W24 Pediatric Intensive Care Procedures
Michele Moss, Brian K. Eble, Gulnur Com
Intubation: Before Procedure
Indications
•
Lower respiratory failure:
•
Inability to ventilate/exchange P
CO2•
Relief increased work of breathing
•
Need for aggressive pulmonary toilet
•
Hemodynamic instability
Contraindications
•
In emergent situations, there is no contraindication for endotracheal intubation.
•
Relative contraindications:
•
Abnormal anatomy; may require an alternative approach to airway management such as cricothyrotomy with retrograde intubation, bronchoscopic intubation
•
Profuse upper airway or lower airway bleeding
•
Increased intracranial pressure (ICP): requires rapid-sequence intubation
•
Cervical or suspected cervical spine injury: requires immobilization of the head and neck
Equipment
•
Monitoring equipment: pulse oximeter, electrocardiogram (ECG), blood pressure
•
Oxygen source: delivered by mask prior to intubation
•
Bag for manual ventilation
•
Anesthesia type bag: expands when connected to gas flow; various designs available but must have adequate flow through system to prevent rebreathing
•
Self-inflating bag: designs vary; many have pressure pop-off at 35 to 45 cm H
2O, so if lungs are severely noncompliant, may not adequately ventilate or oxygenate with this bag or may need to bypass the pop-off
•
Laryngoscope:
•
Check before use for adequate battery and bulb function.
•
Small handle and larger handle are available.
•
Bronchoscopic and video laryngoscopes are available.
•
Endotracheal tubes (ETTs):
•
Appropriate estimated size tube: (Age + 16)/4 = Endotracheal tube size
•
Adjust for extremes in patient size or known abnormality of tracheal size.
•
Tubes are cuffed and noncuffed:
•
Cuffed tubes are universally recommended above age 8 years.
•
Under age 8 years, most recent recommendations are that cuffed tubes may be used. In the past, cuffed tubes were thought to be unnecessary because of the narrow trachea at the level of the cricoid cartilage and potentially risky because of risk of airway injury. Currently the cuffs are high-volume, low-pressure cuffs that require lower pressure to be effective, therefore decreasing the risk of airway injury. For patients with noncompliant lungs requiring higher airway pressures, the presence of a cuff decreases the air leak, allowing for better lung inflation and recruitment.
•
Stylets: available in pediatric and adult sizes; may be needed to help strengthen the pliable ETT to assist in intubation; skill and experience of operator will dictate its usefulness.
•
Suction devices: must be sturdy enough to suction very thick secretions in even the smallest infant
•
End-tidal CO
2 detector: disposable colorimetric CO
2 detectors are available in pediatric and adult sizes; the weight of the patient will determine the size of the device.
•
Means for securing the ETT: either tape or an appropriately sized securement device
•
Airway support devices: these may be useful depending on the stability of the airway:
•
Oral airways: come in various sizes; poorly tolerated in a conscious patient; may be needed for airway maintenance prior to intubation
•
Nasopharyngeal airways: come in various sizes and can relieve nasal and pharyngeal obstruction in conscious patients, including children. The appropriate-sized airway extends from the nares to the tragus of the ear. The diameter should be large enough that it does not cause obstruction and not so large that it causes blanching of the alae nasi, which can lead to necrosis.
•
Laryngeal mask airway: can provide immediate airway access and should be available during even nonemergent intubation in the event the airway is difficult to intubate. They come in a variety of sizes appropriate for pediatric patients. The LMA consists of a wide-bore tube with a standard 15-mm adapter at the proximal end for attachment to the circuit or resuscitation bag. The distal end is an elliptical mask that can be inflated and conforms to the shape of the larynx, providing a low-pressure seal for ventilation at the level of the larynx (see
Procedure).
Anatomy
The pediatric airway changes with age and development and differs from the adult airway in many aspects. Understanding these differences and being aware of the age-related changes are important for optimal airway management. The larynx in children is located higher in the neck, with the epiglottis being at the level of C1 as a neonate and at the level of C3-C4 by 6 months of age, as opposed to the adult, where the larynx is around C5. This more superior position of the larynx creates more acute angulation during laryngoscopy and can make visualization of the glottic opening more difficult. Also, the tongue is located more superiorly and closer to the palate in children than in adults and is larger in relation to the bony structures of the cranium, potentially causing airway obstruction. The narrowest portion of a child’s airway is the subglottic region, whereas the narrowest portion of an adult airway is the vocal cords. This difference has allowed for uncuffed tracheal tubes to be used in infants and young children. Another major difference is that children have a more protuberant occiput, which may cause excessive neck flexion. Finally, the infant’s nares are smaller. Because infants are obligate nasal breathers for the first 6 months of life, occlusion of the nasal passages with secretions, edema, or blood can cause significant resistance to airflow and significantly increase the work of breathing.
Procedure
•
Secure equipment and test functionality:
•
Test patency of intravenous (IV) access.
•
Check bag and mask for adequate oxygen flow.
•
Check suction device for adequate suction.
•
Check laryngoscope handle and blade for presence of bright light.
•
For cuffed ETT, check cuff for ability to hold air.
•
Place stylet in ETT if desired.
•
Have ETT one size larger and smaller available.
•
Preoxygenate patient; if possible allow the patient to breathe spontaneously on F
IO2 1.0 or as much as can be delivered in order to maximally increase the patient’s Pa
O2 prior to intubation attempt.
•
Administer pharmacologic agents:
•
Anticholinergic may be delivered first.
•
Sedatives are given next, observing closely for changes in respiration and hemodynamics; may need to have airway and breathing supported just with sedative administration.
•
Neuromuscular blockade is delivered last and only after determining the airway can be managed with bag and mask; if not, the neuromuscular blocker should not be given and intubation attempted with the patient breathing spontaneously.
•
Open the mouth using the thumb and finger in scissor-like fashion between teeth.
•
Insert the laryngoscope:
•
Hold the laryngoscope in the left hand.
•
Place it in the right side of the mouth.
•
Sweep the tongue and laryngoscope toward the left.
•
Place the tip of the laryngoscope in the vallecula or onto the epiglottis itself.
•
Visualize the larynx by lifting the mandible with the laryngoscope blade toward the ceiling at a 45- to 60-degree angle to the child’s chest. Avoid “cranking” the laryngoscope back as if on a fulcrum, because this can cause injury to the lips and teeth.
•
Visualize the cords, and then place the ETT in the right corner of the mouth beside the laryngoscope blade and advance the tube through the vocal cords. Avoid passing the tube down the laryngoscope itself, as that blocks the view of the larynx and straightens the tube, making it difficult to pass through the vocal cords.
•
The tube should be advanced with the vocal cord mark just past the vocal cords to avoid right mainstem intubation.
After Procedure
Postprocedure Care
•
Immediately ensure the correct position of the ETT:
•
Place the end-tidal CO
2 detector, noting appropriate color change depending on the brand of detector. Color change should occur within six breaths unless the patient is in cardiac arrest or impending arrest.
•
Observe equal bilateral chest excursion with bag ventilation.
•
Observe maintenance of appropriate oxygen saturation.
•
Auscultate bilateral breath sounds.
•
If a cuffed ETT is used, inflate the cuff with the least amount of volume necessary to prevent a leak around the ETT; overinflation of the cuff may lead to injury of the tracheal mucosa and cartilage.
•
Secure the ETT using tape or a securement device.
•
Confirm ETT position with chest radiograph.
•
Suction the ETT post procedure; secretions can obstruct the tube.
Complications
•
Esophageal intubation: quickly determined by lack of CO
2 detection, lack of chest wall movement, and lack of breath sounds
•
Malposition of the ETT most commonly into the right mainstem bronchus; common in small infants owing to the short length of their trachea; detected by asymmetric chest rise and asymmetric breath sounds. If necessary, confirm position radiographically.
•
Wrong size ETT, most commonly a too-small uncuffed tube, allowing for excessive air leak and inability to ventilate and oxygenate the patient; requires reintubation with proper tube size
•
Undiagnosed difficult airway resulting in loss of airway during procedure or inability to place ETT; must be managed immediately either with laryngeal mask airway (LMA) or if necessary, cricothyroidotomy; may need fiberoptic bronchoscopy to visualize airway or may need creation of surgical airway
•
Hemodynamic instability during procedure due to cardiovascular depressant effects of sedatives, hypoxemia during the procedure, or the patient’s underlying disease process. May need intravascular volume expansion or even chemical resuscitation if severe enough.
•
Aspiration during intubation due to full stomach at time of intubation; risk is decreased if patient is placed nil per os (NPO) for at least 6 hours prior to intubation; however, aspiration is always a risk. Aspiration in patients known not to be NPO but who need urgent or emergent intubation is decreased with emptying the stomach with a large-bore nasogastric (NG) tube and with cricoid pressure maneuver during intubation.
•
Patients with increased intraocular pressure may have worsening of the pressure, even resulting in extrusion of the vitreous, so rapid-sequence intubation as with increased ICP is recommended.
•
Oral injuries are possible:
•
Tooth injury or loss; check for loose teeth prior to intubation if time allows.
•
Lacerations, bruising to lips and oropharynx
•
Damage to tonsils, including avulsion
•
Damage to vocal cords and laryngeal nerve, resulting in paralytic cord(s)
•
Cervical spinal cord injury in patient with unstable cervical spine; risk is decreased when head and neck are immobilized at time of intubation.
Outcomes and Evidence
•
Successful intubation in the pediatric patient depends on the length of training, level of supervision, ongoing experience of the practitioner, and the use of rapid-sequence intubation.
•
Cuffed ETTs are as safe as uncuffed ETTs in the pediatric patient in a prospective data collection study in a pediatric intensive care unit (PICU).
•
Patients with multiple trauma and possible cervical spinal cord injuries who were intubated emergently had no further neurologic loss following intubation, according to a retrospective study of 237 injured patients; 21 patients (8.9%) had cervical cord or bone injury; 213 patients were orally intubated.
Suggested Reading
Levy RJ, Helfaer MA. Pediatric airway issues. Crit Care Clin 2000;16:489-504.
Thompson A. Pediatric airway management. In: Fuhrman BP, Zimmerman JJ, editors. Pediatric Critical Care. St. Louis: Mosby-Year Book; 2006.p. 485.
Shirm S. Manual maneuvers for opening the airway. In: Diekmann RA, Fiser DA, Selbst SM, editors. Illustrated Textbook of Pediatric Emergency and Critical Care Procedures. St Louis: Mosby-Year Book; 1997. p. 98-9.
American Heart Association Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) of Pediatric and Neonatal Patients. Advanced Life Support. Pediatrics 2005;117:e1005.
Garey DM, Ward R, Rich W, Heldt G, Leone T, Finer NF. Tidal volume threshold for colorimetric carbon dioxide detectors available for use in neonates. Pediatrics 2008;121:e1524.
Newth CJ, Rachman B, Patel N, Hammer J. The use of cuffed versus uncuffed endotracheal tubes in pediatric intensive care. J Pediatr 2004;144:333-7.
Park C, Bahk JH, Ahn WS, Do SH, Lee KH. The laryngeal mask airway in infants and children. Can J Anaesth 2001;48:413-7.
Patel MG, Swadia VN, Bansal G. Prospective randomized comparative study of use of PLMA and ET tube for airway management in children under general anesthesia. Indian J Anaesth 2010;54(2):109-15.
Rhee KJ, Green W, Holcroft JW, et al. Oral intubation in the multiply injured patient: the risk of exacerbating spinal cord damage. Ann Emerg Med 1990;19:511.
Intraosseous Infusion: Before Procedure
Contraindications
•
Previous unsuccessful attempt at that site
•
Infected or burned areas; relative contraindication
•
Vascular compromise to the extremity
Anatomy
The preferable site for insertion is the anterior tibia, 1 to 2 cm below the tibial tuberosity on the medial aspect of the tibia. Other sites include the distal femur, medial malleolus, and anterior superior iliac spine. These sites are useful in pediatric patients from preterm neonates to adolescents. A sternal access system is now available for adult-sized patients.
Procedure
•
Prepare site using sterile technique.
•
Needle entry technique:
•
Standard:
•
Advance needle until sudden decrease in resistance is felt, indicating bone marrow has been entered.
•
Powered insertion:
•
Place needle into powered injection gun.
•
Place needle in appropriate location on patient.
•
Attach connector tubing, and begin infusion.
After Procedure
Postprocedure Care
•
Careful stabilization of the intraosseous needle
•
Close observation for evidence of extravasation
Complications
•
Common:
•
Extravasation of fluid:
•
Due to posterior penetration of the cortex
•
Due to incomplete penetration of the cortex
•
Through a nutrient vessel foramen
Outcomes and Evidence
•
Intraosseous infusion
•
Easily and rapidly performed in emergency situations in both the prehospital and hospital environments
•
Effective in delivering fluids, blood, and medications in emergency situations
•
Safe, but attention to presence of infiltration or misplacement of the needle is important in preventing complications.
•
Randomized control trial comparing standard bone marrow needle placement versus powered injector technique showed no significant difference with respect to success rate of placement, adverse events, and time to successful placement. Both techniques were successful about 80% of the time.
Suggested Reading
Fiser DH. Intraosseous infusions. N Engl J Med 1990;32:1579-81.
Glaeser PW, Hellmich TR, Szewezuga D, Losek JD, Smith DS. Five-year experience in prehospital intraosseous infusions in children and adults. Ann Emerg Med 1993:22:1119-24.
Horton MA, Beamer C. Powered intraosseous insertion provides safe and effective vascular access for pediatric emergency patients. Pediatr Emerg Care 2008 Jun;24(6):347-50.
Hartholt KA, van Lieshout EM, Thies WC, Patka P, Schipper IB. Intraosseous devices: A randomized control trial comparing three intraosseous devices. Prehosp Emerg Care 2010 Jan-Mar;14(1):6-13.
Von Hoff DD, Kuhn JG, Burris HA, Miller LJ. Does intraosseous equal intravenous? A pharmacokinetic study. Am J Emerg Med 2008;26:31-8.
Central Venous Catheterization: Before Procedure
Indications
There are many indications for insertion of temporary central venous catheters (CVC) in pediatric patients, and often multiple indications coexist. Because there is risk associated with both insertion and maintenance of these catheters, it is imperative that a true indication for placement be met. If more than one indication exists, the risk/benefit ratio falls in favor of catheter placement.
•
Monitoring of central venous pressure (CVP) and measurement of central venous oxygen saturation (Scv
O2) in hemodynamically compromised patients
Contraindications
All contraindications are relative, but the risks and benefits of the procedure must be weighed carefully.
•
Coagulopathy:
•
Correction of the coagulopathy should be attempted prior to procedure if the acuity of the situation allows.
•
Sites with more risk in coagulopathic patients include subclavian and internal jugular veins; topical pressure to decrease bleeding is more effective at the femoral site.
•
Site-specific contraindications:
•
Avoid femoral vein catheterization in patients with abdominal catastrophes, because patency of more central veins cannot be assured.
•
Avoid internal jugular catheterization in patients with increased ICP.
•
Patients with hyperinflated lungs are at increased risk of pneumothoraces with subclavian or internal jugular catheterization.
•
Patients with active bacteremia are at risk for colonizing the CVC, so ideally the CVC would not be placed until blood cultures are negative. That is not always possible, depending on the acuity of the patient and the patient’s peripheral venous access.
Equipment
Proper insertion technique using full sterile barrier precautions and chlorhexidine prep of the skin have been shown to decrease infections associated with CVCs. Additionally, having the equipment including sterile gloves and drapes together in one location, such as a cart, increases the compliance with sterile technique by the insertion practitioner and makes insertion more efficient. A checklist of insertion practice also improves the compliance of proper technique.
•
Sedation appropriate for age and condition of patient
•
Local analgesia:
•
1% lidocaine with sterile syringe and narrow-gauge needle for infiltration
•
Topical analgesia may be used prior to sterilely preparing the skin for adding analgesia.
•
Sterile gloves, caps, masks, sterile drapes
•
Skin preparation antiseptic:
•
2% chlorhexidine-alcohol based skin prep is recommended.
•
Alternatives include 70% alcohol, tincture of iodine, iodophor.
•
Steel hollow needles, guidewire, dilator appropriately sized for patient and catheter; kits containing the catheter, needles, guidewire, vessel dilator, and other equipment necessary for insertion are commercially available.
•
Heparinized saline flush
•
Dressing:
•
Sterile, transparent, semipermeable dressing
•
Sterile gauze dressing if area is bleeding or wet
Anatomy
The selection of the site for insertion is based on the skill and experience of the operator and the patient’s condition and size. The femoral veins are relatively easy to access in nearly all pediatric patients. Although a risk with any site, bleeding is more easily controllable with femoral catheterization. As opposed to adults, the risk of femoral catheterization in infants and children does not appear to present a greater risk of infection than other sites. Use of the internal jugular vein is also relatively safe in most patients. The right internal jugular is associated with fewer complications than the left. Subclavian venous access is noted to have higher complications at the time of insertion, but the catheter is more easily secured and more comfortable for a mobile patient.
Access for the femoral vein in pediatric patients is similar to that in adults. The pulsations of the femoral artery are located below the inguinal ligament, and the vein is accessed medial to the artery about 1 cm below the inguinal ligament. If pulsations are not palpable, the site can be located halfway between the symphysis pubis and the anterior superior iliac spine. The right femoral vein is generally the preferred site because entry into the inferior vena cava is straighter, with the catheter less likely to enter other minor veins. For right-handed operators, there is more success of entry. Left-handed operators may choose the left femoral vein for easier access. The patient should be supine with legs positioned slightly frog-legged. Often a rolled towel or small blanket is needed underneath the buttocks to elevate and straighten the femoral vessels, allowing easier access.
For internal jugular access, the patient is placed supine in Trendelenburg position about 30 degrees head down if tolerated. The head is turned away from the side to be catheterized. The right side is preferable because of decreased complications and minimal manipulation to enter the superior vena cava. There are three techniques for entry to the internal jugular veins in children. Become proficient at one rather than attempting all three. The anterior approach is most common. First identify the carotid artery and the anterior border of the sternocleidomastoid muscle. The insertion site is at the midpoint of this anterior border. The needle should be introduced at a 30-degree angle and aimed at the ipsilateral nipple. The patient is placed in the same position for the subclavian approach, with the head turned away from the site of insertion. The suprasternal notch and the clavicle are identified. The needle is inserted below the lateral two-thirds of the clavicle and aimed at the suprasternal notch.
For subclavian access, a roll is placed between the shoulders and the patient positioned slightly in Trendelenburg position. The site of entry is just inferior to the lateral and middle junction of the clavicle. The needle is directed to the suprasternal notch and passes underneath the clavicle to enter the subclavian vein.
Procedure
The Seldinger technique is the most common for placing CVCs in infants and children. With ultrasound guidance, this technique is associated with decreased complications and decreased number of attempts in pediatric patients. In extreme circumstances, direct visualization of the vein by cutdown technique may be necessary.
•
Seldinger technique:
•
Wash hands and put on sterile gown and gloves.
•
Sterilely prepare skin with 2% chlorhexidine scrub for at least 30 seconds, with at least 30 seconds of drying time for the chlorhexidine. For the groin, a 2-minute scrub with 30-second dry time is recommended.
•
Sterilely drape the area using full barrier precautions.
•
Numb the skin and underlying tissues.
•
Pass the introducer needle into the vein, aspirating with a slip tip syringe.
•
Make a small incision at the site of the needle entry as large as the diameter of the vessel dilator.
•
Remove the needle, taking care to keep the guidewire in position in the vessel, and then pass the vessel dilator over the guidewire to dilate the vein.
•
Remove the vessel dilator, again taking care to leave the guidewire in place.
•
Pass the catheter over the wire and into position; then remove the guidewire.
•
Aspirate blood and any air from the catheter, and flush with heparinized saline; repeat for all ports.
•
Secure the catheter with suture.
•
Dress the catheter with the antiseptic-impregnated disc if desired, and then place the transparent dressing.
After Procedure
Postprocedure Care
Sterile insertion practices as already described and bundled maintenance care have been shown to significantly decrease the risk of CVC-associated bloodstream infections.
•
Checklists and CVC kits:
•
Providing a checklist of CVC maintenance procedures aids in reminding caregivers all the steps involved in CVC care.
•
Kits of equipment needed for maintenance procedures, complete with all necessary materials and readily available in one place, aid in ensuring complete and appropriate performance of routine care.
•
The catheter and catheter site must be assessed regularly:
•
Daily assessment of the need of the catheter should be reviewed by the healthcare team, including nurses and physicians, and the catheter should be removed if the indications for placement no longer exist.
•
The site should be examined for evidence of infection, such as redness at the site, drainage, swelling, or pain,
•
The catheter should be examined for positioning, especially how much catheter is outside the skin and whether the securing maneuvers—suture or device—are still in place.
•
Quality of dressing should be noted: whether it is still occlusive, presence of wetness under the dressing, and so forth.
•
Dressing:
•
Types of dressings:
•
Transparent, semipermeable dressing: allows visualization of the site and does not have to be changed as frequently
•
Gauze and tape: best used when the site is wet from blood, other fluid, or sweat; requires more frequent changes
•
Dressing change:
•
Frequency:
•
For transparent, semipermeable dressing: once a week if site remains clean and dry
•
For gauze and tape dressing: no less than every 48 hours
•
Dressing should be changed whenever the site is wet.
•
Procedure:
•
Caregiver should wear cap, mask, and sterile gloves.
•
Site should be cleaned as it was when catheter was inserted, most commonly with 2% chlorhexidine-alcohol.
•
Antiseptic device replaced if being used
•
Catheter resecured with suture if needed
•
Dressing reapplied and labeled as to when to change again
•
Infusion tubing: various tubing systems are unit specific.
•
Tubing should be changed regularly but not excessively:
•
Administration sets no more than every 72 hours unless soiled
•
Tubing that has administered blood, blood products, or lipids within 24 hours
•
Change caps (if used in the system) no more than every 72 hours and when administration set is changed.
•
Access points must be cleaned with antiseptic (chlorhexidine or alcohol) by scrubbing and allowing the antiseptic to dry before entering for infusing or aspirating blood.
•
Stopcocks are generally discouraged because of the difficulty in maintaining antisepsis.
•
Tubing should be assembled using aseptic or sterile technique.
•
Flushing is performed for multiple reasons:
•
Check patency of the line
•
Clear the line of medications or blood products that may cause precipitation if in contact with other medications
•
Clear the line with heparin-containing fluid to prevent thrombosis
•
Lock the line or port that is not being used with concentrated heparin or antibiotic/heparin flush
•
Routine replacement of the catheter is not recommended, especially rewiring the catheter, as this is associated with increased risk of infection. Because of limited venous access, routine rotation of CVC in children is not recommended.
Complications
•
Insertion complications:
•
Bleeding due to arterial puncture, venous perforation, or coagulopathy:
•
External bleeding at the site
•
Hematoma: mostly minor but can be significant, such as neck hematoma from internal jugular placement, causing airway compression or retroperitoneal hematoma from femoral placement
•
Hemothorax from internal jugular or subclavian placement
•
Hemopericardium rarely occurs.
•
Pneumothorax: increased risk with internal jugular and subclavian placement
•
Maintenance complications:
•
Infection:
•
Bloodstream infection is a significant, costly complication that results in morbidity and increases mortality in some patients, but with attention to insertion and maintenance practices can be significantly decreased.
•
Catheter occlusion due to thrombosis or precipitate
•
Vascular thrombosis in vessel; more common with chronic catheters; may be more common than recognized and often results in occlusion and loss of vessel patency, often permanent
•
Catheter erosion can result in pleural effusions or cardiac tamponade.
Outcomes and Evidence
•
Measurement of CVP allows calculation and maintenance of perfusion pressure (mean arterial pressure minus CVP), which provides better tissue perfusion in shock states.
•
In a prospective randomized trial comparing pediatric patients with septic shock treated with and without Scv
O2 goal-directed therapy, patients treated with Scv
O2 goal-directed therapy had significantly less 28-day mortality (11.8% versus 39%) and less organ dysfunction than patients without.
•
In a prospective study of planned transition in pediatric ICU patients from the landmark technique to the use of ultrasound guidance, use of ultrasound to guide placement of CVC was associated with decreased complications and fewer access attempts.
•
In a multi-institutional, interrupted time-series design with historical control data in 29 PICUs, utilizing two CVC care practice bundles, an insertion bundle, and a maintenance bundle, the rate of catheter-associated bloodstream infections were decreased by 43% from 5.4 to 3.1 infections per 1000 central line days.
Suggested Reading
Brierley J et al. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med 2009;37(2):666.
Ceneviva G, Paschall JA, Maffei F, et al. Hemodynamic support in fluid refractory pediatric septic shock. Pediatrics 1998;102:e19.
LeDoux D, Astiz ME, Carpati CM, et al. Effects of perfusion pressure on tissue perfusion in septic shock. Crit Care Med 2000;28:2729-32.
Vascular access. In American Heart Association: PALS Provider Manual. Dallas: AHA; 2002. p. 155-72.
Stenzel JP, Green TP, et al. Percutaneous femoral venous catheterizations: A prospective study of complications. J Pediatr 1989;114:411-5.
Froelich CD, Rigby MR, Rosenberg ES, Li R, Roerig PL, Easley KA et al. Ultrasound guided central venous placement decreases complications and decreases placement attempts compared with the landmark technique in patients in a pediatric intensive care unit. Crit Care Med 2009 March;37(3) 1090-6.
Miller M, Griswold M, Harris JM, Yenokyan G, Huskins C, Moss M et al. Decreasing catheter-associated bloodstream infections in the PICU: Results from the NACHRI CA-BSI Quality Improvement Collaborative, Pediatrics 2010;125:206-13.
Best practice guidelines in the care and maintenance of pediatric central venous catheters. Pediatric Vascular Access Network. Herriman, Utah: Association of Vascular Access; 2010.
O’Grady NP, Alexander M, et al. Guidelines for the prevention of intravascular catheter-related infections. Pediatrics 2002;110:e51.
Richards MJ, Edwards JR, et al. Nosocomial infections in pediatric intensive care units in the United States: National Nosocomial Infections Surveillance System. Pediatrics 1999;103:103-9.
de Oliveira CF, de Oliveira DS, Gottschald, AF, et al. ACCM/PALS haemodynamic support guidelines for paediatric septic shock: An outcomes comparison with and without monitoring central venous oxygen saturation. Intensive Care Med 2008;34:1065-75.
Journeycake J, Buchanan G. Thrombotic complication of central venous catheters in children. Curr Opin Hematol 2003;10;369-74.
Shah PS, Kalyn A, Satodia P, et al. A randomized, controlled trial of heparin versus placebo infusion to prolong the usability of peripherally placed percutaneous central venous catheters (PCVCs) in neonates: the HIP (Heparin Infusion for PCVC) study. Pediatrics 2007;119:e284-91.
O’Grady NP, Alexander M, Dellinger EP, Gerberding JL, Heard SO, Maki DG et al; Healthcare Infection Control Practices Advisory Committee. Guidelines for the prevention of intravascular catheter-related infections. Infect Control Hosp Epidemiol 2002;23(12):759-69.
Pulmonary Artery Catheterization: Before Procedure
Indications
•
Pulmonary hypertension, either primary or secondary
•
Severe shock unresponsive to fluid resuscitation and vasoactive infusions
•
Severe respiratory failure requiring high positive airway pressures with associated hemodynamic compromise
Contraindications
•
No absolute contraindications
•
Relative contraindications:
•
Coagulopathy, which may cause vascular hemorrhage
•
Tricuspid or pulmonary insufficiency may make bedside placement difficult.
•
Atrial or ventricular arrhythmias may deteriorate owing to the presence of the intracardiac line.
•
Intracardiac shunts, tricuspid insufficiency, or pulmonary insufficiency may make measurement of cardiac output by the thermodilution method uninterpretable.
Equipment
•
For percutaneous placement—not operative placement of single-lumen catheters—multiple types are available but should be narrow gauge, such as 20 gauge, to decrease the risk of intrapulmonary artery thrombosis.
•
Sedation and analgesia appropriate for age and condition of patient
•
Skin preparation antiseptic:
•
2% chlorhexidine-based skin prep is recommended.
•
Alternatives include 70% alcohol, tincture of iodine, iodophor.
•
Sterile gloves, caps, masks, sterile drapes—large enough for full sterile barrier
•
Swan-Ganz type pulmonary artery catheter:
•
Components:
•
Distal port (end hole) for pulmonary arterial and pulmonary occlusion pressure measurement
•
Thermistor at tip of catheter
•
Sizes:
•
5F for patients less than 15 kg
•
Variable distance between the ports:
•
The proximal port should be in the right atrium (RA).
•
Distal port in the pulmonary artery (PA)
•
Distance between RA and PA in various pediatric patients has been determined and can be used to determine which catheter is appropriate.
•
Introducer sheath: one French size larger than the catheter, with a sterile sleeve to cover the catheter
•
Heparinized saline flush
•
Pressure tubing with transducer connected to a monitor so pressure tracings can be monitored during catheter placement
Anatomy
The site of placement depends on many factors, including skill of the operator, size of the patient, presence of a coagulopathy, medical condition of the patient, and accessibility of the vein. The sites most commonly used are the femoral veins, internal jugular veins, and subclavian veins. Although any of these sites will allow passage of the catheter into the right atrium and on into the right ventricle and pulmonary artery, less manipulation of the catheter is needed using the right internal jugular vein or the left subclavian vein. However, the right femoral vein also requires less manipulation and is very commonly used because of its easier accessibility and fewer complications in patients with bleeding diatheses, and essentially no risk of pneumothorax in patients with severe lung disease. Other veins at these locations can also be used, but more manipulation may be necessary with bedside placement.
Procedure
•
Single-lumen pulmonary arterial catheter is placed with direct visualization in the operating room.
•
The Swan-Ganz type PA catheter is placed percutaneously or rarely by venous cutdown at the bedside.
•
Using sterile technique and full barrier precautions, as in the placement of a central venous catheter, the introducer sheath is placed using the Seldinger technique.
•
The catheter is passed through the introducer sheath and the sterile sleeve. During insertion, the balloon is inflated to allow the catheter to follow the blood flow, and the distal port is transduced so the pressure tracing can be monitored. The tracing is noted to be that of a right atrial trace initially, then as the catheter passes the tricuspid valve, the tracing becomes that of a ventricular pressure trace with a low diastolic pressure. The catheter then is allowed to flow into the pulmonary artery, and the tracing is that of an arterial trace, with the systolic pressure being the same as the right ventricle but the diastolic pressure being higher. The catheter, still with the balloon inflated, is then advanced into the pulmonary arterial occlusion position, and again the trace is that of an atrial trace but with slightly higher values than the right atrial trace. The balloon is then deflated, and the pulmonary arterial trace should recur. If not, the catheter should be pulled back until a good pulmonary artery trace is seen, and then the balloon is reinflated to confirm the catheter will “wedge” or float into the occlusion position. As the catheter is advanced, attention must be paid to the ECG, as atrial or ventricular ectopy may occur. The major difference in passing the catheter in pediatric patients is that the turns and torques of the catheter must be made with more finesse than in adults because the distances are shorter, and the cavities of the right atrium and ventricle are smaller.
•
After the catheter is stable in good position, it should be secured within the sterile sleeve. The introducer sheath should be secured with suture and the site dressed as with a central line.
•
Measurement of thermodilution cardiac output:
•
A known volume of fluid at a lower temperature than blood (either iced or room temperature) is injected into the proximal port of the catheter, and the temperature change at the thermistor is noted. The amount of heat loss allows for calculation of flow.
•
A smaller volume of injectate is used in the 5F catheter to avoid fluid overload of the patient.
•
Iced injectate is not recommended in pediatrics, because repeated measures may result in hypothermia for small infants and children.
•
Room temperature injectate is recommended for the smaller pediatric patient.
•
The type of fluid injected also must be taken into consideration for the pediatric patient if repeated measures are to be made—usually should be normal saline.
•
Generally, three injections should be made during each measurement period, and with repeated measurements, that volume can potentially affect the electrolytes of the pediatric patient.
•
The cardiac output measured in this way is reported divided by the patient’s body surface area as the cardiac index.
After Procedure
Postprocedure Care
•
Catheter care and dressing as for central venous line
•
Balloon is never left inflated because of the risk of pulmonary infarction
•
Continuous monitoring of both the right atrial (proximal) port and the pulmonary arterial port (distal) to ensure the catheter stays in proper location
•
Regular chest radiographs to confirm catheter position
Complications
•
Prolonged use:
•
Infection at the site or in the bloodstream
•
Trauma to the tricuspid or pulmonary valve usually clinically insignificant but may predispose to endocarditis
•
Thrombosis of the vein of entry or the pulmonary artery
•
Rare:
•
Rupture of the pulmonary artery with balloon inflation
Outcomes and Evidence
•
Monitoring PA pressure in the postoperative period in infants undergoing cardiac surgery has been shown to help guide therapy in prospective descriptive studies but not randomized controlled studies.
•
Using cardiac output as measured by thermodilution has been helpful when guiding resuscitation during shock in pediatrics.
•
Studies showing improved outcome using the PA catheter are not available.
Suggested Reading
Swan HJC, Ganz W, Forester J, et al. Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter. N Engl J Med 1970;283:447-50.
Thompson AE. Pulmonary artery catheterization in children. New Horiz 1997;5:244-9.
Jansen JRC: The thermodilution method for the clinical assessment of cardiac output. Intensive Care Med 1995;21:691-7.
Hopkins RA, Bull C, Hawaorth SG, et al. Pulmonary hypertensive crises following surgery for congenital heart defects in young children. Eur J Cardiothorac Surg 1991;5:628-34.
Borland LM. Allometric determination of the distance from the central venous pressure port to wedge position of balloon-tip catheters in pediatric patients. Crit Care Med 1986;14:974-6.
Carcillo JA, Davis AL, Zaritsky A. Role of early fluid resuscitation in pediatric septic shock. JAMA 1991;266:1242-5.
Adatia I, Atz Am, Jonas RA, et al. Diagnostic use of inhaled nitric oxide after neonatal cardiac operations. J Thorac Cardiovasc Surg 1996;112:1403-5.
Intraarterial Catheter: Before Procedure
Indications
•
Continuous measurement of arterial blood pressure
•
Hemodynamic instability with real or potential hypotension
•
Severe hypertension requiring continuous vasoactive infusions
•
Measurement of cerebral perfusion pressure in patients with increased ICP
•
Frequent assessment of arterial blood gases
•
Rarely, frequent blood sampling in patients who have relative contraindications to central venous access such as diabetic ketoacidosis
Contraindications
•
Perfusion of the extremity distal to the arterial catheterization would be compromised by the catheter placement.
•
Skin disruption at the site in insertion
•
Coagulopathy is a relative contraindication.
Equipment
•
Analgesic agents:
•
1% lidocaine local with 25-gauge needle and syringe
•
Topical anesthetic such as EMLA
•
Heparinized saline flush solution
•
Tubing set:
•
Luer-Lok tubing to attach to the catheter: type depends on PICU nursing standards
•
Pressure tubing to extend to the pressure transducer
•
Pressure transducer connected to monitor
•
Securement equipment: tape, suture, and/or clear adherent dressing
Anatomy
Arterial catheterization is performed in pediatric patients using the peripheral and femoral arteries. For neonates, the umbilical artery is used. The peripheral arteries most commonly used in pediatrics are the radial, dorsalis pedis, and posterior tibial arteries. Ulnar arteries can also be used, but attention should be paid to the patency of the radial artery prior to accessing the ulnar artery. The femoral artery is also accessible in pediatric patients.
Procedure
•
Apply topical analgesic in patients who are conscious or minimally sedated.
•
Prepare skin and drape for sterile procedure.
•
Inject 1% lidocaine local in the skin and around artery, taking care to aspirate to avoid intraarterial injection.
•
For direct insertion:
•
Direct catheter toward artery and when arterial blood flows back into the catheter, carefully advance catheter about 1 to 2 mm, and then remove stylet.
•
Attach connecting tubing and aspirate blood, removing air bubbles, and then inject heparinized saline. Blood should be easily aspirated into the syringe.
•
Using Seldinger technique (most common technique for femoral arterial access but can be used for any commonly used artery):
•
Using steel needle or butterfly needle with the tubing detached, direct needle towards the artery.
•
When arterial blood is obtained and flowing freely, advance the guidewire through the needle; it should pass easily with no resistance.
•
Then remove the needle and pass the catheter over the wire and into the artery.
•
Remove the wire and attach connecting tubing; aspirate blood, removing air bubbles, then flush with heparinized saline. Blood should be easily aspirated into the syringe.
•
Then attach connecting tubing to the high-pressure tubing and transducer, allowing the arterial waveform to be visualized.
After Procedure
Postprocedure Care
•
Continuous blood pressure monitoring with appropriate alarms
•
Continuous fluid delivery, most commonly with heparin-containing fluid to prevent clot formation in the catheter
•
Frequent evaluation of the system to detect any disruption of the catheter system
•
Frequent evaluation of perfusion to the extremity distal to the catheter and to the skin in the area around the catheter
•
Evaluation of the securement of the catheter to prevent inadvertent dislodgement
•
Dressing changes, including cleaning of the site to prevent infection
Complications
•
Bleeding at the site:
•
At time of insertion, this can be minor.
•
If patient is coagulopathic, bleeding may be more of a concern.
•
Infection is rare with percutaneous catheters.
•
Exsanguination:
•
May occur if any part of the arterial catheter system becomes disconnected
•
Prevented by continuous monitoring with appropriate alarms which can immediately detect loss of blood pressure
•
Frequent observation and checking of the system is also necessary.
Outcomes and Evidence
•
No randomized controlled studies on the use of arterial monitoring and outcome are available in pediatrics.
Suggested Reading
Adams JM, Rudolph AJ. The use of indwelling radial artery catheters in neonates. Pediatrics 1975;55(2); 261-5.
Franklin C. The technique of radial artery cannulation. Tips for maximizing results while minimizing the risk of complications. J Crit Illness 1995;10(6) 424-32.
Frezza EE, Mezghebe H. Indications and complications of arterial catheter use in surgical or medical intensive care units: Analysis of 4932 patients. Am Surg 1998;64:127-31.
King MA, Garrison MM, Vavilala MS, Zimmerman JJ, Rivara FP. Complications associated with arterial catheterization in children. Pediatr Crit Care Med 2008 July;9(4):367-71.
Defibrillation: Before Procedure
Contraindications
•
No contraindications in a patient with proven or suspected VF
Equipment
•
Defibrillator:
•
Biphasic type: requires lower energy
•
Automatic external defibrillators (AEDs)
Anatomy
The placement of the pads or paddles is essentially the same as for adults. One is placed on the upper right side of the chest and the other at the apex of the heart, directly over the heart and to the left of the left midclavicular line. For some infants, because their chest is so small, the pads/paddles may still touch in this location. In this case, the pads/paddles may be placed in an antero/posterior position with one placed on the chest to the left of the sternum and another on the back below the scapula.
Procedure
•
Follow Pediatric Advanced Life Support (PALS) defibrillation sequence recommendations.
•
Place pads or paddles in the proper location.
•
Automatic external defibrillation:
•
Different brands of AEDs have varying ability to defibrillate pediatric patients. It is best to use a device with pediatric attenuation ability and one that can recognize pediatric shockable rhythms (PALS)
•
Apply patches and follow instructions given by AED if shockable rhythm is present.
After Procedure
Postprocedure Care
•
Determine treatable causes of VF and treat.
•
Start antiarrhythmic agents to prevent recurrence.
Complications
•
Major complication is inability to convert to perfusing rhythm or deterioration into asystole; may convert into another arrhythmia
•
Skin burns are the most common complication and rarely are clinically significant.
•
Myocardial damage can occur, but using doses of more than 4 J/kg have been reported to have few adverse effects.
•
Blood clots have been reported in adults.
Outcomes and Evidence
•
Defibrillation using a dose of 2 J/kg was successful in 91% of shocks in a retrospective study of children.
•
Out-of-hospital pediatric patients with ventricular fibrillation had a 20% chance of surviving to discharge from a secondary analysis of data from a randomized controlled study of out-of-hospital airway management.
•
In hospitalized pediatric patients with cardiac arrest whose initial rhythm was ventricular fibrillation or ventricular tachycardia, a survival-to-discharge rate of 35% was reported in a National Registry of Cardiopulmonary Resuscitation prospective data analysis.
•
AEDs have been shown to be effective for pediatric patients older than 1 year of age in multiple studies, but efficacy in patients younger than 1 year has not been determined.
Suggested Reading
Samson RA, Atkins DL. Tachyarrhythmias and defibrillation. Pediatr Clin North Am 2008;55(4):887-907.
Gutgesell HP, Tacker WA, et al. Energy dose for ventricular defibrillation of children. Pediatrics 1976;58:898-901.
Clark CB, Zhang Y, et al. Pediatric transthoracic defibrillation: Biphasic versus monophasic waveforms in an experimental model. Resuscitation 2001;51:159-63.
Mogayzel C, Quan L, Graves JR, et al. Out-of-hospital ventricular fibrillation in children and adolescents: causes and outcomes. Ann Emerg Med 1995;25:484-91.
Kerber RE, Becker LB, Bourland JB, et al. Automatic external defibrillators for public access defibrillation: recommendations for specifying and reporting arrhythmia analysis algorithm performance, incorporating new waveforms, and enhancing safety: a statement for health professionals from the American Heart Association Task Force on Automatic External Defibrillation, Subcommittee on AED Safety and Efficacy. Circulation 1997;95:1677-82.
Atkins DL, Hartley LL, York DK. Accurate recognition and effective treatment of ventricular fibrillation by automated external defibrillators in adolescents. Pediatrics 1998;101(pt 1):393-7.
Atkinson E, Mikysa B, Conway JA, Parker M, Christian K, Deshpande J et al. Specificity and sensitivity of automated external defibrillator rhythm analysis in infants and children. Ann Emerg Med 2003;42:185-96.
Young KD, Gausche-Hill M, McClung CD, Lewis RJ. A prospective, population-based study of the epidemiology and outcome of out-of-hospital pediatric cardiopulmonary arrest. Pediatrics 2004;114:157.
Samson RA, Nadkarni VM, Meaney PA, et al. Outcomes of in-hospital ventricular fibrillation in children. N Engl J Med 2006;354:2328-39.
Cardioversion: Before Procedure
Indications
•
Atrial tachycardias that have failed medical management
Contraindications
•
Unstable ventricular tachycardia or VF, which need to be defibrillated
•
Patients on digoxin will have a lowered VF threshold and may develop VF with cardioversion.
•
Patients with chronic atrial fibrillation or atrial flutter are at risk of embolism from atrial thrombi and should not be cardioverted until a transesophageal echocardiogram shows no evidence of thrombus.
Equipment
•
Defibrillator with ability to synchronize the discharge with ECG
•
Sedation and analgesia should be provided following safe sedation guidelines.
Anatomy
The placement of the pads or paddles is essentially the same as for defibrillation. One is placed on the upper right side of the chest and the other at the apex of the heart, directly over the heart and to the left of the left midclavicular line. For some infants, because their chest is so small, the pads/paddles may still touch in this location. In this case, the pads/paddles may be placed in an antero/posterior position with one pad on the chest to the left of the sternum and one pad on the back beneath the left scapula.
Procedure
•
Apply appropriate-sized pads or paddles to chest.
•
Attach the ECG pads for the defibrillator or position the paddles such that a good ECG trace is obtained.
•
Turn defibrillator setting to synchronous mode.
•
Set the energy to 0.5 to 1 J/kg.
•
Hold the discharge button down until the dose of energy is delivered which will occur after the defibrillator has detected two to three complexes.
After Procedure
Postprocedure Care
•
Observe rhythm for recurrence.
•
Begin antiarrhythmic therapy based on original rhythm and presence of underlying heart disease.
•
Observe skin for evidence of burns.
Complications
•
Other abnormal rhythms can occur:
•
If VF occurs, change the mode to asynchronous and immediately defibrillate with 2 J/kg and follow the PALS VF sequence.
•
Bradycardias may occur and are usually transient, but if persistent may administer atropine.
•
Thromboembolism may occur if atrial thrombi are present and may result in stroke or limb ischemia.
•
Skin burns may occur but are rare with the low dose of energy.
•
Myocardial injury is possible but rare at this low dose of energy.
Outcomes and Evidence
•
Cardioversion was known to be effective in atrial arrhythmias more than 80% of the time in a prospective observational study.
•
Blinded randomized trials of cardioversion versus other methods of converting atrial arrhythmias have not been done in children.
Suggested Reading
Lown B, Amarasingham R, Neuman J. New method for terminating cardiac arrhythmias: use of synchronized capacitor discharge. JAMA 1962;182:548.
Bjerkelund C, Orning OM. An evaluation of DC shock treatment of atrial arrhythmias: immediate results and complication in 437 patient with long term results in the first 290 of these. Acta Med Scand 1968;184:481.
Sacchetti A, Moyer V, et al. Primary cardiac arrhythmias in children. Pediatr Emerg Care 1999;15;95-8.
Young KD, Seidel JS. Pediatric cardiopulmonary resuscitation: A collective review. Ann Emerg Med 1999;33;195-205.
Van Hare GF, Porter CJ. atrial flutter and atrial fibrillation in the science and practice of pediatric cardiology. 2nd ed. Philadelphia: Williams and Wilkins; 1998. p. 2110.
Temporary Cardiac Pacing: Before Procedure
Indications
•
Symptomatic bradycardia:
•
Sinus bradycardia not usually symptomatic or improves with adequate oxygenation and ventilation
•
Other bradydysrhythmias will often respond to atropine or β-adrenergic agonists
•
Pace termination of tachydysrhythmias such as intraatrial reentrant tachycardia (IART)
Contraindications
•
Relative contraindications:
•
Epicardial pacing:
•
Dense fibrous scar around the heart may make placement difficult or lead to high thresholds.
•
Transesophageal pacing:
•
Postorthotopic heart transplant, because tissue near esophagus is recipient left atrial tissue and electrically isolated from donor heart
•
Transcutaneous pacing:
•
Capture may be impossible in extreme obesity, pericardial effusion, or increased thoracic capacity.
•
Pacing during cardiac arrest typically futile
Equipment
•
Bipolar transvenous pacing catheters, active fixation (must be placed under fluoroscopy) or balloon tipped, commercially available in size 3F and larger
•
Temporary pacing box (ensure adequate battery supply) with connection cables
•
Long introducer needle or commercially available kit as needed if transthoracic puncture intended
•
External pacing pads and unit; suggest defibrillation unit and paddles or pads, also available
•
Temporary pacing wires per surgeon preference at time of sternotomy
Procedure
First establish stable airway, adequate ventilation and oxygenation, consider atropine or β-adrenergic agonists.
Temporary Transvenous Ventricular Pacing
•
Choice of vein dependent on operator comfort and skill (frequently right internal jugular; may also use femoral). May require fluoroscopy to manipulate into right ventricle or subclavian veins. Consider avoiding left subclavian vein if patient is candidate for permanent transvenous system, usually greater than 20 kg.
•
Bedside placement typically requires balloon-tipped catheter; consider placement under fluoroscopic guidance if time permits.
•
Under sterile conditions, introducer sheath placed in central vein by modified Seldinger technique; consider use of ultrasound guidance.
•
If vein diameter permits placement of sheath one French size larger than necessary for pacing catheter, then side-arm of sheath may be used for central venous access as well.
•
Catheter is advanced under sterile procedure from central vein through sheath to right atrium and across tricuspid valve into right ventricle. Position is confirmed by attaching catheter leads either to ECG and noting intracardiac electrograms (sharp spikes which correspond to surface P waves when catheter tip is in atrium or to surface QRS when catheter tip in ventricle), or by attaching catheter leads to pacing box and noting atrial or ventricular capture.
•
Threshold testing is performed as follows: pacemaker output is decreased incrementally until loss of capture is noted, then output is generally increased to double the pacing threshold to ensure adequate safety margin.
•
Temporary pacing lead is secured in place, typically with suture and/or clear adhesive dressing, and position is confirmed by chest x-ray or echocardiogram.
•
Pacing mode depends on clinical circumstance. Ideally, this would be demand mode such as VVI or DDD to inhibit pacemaker output when intrinsic beat is sensed, thus preventing pace induction of tachydysrhythmias or ventricular fibrillation. However, when sensing thresholds are marginal, asynchronous pacing may be necessary.
•
Pacing and sensing thresholds should be determined at least daily while patient requires temporary pacemaker.
Epicardial Pacing
•
Temporary pacing wires may be placed by cardiothoracic surgeon at time of sternotomy, typically one bipolar lead on the atrium (commonly placed to the right of the sternum) and one bipolar lead on the ventricle (commonly placed to the left of the sternum). Wires are then tunneled through the anterior chest wall and secured in place.
•
Pacing wires may be connected to temporary pacing box if clinically needed.
•
Threshold testing and selection of pacing mode is performed as detailed earlier.
•
Removal of temporary pacing wires occurs with gentle traction.
Transesophageal Pacing
•
Relatively easy technique for pacing atrium, especially “overdrive” pacing of atrial tachydysrhythmias. Not generally useful for pacing ventricle and typically uncomfortable.
•
Standard transvenous pacing catheter is lubricated and advanced through the nose into the distal esophagus to the approximate level of the atrium.
•
As catheter is passed, may be helpful to connect leads to ECG. The location where the ECG signal voltage is greatest should be the position where pacing will be most effective.
•
Catheter is connected to pacing box.
Transcutaneous Pacing
•
Very painful, best reserved for unconscious or heavily sedated patient
•
Two sizes of pacing patches available: pediatric size for patients up to 15 kg, adult size recommended for patients over 15 kg
•
Patches are placed on patient’s chest, labeled front (negative electrode) and back (positive electrode); may also be placed over right chest and apex of left ventricle
•
Because current must traverse chest wall, output required is typically large, up to 200 milliamps, with a wider pulse width of 20 to 40 msec. Once ventricular capture is achieved, the output is decreased as much as possible.
Transthoracic Ventricular Pacing
•
Rarely indicated in desperate situations, when other access to ventricular pacing has failed
•
Requires long introducer needle or commercially available kit
•
Skin is prepped and draped under sterile precautions.
•
Introducer needle attached to slip tip syringe is advanced from left xiphocostal angle 30 degrees to skin, directed toward left shoulder while aspirating. Aspiration of blood confirms needle placement in right ventricle.
•
Pacing catheter or wire is advanced into right ventricle and secured in place; position is confirmed by x-ray or echocardiogram.
After Procedure
Postprocedure Care
•
Continuous monitoring of cardiac rhythm through telemetry
•
Sedation and/or analgesia as warranted
•
Conversion of pacing mode as feasible to temporary transvenous or permanent implanted device if clinically indicated
•
Routine reevaluation of pacing and sensing thresholds at least daily, and reassessment of underlying cardiac rhythm and need for continued pacing
Complications
•
Temporary transvenous ventricular pacing:
•
Complications of venous access (failure to gain access, bleeding, pneumothorax, infection)
•
Complications of pacing leads (dysrhythmias, cardiac perforation, loss of capture)
•
Transesophageal pacing:
•
Chest pain common, typically requires analgesia or sedation
•
Esophageal perforation (rare)
•
Transthoracic pacing:
•
Cardiac tamponade is common.
•
Injury to heart or great vessels, pneumothorox or hemothorax, coronary artery laceration, liver or lung laceration
Outcomes and Evidence
•
There is current debate regarding the prophylactic placement of temporary pacing wires in all pediatric patients undergoing heart surgery. Perhaps lower-risk patients do not need empirical pacing wires placed in the operating room (OR).
•
Temporary pacing wires placed in the OR may be used in up to 26% of postoperative congenital heart patients, with half of those uses for diagnostic rather than pacing purposes.
Suggested Reading
Kannankeril PJ, Fish FA. Disorders of cardiac rhythm and conduction, Moss and Adams’ Heart disease in infants, children, and adolescents: including the fetus and young adults. In: Allen HD, Driscoll DJ, Shaddy RE, Feltes TF, editors. Philadelphia: Lippincott; 2008.
Villain E. Indications for pacing in patients with congenital heart disease. Pacing Clin Electrophysiol 2008;31:S17-20.
Fishberger SB, Rossi AF, Bolivar JM et al. Congenital cardiac surgery without routine placement of wires for temporary pacing. Cardiol Young 2008;18:96-9.
Moltedo JM, Rosenthal GL, Delaney J et al. The utility and safety of temporary pacing wires in postoperative patients with congenital heart disease. J Thorac Cardiovasc Surg 2007;134:515-6.
Pinto N, Jones TK, Dyamenahalli U et al. Temporary transvenous pacing with an active fixation bipolar lead in children: a preliminary report. Pacing Clin Electrophysiol 2003;26:1519-22.
Rein AJ, Cohen E, Weiss A, et al. Noninvasive external pacing in the newborn. Pediatr Cardiol 1999;20:290-2.
Cohen MI, Rhodes LA, Spray TL, Gaynor JW. Efficacy of prophylactic epicardial pacing leads children and young adults. Ann Thorac Surg 2004;78:197-202.
Gammage, MD. Temporary cardiac pacing. Br Heart J 2000;83:715-20.
White JD, Brown CG. Immediate transthoracic pacing for cardiac asystole in an emergency department setting, Am J Emerg Med 1985;3:125-8.
Brown CG, Gurley HT, Hutchins GM, et al. Injuries associated with percutaneous placement of transthoracic pacemakers, Ann Emerg Med 1985;14:223-8.
Beland MJ, Hesslein PS, Finlay CF, et al. Noninvasive transcutaneous cardiac pacing in children. PACE 1987;10:1262-70.
Quan L, Graves JR, Kinder DR et al. Transcutaneous cardiac pacing in the treatment of out-of-hospital pediatric cardiac arrests. Ann Emerg Med 1992;21:905-9.
Erickson CC. Temporary cardiac pacing. In Illustrated Textbook of Pediatric Emergency and Critical Care Procedures, 1st ed. St, Louis, Missouri: Mosby-Year Book, Inc; 1997. p. 312-22.
Transesophageal Echocardiography: Before Procedure
Because the transthoracic echocardiographic windows of pediatric patients are often superior to those of adults, the development of transesophageal echocardiography (TEE) in children initially lagged behind its development in adults. Presently, however, TEE has assumed a critical role in the evaluation of children with congenital and acquired heart disease.
Indications
•
Perioperatively at time of cardiac surgery:
•
Preoperatively:
•
Specifically characterize congenital heart disease prior to planned surgical intervention
•
Postoperatively:
•
Evaluate for intracardiac air prior to weaning from cardiopulmonary bypass
•
Evaluate for residual defects such as shunts, valvular insufficiency, residual obstruction, and myocardial dysfunction
•
2% to 15% of planned cardiac surgical procedures significantly changed based on the results of the intraoperative TEE
•
Cardiac catheterization laboratory:
•
During interventions such as atrial and ventricular septal defect occluder devices, balloon valvuloplasty procedures, stenting procedures, and endomyocardial biopsies
Contraindications
•
Relative contraindications:
•
Unrepaired tracheoesophageal fistula
•
Recent esophageal surgery
•
Esophageal obstructive lesions
•
Active gastrointestinal bleeding
•
Other considerations:
•
Because neck flexion and extension are frequently required for probe placement, cervical spine abnormalities should be ruled out prior to the procedure.
•
For patients who require anticoagulation, parameters should be maintained at the lower end of the therapeutic range.
Equipment
•
Appropriately sized TEE probe
•
Echocardiogram (ultrasound) machine
Procedure
Because the size of the probe relative to the size of the esophagus and adjacent structures is larger in pediatric patients, and because patients must be cooperative for the procedure to be performed safely, TEE in pediatric patients is generally performed under deep sedation or, more commonly, general anesthesia. Endotracheal intubation for airway protection and controlled ventilation is recommended for smaller patients at increased risk of mechanical airway compromise, children with systemic illnesses that increase their risk of respiratory depression with sedation, children at increased risk of aspiration or impaired airway control, and children with poor underlying cardiorespiratory status such as severe cyanosis or poor ventricular function. The TEE probe is lubricated and advanced through the oropharynx into the esophagus. Passage of the probe into the esophagus may be facilitated by flexion of the patient’s neck or a jaw lift maneuver. A complete two-dimensional color Doppler and pulsed-wave and continuous-wave Doppler interrogation of the cardiac chambers, valves, and great vessels is then performed as clinically indicated.
The greatest strength of TEE lies in its ability to image the heart and great vessels not adequately accessible through transthoracic windows, especially the more posterior cardiac structures. These include delineation of atrial anatomy, pulmonary veins, and systemic venous return, both in patients with unrepaired congenital heart disease and in patients post intraatrial baffle procedures. TEE may also be useful in examining the atrioventricular valves, the left ventricular outflow tract, levels of pulmonary outflow tract obstruction, the pulmonary artery confluence, and proximal branch pulmonary arteries. Limitations to TEE include imaging structures obstructed by bronchial air and limited imaging planes available from the esophageal window.
As technology has progressed, miniaturization of echocardiographic probes has permitted transesophageal imaging with increasingly greater resolution even in smaller patients. A commercially available 8F (2.5-mm diameter) probe designed for intracardiac echocardiography (ICE) may be used off label for monoplane transesophageal imaging, even in neonates less than 2 kg. Also recently available are the first real-time three-dimensional TEE probes, which permit accurate evaluation of three-dimensional cardiac structures and may prove valuable in TEE-guided catheter-based interventions.
After Procedure
Postprocedure Care
•
After removal, the TEE probe should be examined for evidence of blood, suggesting pharyngeal or esophageal injury.
•
Post TEE airway management as clinically indicated
Complications
•
Infrequent:
•
Inability to successfully intubate the esophagus
•
Airway compromise likely related to compression of the membranous trachea
•
Compression of posterior vascular structures such as the descending aorta or pulmonary veins
Outcomes and Evidence
•
Outcomes in pediatric TEE depend largely on the surgical or catheter-based interventions performed at the time of echocardiographic exam.
•
Intraoperative TEE has been shown to impact decision making in approximately 2% to 15% of cardiopulmonary bypass cases.
Suggested Reading
Zyblewski SC, Shirali GS, Forbus GA, et al. Initial experience with a miniaturized multiplane transesophageal probe in small infants undergoing cardiac operations. Ann Thorac Surg 2010;89:1990-94.
Garg R, Murthy K, Rao S, Muralidhar K. Intraoperative trans-esophageal echocardiography in congenital heart disease. Ann Card Anaesth 2009;12:166.
Perk G, Lang RM, Garcia-Fernandez MA, et al. Use of real-time three-dimensional transesophageal echocardiography in intracardiac catheter based interventions. J Am Soc Echocardiogr 2009;22:865-82.
Drinker LR, Camitta MGW, Herlong JR, et al. Use of the monoplane intracardiac imaging probe in high-risk infants during congenital heart surgery. Echocardiography 2008;25:999-1003.
Sundar S, DiNardo JA. Transesophageal echocardiography in pediatric surgery. Int Anesth Clinics 2008;46:137-55.
Kavanaugh-McHugh A, Tobias JD, Doyle T, et al. Transesophageal echocardiography in pediatric congenital heart disease. Cardiol Rev 2000;8:288-306.
Randolph GR, Hagler DJ, Connolly HM, et al Intraoperative transesophageal echocardiography during surgery for congenital heart defects. J Thorac Cardiovasc Surg 2002;124:1176-82.
Greene MA, Alexander JA, Knauf DG, Talbert J, Langham M, Kays D et al. Endoscopic evaluation of the esophagus in infants and children immediately following intraoperative use of transesophageal echocardiography. Chest 1999;116:1247-50.
Flexible Bronchoscopy: Before Procedure
Indications
Under most circumstances, flexible airway endoscopy in critically ill children should be undertaken by an experienced pediatric bronchoscopist.
•
Airway evaluation:
•
Stridor (acute, postextubation)
•
Suspected airway lesion
•
Wheezing unresponsive to medical therapy
•
Localized hyperinflation
•
Suspected congenital anomalies
•
Detection of suspected foreign body
*•
Postoperative evaluation of anastomotic sites
•
Therapeutic indications:
•
Selective bronchial intubation
•
Removal of large mucus plugs and respiratory secretions
•
Removal of bronchial casts
•
Instillation of surfactant in acute lung injury
•
Instillation of mucolytic agents in refractory atelectasis
•
Fibrin glue therapy for the treatment of bronchopleural fistula
Contraindications
•
Absolute contraindications:
•
Airway size too small for the available bronchoscope
•
Severe cardiovascular instability
•
Lack of trained personnel, inadequate equipment
•
The procedure will elicit no information of value.
•
Relative contraindications:
•
Severe pulmonary arterial hypertension
•
Profound hypoxemia despite 100% oxygen supplementation
•
Significant risk of cerebral herniation
•
PEEP greater than 10 cm H
2O
•
Mean arterial pressure less than 65 mm Hg on vasopressor therapy
Equipment
•
A number of directable, flexible bronchoscopes are available for pediatric use, and each instrument has unique characteristics and limitations:
•
The 2.2-mm ultrathin bronchoscope does not have a suction channel, but it may pass through ETTs with internal diameters as small as 2.5 mm, and therefore it is extremely useful in the neonatal ICU.
•
In nonintubated infants and in children intubated with 3.5- to 4.5-mm ETTs, the 2.7- to 2.8-mm bronchoscopes are especially useful and less prone to obstruct the airway than larger instruments.
•
A 3.4- to 3.8-mm bronchoscope is the most commonly used endoscope that can be used in nonintubated children aged 2 to 10 years, or in children intubated with 5.0- to 6.0-mm ETTs.
•
The instrument most commonly used in adults and larger-sized children is 4.7 to 4.9 mm in outside diameter and has a 2-mm suction channel.
•
Topical lidocaine solution 2% for the nose and larynx, 1% for the lower airway (maximum dose should not exceed 5-7 mg/kg)
•
Oxygen source and tubing
•
Bag and mask, laryngoscope, ETTs
•
1 : 10000 epinephrine for management of airway bleeding (0.1 mL epinephrine in 5-10 mL NS)
•
Two wall-mounted suction units (one for the bronchoscope)
•
Resuscitation drugs and equipment
•
Clear airway endoscopy mask in nonintubated children allows simultaneous insertion of the bronchoscope through a side port and delivery of continuous positive airway pressure
•
An adapter attached to the ventilator circuit and ETT, with an aperture that seals around the bronchoscope
•
Specimen traps and syringes
•
Sterile normal saline to be used for instillation
•
Lidocaine jelly to anesthetize the nasal passage in nonintubated patients
•
Water-soluble lubricant for the bronchoscope
•
Video camera, recorder, and high-resolution television monitor placed on a mobile cart
Anatomy
In addition to obvious size differences between pediatric and adult airways, there are anatomic differences that predispose the infant and young child to airway obstruction with respiratory illness or manipulation. Thus, in nonintubated children, specific techniques that take into account these anatomic differences may be required to maintain airway patency and prevent airway injury.
•
The tongue: relatively larger in proportion to the oral cavity
•
The posterior pharynx: on the posterior wall, and often extended into the choana, adenoid tissue can be seen in young children.
•
The larynx: the infant larynx lies nearly two vertebral bodies higher in the neck than that of the adult and is located more anteriorly; laryngeal structures are more compliant.
•
The epiglottis has a much more pronounced curvature (omega shaped) that is angled away from the tracheal axis.
•
The arytenoids cartilages may be very prominent in the infant.
•
The first tracheal ring (the cricoid cartilage) is the smallest cross-sectional area of the airway in young children.
•
The normal shape of the trachea in children is nearly round, with cartilages extending visibly through an arch approximately 320 degrees. The membranous portion of the trachea is more mobile in the upper third of the trachea.
•
The carina is very sharp in adults, but it is often blunted in children. The right mainstem bronchus is immediately seen on peering down the trachea.
•
The right lung:
•
The right upper lobe takes off just beyond the carina, and the lobar bronchus is very short and has three segmental bronchi including anterior, posterior, and apical.
•
The right middle lobe takes off at an acute angle anteriorly and divides into lateral and medial segments.
•
The basilar segments of the lower lobe may be variable and include apical, medial, anterior, lateral, and posterior segments.
•
The left lung:
•
The left upper lobe divides into apical posterior and anterior segments and lingular segments.
Procedure-Related Considerations
•
Communication between the critical care team and bronchoscopist is essential to establish whether flexible airway endoscopy is the most appropriate approach for evaluation and/or management of the patient’s airway or pulmonary problem, what procedure should be performed, and what additional preprocedure evaluation of the patient is required.
•
In general, the bronchoscopist should evaluate the patient’s cardiopulmonary stability; review metabolic, hematologic, and coagulation laboratory results; review chest radiographs; and determine the size, if present, of any artificial airways.
•
Patients who are known to be at risk for bronchospasm should be given preprocedure bronchodilators and steroids.
•
Even intubated patients may aspirate around a cuffed ETT when the tube is moved during manipulation of the bronchoscope; therefore, the stomach should be emptied prior to the procedure (fasting 4-6 hours for milk and solids and 3 hours for water).
•
In the child with brain injury, flexible airway endoscopy should be performed with caution because ICP may transiently but significantly increase during the procedure.
Procedure
•
Sedation and monitoring:
•
In children undergoing flexible airway endoscopy, sedation is almost always required to obtain useful information and avoid discomfort and airway trauma.
•
Appropriate monitoring of critically ill children undergoing flexible airway endoscopy includes the presence of a second physician (intensivist preferred).
•
Continuous monitoring of oxygen saturation, respiratory rate, and cardiac rate and rhythm, as well as intermittent (or continuous) monitoring of blood pressure
•
Oxygenation and ventilation:
•
Although the bronchoscope may occupy 10% of the tracheal lumen in a nonintubated patient, the instrument takes up a larger percentage of available space in an ETT.
•
The presence of a bronchoscope in the airways results in physiologic alteration including increased airway resistance associated with decreased minute ventilation. In spontaneously breathing patients, expiratory resistance will increase more than inspiratory resistance; in intubated patients, gas exchange may be dramatically altered.
•
Positive end-expiratory pressure (PEEP) should be reduced to avoid inadvertent large increases in PEEP due to increased expiratory resistance.
•
Patients undergoing bronchoscopy are always at risk for hypoxia. Therefore, supplemental oxygen should be given, and Sa
O2 should be maintained above 90% throughout the procedure.
•
Suctioning should be limited to the shortest possible time, because it removes gas from the lungs and may cause hypoxemia.
•
Diagnostic/therapeutic techniques:
•
Bronchoalveolar lavage (BAL):
•
Contamination from the upper airway occurs, because the bronchoscope traverses either the upper airway or ETT.
•
The procedure for BAL in children is not standardized.
•
The number and size of nonbacteriostatic saline aliquots instilled remains controversial, but typically 2 to 5 aliquots of 0.5 to 1 mL/kg, usually not exceeding 20 mL/aliquot, are utilized.
•
The usual return of BAL fluid is 40% to 60%. In most clinical laboratories, a minimum of 5 to 10 mL of BAL fluid is usually required to perform total cell and differential counts as well as standard pathologic and microbiologic studies.
•
The importance of total and differential cell counts and pathologic evaluation of BAL fluid should not be underestimated. Consultation with an infectious disease specialist, pathologist, and/or the microbiology laboratory may be helpful in prioritizing studies and improving diagnostic yield of BAL fluid studies.
•
The position of the ETT should be checked at the end of the procedure.
•
Protected specimen brush (PSB):
•
The brush is protected from upper airway contamination by an outer catheter and occluding plug.
•
While passed through the instrument channel of the bronchoscope, the sheathed brush does not come into contact with upper airway or ETT secretions.
•
Once catheter is in the distal airway, the plug is removed and the sample is collected.
•
Bronchoscopic needle aspiration (BNA):
•
Used for sampling of lymph nodes located in the paratracheal, subcarinal, and perihilar areas
•
Can be used in the diagnosis of endobronchial lesions
•
Used mostly in adults for the diagnosis and staging of thoracic malignancies
•
Laser bronchoscopy:
•
In patients with airway obstruction due to surgically unresectable malignancies
•
Preparation of airways for insertion of airway stents
•
Exclusively used in adults
After Procedure
Postprocedure Care
•
Careful monitoring should be continued after the procedure, at least until the child has returned to pre–flexible airway endoscopy neurologic and cardiopulmonary status.
•
The ability to rapidly reintubate the patient is essential.
•
Chest x-ray indicated in patients whose respiratory status does not return to preprocedure status for the evaluation of complications
Complications
•
Physiologic complications (more common):
•
Arrhythmias:
•
Vagal stimulation related to inadequate topical anesthesia
•
Myocardial sensitization due to hypoxemia
•
Inadequate sedation may cause excessive catecholamine release.
•
Direct mechanical stimulation of the airway
•
Bacteriologic complications (rare):
•
20% to 30% of patients will develop transient fever following BAL (always self-limited).
•
Spreading infection from one area of the lung to another is possible.
•
Spilling of local pus into other airways
•
Bacterial endocarditis prophylaxis should be undertaken in patients with congenital heart defects.
Outcomes and Evidence
•
Flexible bronchoscopy is an important tool in diagnosing and managing various pulmonary conditions in critically ill patients. Although special challenges exist for performing bronchoscopy in mechanically ventilated patients, if proper pre-procedural training and planning are done and the patient is monitored carefully during the procedure, bronchoscopy can be performed quickly and safely at the bedside in most critically ill patients.
•
Flexible bronchoscopy has a high diagnostic yield in immunocompromised patients with pulmonary infiltrates.
•
Bronchoscopy has been shown to be effective in removing retained secretions and improving atelectasis.
Suggested Reading
Wood RE, Fink RJ. Applications of flexible fiberoptic bronchoscopes in infants and children. Chest 1978;73(Suppl. 5):737-40.
Nicolai T. Pediatric bronchoscopy Pediatr Pulmonol 2001;31:150-64.
Balfour-Lynn IM, Spencer H. Bronchoscopy—how and when? Paediatr Respir Rev 2002;3:255-64.
Schellhase DE. Pediatric flexible airway endoscopy Curr Opin Pediatr 2002;14:327-33.
Bush A. Bronchoscopy in paediatric intensive care. Paediatr Respir Rev 2003;4:67-73.
Ernst A, Silvestri GA, Johnstone D. Interventional pulmonary procedures—guidelines from the American College of Chest Physicians. Chest 2003;123:1693-717.
Kerwin AJ, Croce MA, Timmons SD, et al. Effects of fiberoptic bronchoscopy on intracranial pressure in patients with brain injury—a prospective clinical study. J Trauma 2000;48:878-83.
Schneider W, Berger A, Mailänder P, Tempka A. Diagnostic and therapeutic possibilities for fiberoptic bronchoscopy in inhalational injury. Burns Incl Therm Inj 1988;14:53-7.
Hara KS, Prakash UB. Fiberoptic bronchoscopy in the evaluation of acute chest and upper airway trauma. Chest 1989;96:627-30.
Lee SL, Cheung YF, Leung MP, et al. Airway obstruction in children with congenital heart disease: Assessment by flexible bronchoscopy. Pediatr Pulmonol 2002;34:304-11.
Sidman J, Wheeler WB, Cabalka AK, et al. Management of acute pulmonary hemorrhage in children. Laryngoscope 2001;111:33-5.
Kreider ME, Lipson DA. Bronchoscopy for atelectasis. Chest 2003;124:344-50.
Davidson G, Coutts J, Bell G. Flexible bronchoscopy in pediatric intensive care. Pediatr Pulmonol 2008;43:1188-92.
Bar-Zohar D, Sivan Y. The yield of flexible bronchoscopy in pediatric intensive care patients. Chest 2004;126:1353-9.
Liebler JM, Markin CJ. Fiberoptic bronchoscopy for diagnosis and treatment. Crit Care Clin 2000;16:83-100.
Raoof S, Mehrishi S, Prakash UB. Role of bronchoscopy in modern medical intensive care units. Clin Chest Med 2001;22.
ERS Task Force: Flexible endoscopy of paediatric airways. Eur Respir J 2003;22:698-708.
ERS Task Force on bronchoalveolar lavage in children: Bronchoalveolar lavage in children. Eur Respir J 2000;15:217-31.
Peikert T, Rana S, Edell ES. Safety, diagnostic yield, and therapeutic implications of flexible bronchoscopy in patients with febrile neutropenia and pulmonary infiltrates. Mayo Clin Proc 2005;80:1414-20.
Walker RW. Management of the difficult airway in children. J R Soc Med 2001;94:341-4.
Nakamura CT, Ripka JF, McVeigh K, et al. Bronchoscopic instillation of surfactant in acute respiratory distress syndrome. Pediatr Pulmonol 2001;31:317-20.
Swanson KL, Prakash UB, Midthun DE, et al. Flexible bronchoscopic management of airway foreign bodies in children. Chest 2002;121:1695-700.
Wood RE. Pitfalls in the use of the flexible bronchoscope in pediatric patients. Chest 1990;97:199-203.
Thoracentesis and Thoracostomy: Before Procedure
Indications
•
Thoracostomy:
•
Pneumothorax:
•
Pneumothorax in patient on positive pressure ventilation with concern the pneumothorax can develop tension
•
Needle thoracentesis:
•
Emergent drainage of tension pneumothorax
•
Diagnosis of type of pleural effusion
Contraindications
•
No absolute contraindications
•
Small effusions may be too difficult to drain without risking injury to the lung.
•
Coagulopathy; relative contraindication; should be corrected prior to chest tube placement if time allows
•
Abnormal anatomy such as scoliosis may make the procedure more risky.
•
Overlying skin infection
Equipment
•
For either procedure:
•
1% lidocaine local analgesia
•
Skin preparation, preferably with 2% chlorhexidine
•
Sterile towels and gloves
•
Syringes: slip tip for aspiration and with needles for lidocaine injection
•
Sterile container to receive pleural fluid sample
•
Thoracentesis:
•
Styleted needle:
•
Such as IV catheter, which has the advantage that once the stylet is removed, the catheter remaining in the chest is soft and pliable,
•
Length depends on the size of the patient.
•
Small infants and children: a catheter longer than 2 inches in length is rarely indicated.
•
Larger adolescents or obese children may need catheters 3 to 4 inches in length.
•
Thoracostomy:
•
Chest tube of appropriate size:
•
Depending on patient size and size of intercostal space
•
Larger chest tube is necessary for blood or purulent fluid
•
Smaller tube or pigtail type catheter can be used if draining pneumothorax or transudative or chylous fluid
•
Soft multi-holed pigtail catheters are useful for draining transudative or chylous pleural effusions and simple pneumothoraces not associated with bronchopleural fistulae.
•
Drainage system:
•
Pleur-Evac system with suction if draining a pneumothorax or complex effusion or blood
•
Simple collection bag if transudative or chylous fluid
•
Steel needle, guidewire, and dilator if using Seldinger technique
Anatomy
For either procedure in any location, the needle should be advanced over the top of the rib and into the pleura to avoid injuring the intercostal vessels that run along the inferior aspect of each rib. For emergent needle drainage of a pneumothorax, the patient should be lying supine and the needle placed in the second or third intercostal space in the midclavicular line. For chest tube placement for pneumothoraces, it is preferable to use the fourth intercostal space in the midaxillary line. For drainage of effusions, the needle should be placed either along the midaxillary line or infrascapular where the fluid is greatest. Determining the optimal location for drainage of complex effusions that may be loculated is best done using ultrasound guidance. For placement of the chest tube for large pleural effusions and pneumothoraces, the fourth intercostal space in the midaxillary line is also used.
The position of the patient for needle thoracentesis again depends on the location of the fluid and on the age, size, and stability of the patient. An older child who is stable and cooperative can be seated during the procedure, allowing a posterior approach, which for most nonloculated effusions is optimal. However, unstable children, smaller infants, or any child who needs sedation should be placed in a supine or in a slight decubitus position.
Ultrasound of the chest can be performed to identify the best location for draining the fluid, particularly if the fluid may be loculated, either due to the fluid being purulent or the patient having had previous chest surgery or chest tubes. The ultrasound can be used just to “mark” the best location for drainage or can be used to actually guide the needle insertion.
Procedure
•
Sedation and analgesia: chest tube placement is particularly painful, and sedation and analgesia must be provided that is appropriate for the age and condition of the patient.
•
Skin is prepared for sterile procedure.
•
A 1% lidocaine local analgesic is infiltrated using a small-gauge needle into the skin over the intercostal space to be used. Then, using a longer but still narrow-gauge needle, lidocaine is infiltrated into the subcutaneous tissue, intercostal muscle, and pleura. Care is taken to aspirate as the needle is advanced to avoid intravascular injection of the lidocaine.
•
Needle thoracentesis:
•
The catheter is then advanced through the numbed tissue using a slip tip syringe to aspirate as the needle is advanced. When the needle passes through the pleura, there usually is a “pop,” as the pleura is a “tougher” tissue. Air or fluid is then able to be aspirated. The stylet in the needle can then be removed and the more supple catheter left in the pleura for further aspiration of either the tension pneumothorax or the effusion.
•
Tube thoracostomy; two techniques are used:
•
Standard cutdown technique:
•
After instillation of the local analgesic, a small incision is made that will be slightly larger than the diameter of the chest tube.
•
Mosquito-type forceps are inserted through the incision and tunneled up one rib space then rotated so that the points of the forceps are aiming toward the pleura.
•
They are then advanced over the superior aspect of the rib and through the pleura. Generally, the pleura will give, often with a “pop.”
•
The chest tube is then guided through the defect in the pleura and into the pleural space. Posterior placement of the chest tube is generally optimal for drainage of fluid. Anterior placement, in a patient lying supine, is generally optimal for drainage of a pneumothorax. Occasionally for patients with severe ongoing air leaks requiring prone and supine positioning, placement of anterior and posterior chest tubes may be needed to provide adequate continuous drainage of the pneumothorax.
•
The chest tube is secured with suture and the incision closed with a purse string closure, with the suture wrapped and tied around the chest tube.
•
The tube should also be secured to the child’s side with either tape or a chest-tube securing device (commercially available) to prevent the tube from being pulled out when the child becomes more active.
•
A clean dressing may be applied, but if the site is wet from ongoing drainage, a dressing need not be placed; the area can simply be kept clean and dry.
•
Seldinger technique:
•
After instillation of local analgesia, a hollow needle is introduced into the pleural space while aspirating with a slip tip syringe.
•
When air (in the case of a pneumothorax) or fluid (in the case of an effusion) is aspirated, the syringe is carefully removed, and the guidewire is passed into the pleural space. The wire should advance easily.
•
Once the wire is in place, a small nick the diameter of the chest tube is made in the skin at the needle entry point.
•
The needle is removed and the dilator passed over the wire and through the pleura; then the dilator is removed.
•
The chest tube or pigtail catheter is then passed over the wire. The chest tube may need progressively larger dilators and should have a trocar in it to better advance the tube through the pleura. The wire and trocar are then removed.
•
The tube or catheter is connected to the drainage system, sutured into place, and a dressing applied.
After Procedure
Postprocedure Care
•
A chest x-ray should be performed post procedure to document chest tube location, resolution of the pneumothorax or effusion, and note any new problems related to the tube.
•
If using a closed suction system, patency of the chest tube should be regularly assessed. Regular documentation of the amount of fluid removed should occur. The pigtail catheters may have to be flushed with heparinized saline to maintain patency.
•
Dressing should remain dry or be replaced if not.
Complications
•
Bleeding from the chest wall or lung can occur with or without coagulopathy.
•
Mechanical problems with the tube:
•
Side holes being outside the pleural space
•
The tube itself being placed into the subcutaneous tissue and not the pleural space
•
Occlusion of the tube with fluid or pus
•
Failure of the drainage system, resulting in reaccumulation of a pneumothorax
•
Laceration of the heart, pulmonary artery, diaphragm, liver, or spleen
Outcomes and Evidence
•
Thoracentesis is a safe traditional means of removing pleural fluid for diagnosis and drainage.
•
Thoracostomy can be safely performed in patients of any age and size.
•
The Seldinger technique with placement of a pigtail catheter can be used to effectively drain either pneumothoraces or pleural effusions.
•
In a retrospective review of chest tube placement in pediatric patients in an emergency department, it was noted that the pneumothoraces were all drained in both the pigtail group and the large-bore chest tube group. The patients in the pigtail group appeared to have less pain than the patients with standard chest tubes.
•
In another retrospective chart review of pediatric inpatients who had chest tubes placed, pigtails were noted to be as efficacious in draining serous and chylous pleural as standard chest tubes but less effective in drainage of hemothoraces and not effective in draining purulent effusions.
Suggested Reading
Fiser DH, Graham J, Green J et al. Pediatric Vascular Access and Centeses. In: Fuhrman B, Zimmerman J, editors. Pediatric Critical Care. St Louis: Mosby Elsevier; 2006. p. 151.
Dull KE, Fleisher GR. Pigtail catheters versus large-bore chest tubes for pneumothoraces in children treated in the emergency department. Pediatr Emerg Care 2002;18:265-7.
Roberts JS, Bratton SL, Brogan TV. Efficacy and complications of percutaneous pigtail catheters for thoracostomy in pediatric patients. Chest 1998;114:1116-21.
Ahmed MY, Silver P, et al. The needle-wire-dilator technique for the insertion of chest tube in pediatric patients. Pediatr Emerg Care 1995;11:252-4.
Milikin JS, Moore EE, et al. Complications of tube thoracostomy for acute trauma. Am J Surg 1980;140:738.
Pericardiocentesis and Pericardiostomy: Before Procedure
Indications
•
Cardiac tamponade or impending tamponade due to a pericardial effusion or rarely, in small infants, pneumopericardium
•
Rarely for diagnostic drainage of a pericardial effusion
Contraindications
•
When cardiac tamponade is present, there is no contra-indication.
•
Relative contraindications:
•
Inexperience of the operator
•
Loculation of the effusion
•
Loculation of the effusion where it cannot be reached percutaneously
•
Abnormal patient anatomy
•
Certain situations may be better treated with open pericardiotomy and tube placement, such as hemopericardium, particularly from penetrating trauma, purulent pericarditis, or loculated pericardial effusions with localized tamponade. However, if the patient is acutely in cardiac tamponade, pericardiocentesis can be performed while surgical pericardiotomy is being arranged.
Equipment
•
Sedation: patient should be sedated for both comfort and safety to avoid inadvertent movement that could result in injury to the heart.
•
Sterile gloves and towels
•
1% lidocaine local analgesia
•
Hollow introducer needle
•
Flexible J guidewire that fits through the needle
•
Connecting tubing, stopcock, collection bag
•
Echocardiography equipment
Anatomy
The patient is placed with the head elevated 30 degrees. The safest and easiest approach is the subxiphoid approach, although other approaches have been described. The needle is inserted at the junction of the xiphoid and the left costal margin and is directed toward the left shoulder.
Procedure
•
For emergent cardiac tamponade with or without cardiac arrest, blind needle aspiration with or without tube insertion is indicated.
•
In less acute situations, echocardiographic assessment and direction is indicated:
•
The pericardium is scanned to note the size and location of the fluid, presence or absence of loculated fluid, quality of fluid—whether there is evidence of blood or pus—and presence of cardiac tamponade. Cardiac tamponade is diagnosed by collapse of the right atrial wall, diastolic compression of the right ventricle, abnormal tricuspid and mitral flow velocities with inspiration, and dilated inferior vena cava with lack of collapse during inspiration.
•
The patient is placed on a cardiac monitor to watch for arrhythmias.
•
The skin is sterilely prepped and draped.
•
Lidocaine 1% local analgesia is infiltrated in the skin subxiphoid and then directed toward the lower left costal margin, being careful to aspirate prior to injection.
•
The syringe is carefully removed, and the J-type wire is passed through the needle; its position in the pericardium is confirmed with the echocardiogram.
•
A small nick is made in the skin the diameter of the catheter.
•
The needle is removed, leaving the wire in the pericardial space, and the dilator is passed over the wire. Again, the wire position is confirmed with the echocardiogram.
•
The dilator is then removed, and the catheter is passed over the wire; the position is again confirmed echocardiographically.
•
The wire is then removed and the stopcock and tubing connected to the catheter. The catheter is then aspirated.
•
The catheter is secured with suture, and the site sterilely dressed.
After Procedure
Postprocedure Care
•
The catheter should be allowed to drain passively into a collection bag. The patency of the catheter should be checked and if determined to not be patent, a small amount of sterile heparinized saline can be injected into the catheter to clear any clots or fibrin debris.
•
The dressing should be changed according to CVL dressing standard.
Complications
•
Myocardial perforation may occur but may not result in any significant injury if the ventricle is entered. However, a laceration can occur, resulting in bleeding into the pericardial sac, causing or worsening tamponade.
•
Coronary laceration is a rare occurrence and can result in acute cardiac ischemia and may require emergent operative intervention. It can be associated with death.
•
Entering the pleural space can occur and thus a risk of pneumothorax or hemothorax.
•
Injury to the diaphragm and abdominal viscera can occur as well as pneumoperitoneum or hemoperitoneum.
Outcomes and Evidence
•
Percutaneous drainage of pericardial effusion can be safely performed in children.
•
Echocardiographic guidance improves both success and safety of the procedure.
•
In a data analysis of a prospective echocardiography database of adults, pericardiocentesis performed for tamponade was successful in relieving tamponade in 99% of patients and was the definitive therapy in 82%, with only a 3% incidence of complications.
•
Similar studies in pediatric patients are not available.
Suggested Reading
Zahn EM, Houde C, et al. Percutaneous pericardial catheter drainage in childhood. Am J Cardiol 1992;70:678-80.
Fowler NO. Cardiac tamponade. A clinical or an echocardiographic diagnosis? Circulation 1993;87;1738-41.
Sobol SM, Thomas JM Jr, Evans RW. Myocardial laceration not demonstrated by continuous electrocardiographic monitoring occurring during pericardiocentesis. N Engl J Med 1975;292:1222.
Duvernoy O, Borowiec J, Helmius G, et al. Complication of percutaneous pericardiocentesis under fluoroscopic guidance. Acta Radiol 1992;33:309.
Zahn EM, Houde C, et al. Percutaneous pericardial catheter drainage in childhood. Am J Cardiol 1992;70:678-80.
Armstrong G, Cardon L, Vikomerson D, et al. Localization of needle tip with color Doppler during pericardiocentesis: in vitro validation and initial clinical application. J Am Soc Echocardiogr 2001;14:29.
Duvernoy O, Borowiec J, Helmius G, et al. Complication of percutaneous pericardiocentesis under fluoroscopic guidance. Acta Radiol 1992;33:309.
Maisch B, Seferovic PM, Ristic AD, et al. Guidelines on the diagnosis and management of pericardial diseases: Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. Eur Heart J 2004;25:587.
Tsang TS, Freeman WK, Barnes ME et al. Rescue echocardiographically guided pericardiocentesis for cardiac perforation complicating catheter-based procedures. The Mayo Clinic experience. J Am Coll Cardiol 1998;32:1345.
Tsang TS, Enriquez-Sarano M, Freeman WK et al. Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: clinical profile, practice patterns, and outcomes spanning 21 years. Mayo Clin Proc 2002;77(5):429.
Intracranial Pressure Monitoring: Before Procedure
Indications
•
Cerebral edema:
•
Medical causes:
•
Medical encephalopathies such as diabetic ketoacidosis and Reye syndrome
•
Meningitis or encephalitis with evidence of cerebral edema
•
The use of ICP monitoring in global hypoxic-ischemic injury such as near-drowning after prolonged cardiac arrest is less useful and may not be indicated.
Contraindications
•
Coagulopathy is thought to be an absolute contraindication.
•
Massive cerebral edema with slit-like ventricles may not allow placement of an intraventricular device but will allow a tissue pressure monitor.
Equipment
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The available monitoring systems are discussed in detail in textbook
Chapter 31 on central nervous system monitoring in adults. Specific pediatric data on the advantages or disadvantages of these systems are lacking.
Anatomy
Refer to Chapter 31; same landmarks as adult.
Procedure
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Should be performed by a neurosurgeon skilled in pediatric care
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Sedation and analgesia should be provided that is appropriate for the patient’s age and clinical condition.
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Preparation and procedure guidelines are same as adult placement.
After Procedure
Postprocedure Care
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With the head of the patient elevated at 30 to 45 degrees, the zero reference point for the particular ICP monitoring system should be placed at the outer canthus of the patient’s eye.
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The ICP monitor must be transduced at all times. Tissue monitors can only be zeroed at the time of insertion. Intracranial monitors can be zeroed regularly and should be zeroed at least every 12 hours.
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The drip chamber of the ICP monitors will be at the level designated by the physician for optimal CSF drainage. For patients with increased ICP, some CSF should drain, but too-rapid drainage can result in ventricular collapse and herniation.
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For pressure readings. the system must be off for drainage and open to the patient.
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Components of the system should not be replaced unless a new ICP system is placed or if the components become contaminated.
Complications
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Intracranial infection; most common but still relatively uncommon
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Intracerebral hemorrhage, especially if coagulopathy exists or develops with monitor in place; may occur at insertion or over time; may be intraparenchymal or intraventricular
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Blockage of pressure monitoring with blood or tissue
Outcomes and Evidence
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Increased ICP is associated with decreased survival and poor neurologic outcome. It may be difficult to diagnose in pediatric patients, especially the extent of the increased pressure, so monitoring is warranted.
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Multiple studies as well as consensus practice have shown that aggressive management of increased ICP after TBI may reduce secondary brain injury in both adults and pediatric patients.
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Because of the widespread use of ICP monitoring, no randomized controlled trial in patients with TBI would be possible.
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In a study comparing the Camino tissue monitor with intraventricular pressure monitor in pediatric patients, there was good correlation between the two measurements in the same patient on the same day.
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In a prospective uncontrolled study of complications of tissue pressure monitors in pediatric patients, 7% developed positive tip cultures (risk increased with length of monitoring), and 13% developed loss of waveform, but overall the monitors were safe, especially when used for less than seven days.
Suggested Reading
Adelson PD, Bratton SL, Carney NA, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents. Pediatr Crit Care Med. 4(3 Suppl), 2003.
Bullock R, Chesnut RM, Clifton G, et al. Guidelines for the management of severe traumatic brain injury. J Neurotrauma. 2000;17:451-553.
Blaha M, Lazar D, et al. Hemorrhagic complications of intracranial pressure monitors in children. Pediatr Neurosurg. 2003;39:27-31.
Pople IK, Muhlbauer MS, et al. Results and complications of intracranial pressure monitoring in 303 children. Pediatr Neurosurg. 1995;23:64-67.
Gambardella G, Zaccone C, Cardia E, et al. Intracranial pressure monitoring in children: Comparison of external ventricular device with the fiberoptic system. Childs Nerv Syst. 1993;9:470-473.
Jensen RL, Hahn YS, Ciro E. Risk factors of intracranial pressure monitoring in children with fiberoptic devices: A critical review. Surg Neurol. 1997;47:16-22.
