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 Children’s Hospital Pediatric Critical Care

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

Disclosures We have no disclosures

Procedures Arterial Line Placement Central Venous Line Placement PICC Line Placement Lumbar Puncture

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

Arterial Line Placement Complications Arterial spasms Thrombus Emboli Bleeding Hematoma Infection Necrosis

Arterial Line Placement Preparation Equipment Positioning Confirmation of successful placement

Equipment: Armboard Tape Towel (towel roll) Antiseptic PPE Arterial line kit T-connector Suturing kit Tegaderm

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

Confirmation of successful placement Transduce to assess waveform Blood gas

Central Line Placement Indications No peripheral access Medications/fluid administration Emergencies CVP monitoring Nutrition Frequent blood draws Contraindications Coagulopathy Thrombus Infection Distorted anatomy

Central Line Placement Complications Infection Thrombus Arterial puncture Bladder puncture Bleeding Air embolism Arrthymia

Central Line Placement Preparation Equipment Positioning Confirmation of successful placement

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

Positioning: Place towel under selected leg/buttock area Externally rotate hip (frog leg position) Refer to picture on next slide. NERVE< ARTERY<VEIN Under ultra sound guidance direct needle toward umbilicus at 45 degree angle

Confirmation of placement: KUB Blood gas

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

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

PICC Placement Complications/Risks Catheter damage/breakage/leaking Occlusion Thrombus, fibrin sheath Malposition Infection Catheter-related venous thrombosis Dysrhythmias Embolization of catheter fragment

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

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

PICC Placement Measurement Confirmation of successful placement 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

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

Prevent/treat side effects: 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

Lumbar Puncture Preparation Equipment Physical Exam POSITIONING

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

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

Lumbar Puncture Positioning Adults

Lumbar Puncture Procedure Obtain consent/apply EMLA or topical anesthetic Wash hands, open tray, sterile gown, glove, hat and mask if required by institution Cleanse the site Drape the site Feel for iliac crest and spinal process in line with that Inject lidocaine near insertion site Insert needle bevel toward the head, midline in spine When resistance gives (“POP”) remove stylet and check for CSF Obtain opening pressure first, CSF sample, medication to be injected Reinsert stylet Apply gentle pressure to skin and remove needle Hold pressure with gauze Apply bandaid Return pt to supine position Document your procedure

Confirmation of successful placement Clear CSF with flow