1. 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

2. 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

3. Disclosures
We have no disclosures

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

5. 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

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

7. Arterial Line Placement
Preparation
Equipment
Positioning
Confirmation of successful placement

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

9. 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

10. Confirmation of successful placement
Transduce to assess waveform
Blood gas

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

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

13. Central Line Placement
Preparation
Equipment
Positioning
Confirmation of successful placement

14. 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

15. 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

17. Confirmation of placement:
KUB
Blood gas

18. 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

19. 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

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

21. 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

22. 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

23. 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

24. 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

25. 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 minutes
Hydrate
Caffeine
Blood patch
Oral analgesics

26. Lumbar Puncture
Preparation
Equipment
Physical Exam
POSITIONING

27. 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

28. 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

29. Lumbar Puncture Positioning
Adults

30. 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

31. Confirmation of successful placement
Clear CSF with flow