulanic acid for mammalian bites

• High-Risk Wounds: Highly contaminated wound, wound with foreign body, bite wounds, crush injury, intraoral laceration, wound of hands, feet, or perineum, open fracture, exposed joints and tendons, immunocompromised patient, exposed cartilage, delayed repair, tetanus-prone wounds (Table 25-1)

INDICATIONS

• Suspicion of CNS infection, suspicion of subarachnoid hemorrhage, measurement of opening pressure, diagnosis and/or treatment of idiopathic intracranial hypertension (pseudotumor cerebri), diagnosis of CNS metastases, suspicion of Guillain–Barré

CONTRAINDICATIONS

• Increased intracranial pressure (unless likely due to idiopathic intracranial hypertension)

• Relative contraindications: Bleeding disorder, cardiopulmonary instability, spinal anomaly

EQUIPMENT

• Sterile gloves, mask, antiseptic solution (povidone iodine or chlorhexidine), lumbar puncture (LP) tray, CR monitor and pulse-oximeter, topical anesthetic cream (EMLA, LMX4). Resuscitation equipment should also be available

• Lumbar puncture tray: Typically includes sterile drapes, sterile gauze, lidocaine 1%, 3-cc syringe for lidocaine injection, gauze, adhesive bandage strip, collecting tubes, manometer; +/− spinal needle

• Needle size: Usually 22 gauge; infants: 1.5 inch; 1–12 years: 2.5 inch; >12 years/obese patient: 3.5 inch

TECHNIQUE

1. Preparing and positioning the patient:

   • ✓ Apply topical anesthetic cream to puncture site 30+ minutes prior to procedure

   • ✓ Begin monitoring, consider sedation in uncooperative older child

   • ✓ Two positions commonly used:

     • ■ Lateral recumbent: Assistant holds infant in fetal position. In an older child, assistant holds patient in knee-chest position. A firm hold is essential to success. In infants, avoid forcefully flexing the neck, which may lead to respiratory compromise

     • ■ Sitting position: Patient seated with feet over side of bed with neck/upper body flexed forward over pillow on lap or leaning on bedside tray (does not provide accurate measurement of opening pressure)

   • ✓ Locate the puncture site by palpating the superior aspect of the posterior superior iliac crests. A line between the two crests will intersect approximately at top of L4 at midline. The L3–L4 and L4–L5 interspaces are both suitable LP sites

   • ✓ Prepare the area with antiseptic solution starting at the intended puncture site and swabbing in enlarging circles. Apply sterile drapes, if possible leaving landmarks visible. Anesthetize the interspace with lidocaine 1%. Studies have shown that local anesthetics decrease pain and increase the success rate of LPs

2. Inserting the needle: Ensure the shoulders and hips are perpendicular to the bed. Slowly insert the bevel-up, styletted needle, aiming slightly cephalad, toward the umbilicus. Infants may require a more acute angle of approach. After the needle moves through the epidermal and fat layers, some clinicians remove the stylet before advancing further. Moving beyond the ligamentum flavum/dura into the cerebrospinal fluid (CSF) space, a loss of resistance may be appreciated (“pop”). If the stylet has not been removed, and the “pop” is not appreciated, the physician must remove the stylet every few millimeters to observe for CSF flow

3. Use of manometer: Obtained in the lateral recumbent position. The manometer should be attached to the needle immediately after CSF flow is seen. The opening pressure is the highest recorded level the CSF reaches in the column. Normal opening pressure is approximately 5–20 cm H₂O. The reading will be falsely high in a struggling patient

4. Collection and completion:

   • ✓ Collect approximately 1 cc fluid in each tube. Replace stylet and remove needle. Clean site and apply strip bandage or sterile dressing

   • ✓ Send tubes to lab as follows: Tube 1, Gram stain/culture; tube 2, protein/glucose; tube 3, cell counts; tube 4, any additional studies. If there is concern for subarachnoid hemorrhage, send tube 1 and tube 4 for cell count

INDICATION

• Tension pneumothorax (which may present with deviated trachea, diminished or asymmetric breath sounds, diminished chest wall expansion, or sudden cardiopulmonary decompensation)

EQUIPMENT

• 16- or 18-gauge angiocatheter; 5- to 10-mL syringe; three-way stopcock; antiseptic solution; lidocaine (1%)

TECHNIQUE

• Do not delay if tension pneumothorax suspected

• Place patient in supine position and elevate head of bed to 30 degrees

• Swab area with antiseptic solution

• Provide local anesthesia with 1% lidocaine if time permits

• Using a 16- or 18-gauge angiocatheter attached to a syringe, insert needle perpendicular to the midclavicular line on the upper edge of the third rib. Gently pull back on the syringe as the needle is advanced into second intercostal space. A loss of resistance in the syringe indicates evacuation of air

• Advance the catheter over the needle into the pleural space, and remove the needle. Attach a one-way drainage device to the catheter or intermittently draw back on a syringe connected to the catheter with a three-way stopcock

• Obtain immediate chest radiograph, and consider tube thoracostomy

INDICATIONS

• Frequent arterial or venous blood gases, continuous monitoring of arterial or central venous blood pressures, emergency vascular access, prolonged need for administration of fluids and medications, exchange transfusion

EQUIPMENT

• Umbilical artery catheter (UAC), umbilical vein catheter (UVC), three-way stopcock, radiant warmer, cardiac monitor, pulse oximetry, supplemental oxygen source, antiseptic solution (povidone-iodine), soft restraints, sterile towels, fenestrated drape, sterile gauze, scalpel: no. 11 or 15, forceps: curved, non-toothed (Iris forceps or vessel dilator), forceps: straight, Crile, hemostats: at least four pairs, scissors, suture: 3.0 or 4.0 silk on curved needle, umbilical tape (approximately 15 inches), 3-mL syringes filled with sterile saline (with heparin 0.5–1 U/mL), sterile gown and gloves, mask, hat

• UAC Sizing: Generally 3.5F

• UVC Sizing: Infants <1 kg: 3.5F; infants >1 kg: 5F

PREPARATION

• Determine appropriate equation for insertion depth

• Identify appropriate size catheter to be used

• Gently restrain infant in supine, frog-legged position. Keep infant warm with overhead warmers, and place on cardiac monitor/pulse oximetry with supplemental oxygen available

• Perform hand hygiene and don hat, mask, sterile gown, and sterile gloves

• Prepare umbilical lines by connecting a three-way stopcock and 3-mL syringe filled with sterile heparinized saline to each catheter lumen. Flush each lumen with sterile saline and ensure no air bubbles are present. Turn stopcock so that it is “off to baby”

TECHNIQUE

• Using sterile technique, wash lower 5 cm of umbilical cord and skin surrounding umbilicus with antiseptic solution. Drape with sterile towels

• Loosely tie umbilical tape at base of cord to prevent bleeding. Cut cord with scalpel to length of 1–2 cm above the skin surface. Place fenestrated drape (if available) over cut umbilicus, covering patient completely

• Stabilize cord with forceps or hemostats: Grasp one edge of cord with curved hemostat or grasp opposite sides with two hemostats and evert edges

• Identify the vessels: One central, cephalad, larger lumen, thin-walled vein; two smaller lumen, thick-walled arteries

• Hold catheter 1 cm from tip with toothless forceps and insert into vessel lumen with gentle pressure. Blood return signifies proper insertion

  • ✓ Catheterization of the umbilical vein does not require dilation. Insert the umbilical venous catheter to predetermined depth, check for blood return and flush the venous line. Turn stopcock handle toward infant to stop flow

  • ✓ Catheterization of the umbilical arteries requires gentle dilation with forceps. Dilate arterial lumen using curved, non-toothed, Iris forceps until the arterial opening is large enough to accommodate the umbilical catheter. It is very easy to cause a false track in the Wharton’s jelly if this step is skipped. Insert the umbilical arterial catheter to predetermined depth, check for blood return, and flush the arterial line. Turn stopcock handle toward infant to stop flow

• Secure line placement with 3.0 silk suture through Wharton’s jelly of umbilical cord. Wrap suture around the catheter 2–3 times and tie. Repeat wrap and tie a second time. Do not suture line to skin

• Maintaining the sterile field, confirm proper placement with radiograph of chest and abdomen. Once the sterile field is broken, do not advance the catheter. It may be withdrawn

• Secure catheters to skin with tape bridge or tegaderm per unit policy

• To remove catheter: Place umbilical tape loosely around stump to control bleeding. Remove catheter gradually over 3–4 minutes, allowing vessels to segmentally constrict and/or clot to form

POSITIONING AND INSERTION LENGTH

• Guidelines vary by institution

“High” Umbilical Artery Catheter

• Catheter tip placed just above diaphragm at spinal level T6–T9

• Measure shoulder-to-umbilical length, if less than 13 cm, insert catheter that distance plus 1 cm; if greater than 13 cm, insert catheter that distance plus 2 cm

• Alternatively, UAC length (cm) = [3 × birth weight (kg)] + 9

“Low” Umbilical Artery Catheter

• Catheter tip positioned below diaphragm, just above aortic bifurcation at spinal level L3–L5

• UAC length (cm) = birth weight (kg) + 7 or alternatively, 2/3 the shoulder-to-umbilicus length (cm) distance + length of remaining umbilical cord

Umbilical Vein Catheter

• Normally, catheter tip is placed above diaphragm at the junction of the inferior vena cava and right atrium

• In emergent situations, catheter is passed cephalad for 2–3 cm (preterm) or 4–5 cm (term) until blood return obtained (below portal circulation)

• To estimate normal UVC length: Length (cm) = 2/3 the shoulder-to-umbilicus length (cm) or alternatively (1.5 × birthweight) + 5.5

Risks of procedure:

• Bleeding

• Pericardial effusion/tamponade

• Air embolus

• Vessel perforation

• Arrhythmia

• Thrombosis