INSTRUMENTS AND PROCEDURES

IN
PAEDIATRICS

Dr. Ajero Jeremiah

 INTRODUCTION
The knowledge of instruments and procedures in
Paediatrics cannot be over emphasized.

For better understanding, the instruments and

procedures have been arranged according to
systems.

However, we would start with some instruments

used generally.
 GENERAL INSTRUMENTS
 Needle and Syringe
 Water for Injection
 Weighing Scale & Standiometer
 Stethoscope
 Tape Measure
 Cannula
 Pen Torch
 Clinical Mercury Thermometer
 Wrist watch
 Biohazard Safety Box
 Fluids & Fluid Giving Set
I. Solucet
II. Blood Giving set
III. I.V.F Giving Set
 Specimen Bottles
NEEDLE AND SYRINGE

Types of Needles
Orange – 25 G
Blue- 23 G
Green- 21 G
Black- 19 G

Types/Sizes of Syringe: 10ml, 5ml, 2ml, 1ml

Uses
• Obtaining Blood Samples
• Administration of Drugs.
• Aspiration of fluid e.g. . Pleural, Pericardial,
Peritoneum.
• Inflation of a Catheter’s Balloon.
• Suprapubic Aspirate
WATER FOR INJECTION

Indications
• Reconstitution of Vaccines. E.g. BCG Vaccine.
• Dilution of Drugs. E.g. Calcium Gluconate
• Production of Suspension from powdered drugs.
E.g. Hydrocortisone.
• Inflation of catheter balloon after catheterization.
• Used in Nebulization to administer drugs by
aerosol.
 WEIGHING SCALE

Digital Bathroom Scale

Salter Baby Weighing Scale Digital Clinical Scale

 Used for:
• Children <2years

Bassinet Weighing Scale (Digital & Analogue)

Used for:
• Children >= 2years that can stand.
• Unconscious, worrisome or very ill patients
by subtracting the care giver’s weight from
the weight obtained when he or she is
carrying the child.

Weighing Scale with a Standiometer

 General Uses of Weighing Scale

A. Diagnostic Purposes
• Protein Energy Malnutrition
• Macrosomic Baby
• Large for Gestational Age
• Small Gestational Age
• Failure To Thrive

B. Therapeutic Purposes
• Calculation of Drug, fluid and drug to be administered.

C. Monitoring
• Protein Energy Malnutrition
• Growth Monitoring
• Monitoring of response in Ascites or fluid retention.
STETHOSCOPE

Uses: It is used to listen to sounds which are inaudible to the

unaided ear.
• Bell: used to detect soft low - pitched sounds e.g. murmurs,
bowel sound.
• Diaphragm: used to detect high-pitched sounds. E.g. heart
sounds & respiratory sounds.

Sounds Detected by the Stethoscope in different system

include:
• CVS: heart sounds, murmurs, bruit(renal artery stenosis)
and blood pressure measurement (Korotkoft sounds),
pericardial rub.
• RS.: Breath sounds, crepitation(heart failure & pneumonia)
and rhonchi(Obstructive Airway diseases).
• Abdomen: Bowel sounds.
FLEXIBLE INELASTIC TAPE MEASURE

Uses
1.Anthropometric measurements
• Length (supine < 2 years)
• Occipitofrontal circumference
• Mid arm circumference
• Chest circumference
2. Measuring muscle bulk
3.Measuring length of viscera e.g. liver span (6-8cm in children
and 8-12 cm in adults)
4.Measuring the dimensions of other abdominal masses
5. Measuring abdominal girth in ascites.
6. Measuring apparent and real length of limbs in
Musculoskeletal examination
Shakir strip/ Flexible inelastic tape measure:

Uses:
• MUAC:
• Used for rapid community assessment of malnutrition.
CANNULA AND SIZES

SIZES OF CANNULA
1. Orange- 14 G
2. Grey- 16 G
3. Green- 18 G
4. Pink- 20 G
5. Blue - 22 G
6. Yellow- 24 G
Mnemonic: "Oh Great Green Please Be Yellow“

USES
• Administration of IV infusion fluids.
• Transfusion of blood and blood products.
• Administration of IV drugs.
• Obtaining blood samples for laboratory investigations.
Clinical Mercury Thermometer

Use: Used to measure body temperature.

Types:
• Temporal Thermometer
• Rectal Thermometer
• Oral Thermometer
• Tympanic Thermometer
• Liquid Crystal Forehead strips

Note:
• Normal core temperature is 36.50 C to 37.20 C
• Gold standard for temp measurement is
traditionally rectal which gives a value about 1.0 C
and 0.40 C above the axillary and oral respectively.
• Fever: Rectal >38, Oral > 37.6, Axillary > 37.2
PEN TORCH

Indications
1. To elicit pupillary reflexes
2. To examine the anterior segment of the eye
3. To elicit transillumination in cystic masses
4. To examine the nasal cavity
5. To examine the buccal cavity
BIOHAZARD SAFETY BOX

It is a receptacle labeled for the exclusive

disposal of medical objects and supplies used
by laboratories and healthcare facilities.

It is use to dispose:
• Sharp instruments (i.e., needles, syringes)
• Lab specimen.
• Culture/broth mediums etc.
WRIST WATCH

Uses:
1) To track and record patient vitals.
2) To keep track of the schedule for administration of
medications.
3) To perform pain assessments.
4) For documentation and charting.
5) To keep track of The Time.
FLUIDS & FLUID GIVING SET
1. SOLUCET

Drops/min: (Volume * Constant) / Time (mins)

Features
• Solucet Canister (vol. 150ml) allows delivery of smaller
amounts of fluid, and thus indirectly prevents fluid
overload.
• Graduated.
• Has a diaphragm .
• Has a special point for IV injection without interrupting
the flow of IV fluid .
• No need to puncture the bag before setting up the
line thereby preventing air embolism.
• Delivers 60 drops per mI (constant).
2. BLOOD GIVING SET

Use: For Transfusion of blood and blood derived

products.

Delivers 15 drops per ml (Constant).

3. INTRAVENOUS FLUID GIVING SET

Uses
Used in Administration of intravenous fluids.

Features:
• Has no sieve or filter.

• It is plain (no other special effects).

• Delivers 20 drops per ml (Constant).

 FLUIDS
1) RINGER’S LACTATE
Composition:
• Na - 13 mmols/L
• K - 4mmols/L
• Ca-3mmols/L
• Cl - 109 mmols/L

Indications for Ringer's lactate:

• Severe dehydration (Shock) but patient should be well nourished.
• Hypovolemia.
• Acidosis (cause of Calcium lactate).

Contraindication:
• Cerebral Odema
• Lactic Acidosis
• Metabolic alkalosis
• Severe renal insufficiency
• Liver Dysfunction
2) 0.9% NORMAL SALINE
Composition
Na- 30mmols/L
Cl- 154mmols/L

Indications for normal saline.

• Plasma expander in shock (20 - 30mlskg).
• Moderate-Severe dehydration.
• Partial exchange transfusion.
• Irrigation of the eye in conjunctivitis
• Gastric washout / aspirate
• Irrigation of wounds
• Cold saline lavage
• Saline enema.
• Administration of nebulized drugs
• On-table lavage (Intra-op)
• Administration of anti-snake venom
• Transport of biopsy specimen (improvised).

Contraindications:
Metabolic acidosis
3) DARROW’S SOLUTION

Types:
• Half strength. (K- 18mmols/L, Cl- 52mmols/L, HCO3- 27mmols/L)
• Full strength (not used because of its high K+ content). It is used in the
management of hypokalemia

Indications for half-strength Darrow's solution:

• Gastrointestinal indications: Paralytic ileus, Diarrhoeal diseases, Severe
malnutrition.

• Renal indications: Drug induced hypokalemia e. g Furosemide, Wilson's disease,

Drugs: lithium, amphotericin, Fanconi's syndrome, Bartter's syndrome, Renal
hypertension secondary to renal artery stenosis.

• Endocrine indications: Secondary hyperaldosteronism (Liver cirrhosis, heart

failure) Diabetic ketoacidosis.
Contraindications:
• Severe dehydration Shock.
• Acute Kidney Injury.
• Burns.
• Immediate Post-operative Period .
• Severe crush injury (Rhabdomyolysis).
• Patients on drugs such as Potassium Sparing diuretics (Spironolactone,
Amiloride) ACE I, ARBS B-blockers, cytotoxic drugs and suxamethonium.
• Hypoaldosteronism.

Alternatives to Potassium replacement

• KCI
• КзРО4
• Potassium enhancing drugs (spironolactone)
• Potassium citrate Potassium acetate
4) 4.3% DEXTROSE IN 0.18% NORMAL SALINE

Composition:
• Na=30mmols/L;
• Dextrose=236mmols/L
• Cl=30mmols/L

Indication:
• Used in maintenance fluid therapy.
• Dextrose Saline for a child who can eat.
• Dextrose Saline for a child who cannot eat but is normoglycaemic.
• D12.5 or bolus dextrose 6 hourly in a child who cannot eat but is hypoglycemic.

Contraindication
• Hyperglycemia
• Hypokalemia
5) 50% DEXTROSE

Uses
• To increase glucose concentration of other fluids as in
preparation of D10 and D12.5.

In D12.5, 75mL of 50% dextrose is added to the bag of 4.3%

(instead of 50mL of D10).

• In the management of hyperkalemia

• Correction of hypoglycemia

Contraindication:
Hyperglycemia
Hypokalemia
6) CALCIUM GLUCONATE

Uses:
• Hypoglycemia
• Hyperkalemia
• In EBT

Precaution:
• Should be administered slowly by push Patient
• Should be monitored with ECG because excessive Ca
infusion may lead to cardiac arrest in systole.
• A secured IV line must be present. Extravasation causes
severe sloughing and tissue burns or necrosis often
requiring skin grafting.
7) SODIUM BICARBONATE

Uses:
• Metabolic acidosis in DKA.
• Diarrhoeal diseases.
• Hyperkalemia.
• Alkalinization of urine e.g. in TLS.

Complications:
• Fluid overload (from Na*)
• Tetany (from HC03)
 DIAGNOSTIC SET
1. AUROSCOPE / OTOSCOPE

Indications:
• Infections. E.g. Otitis media, Otitis externa, Bullous
myringitis, Chronic serous otitis media.

• Foreign bodies in the ear Trauma to the ear.

• Neoplasms of the ear.

2. TONGUE DEPRESSORS

Types
• Wooden (disposable)
• Metal.

Parts
• The curved end is used by the examiner for holding the instrument.
• The flat end is introduced unto the oral cavity.

Uses:
I. Examination of oral cavity.
II. To test for gag reflex.
III. For posterior Rhinoscopic examination.
IV. In examination of the oral cavity or throat.
V. Peritonsillar abscesses.
Throat swabs can be performed simultaneously with the examination.
 Parts:
3. OPTHALMOSCOPE • Two (2) Apertures
• Filter
• Mirrors
• Lens adjuster
• Moveable switch
• Self-illuminating electrical device

Indications:
1. To detect raised intra cranial pressure as evidenced by
blurring of the outline of the disc (papilloedema, a late
sign, unlikely to be seen in children when fontanelles
have not yet closed) .
2. To check for the Choroid tubercles which are
pathognomonic of Tuberculous meningitis.
3. To check for the dot and blot haemorrhages of diabetic
retinopathy.
4. To check for the cotton wool or flames haemorrhages of
hypertensive retinopathy.
5. To check for retinal haemorrhages in children with
cerebral malaria - indicative of poor prognosis.
4. NASAL SPECULUM
Parts:
Speculum and the self-illuminating device.

Indications:
• Nasal discharge.
• Epistaxis.
• Nasal polyps.
• Foreign body
 Parts:
5.Laryngoscope • Vertical handle.
• Horizontal part (blade) which manipulates the tongue.

Types:
• Curved blade laryngoscope (Macintosh Laryngoscope) used in older
children and adults.
• Straight blade laryngoscope (Magill) Laryngoscope used in neonates.

Uses.
• For detailed examination of the larynx.
• For removal of foreign body from the larynx.
• For intubation and suction of the lungs in neonates to prevent
meconium aspiration.
• For examination of congenital abnormalities i.e. Laryngeal webs.
• For intubation.

Contraindications
• Acute epiglottis.
• Laryngeal diphtheria.
• Pertussis.
6. LARYNGEAL MIRROR

Parts:
• Long slender rod.
• Small circular mirror mounted at the tip of
the rod.

Indications:
• Visualization of base of tongue, larynx and
piriform fossa
• Removal of foreign bodies like fish bone ill.
SPECIMEN BOTTLES

Types
A) Anti-coagulated bottle. E.g. Include
• EDTA bottle.
• Lithium Heparin bottle.
• Fluoride oxalate.
B) Non-anticoagulated bottles/ Plain bottles.
• Ordinary Plain Bottle.
• Universal bottle.
• Cryobottles.
1) ETHYLENE DIAMINE TETRA ACETIC ACID (EDTA) BOTTLE
• Bottle Cap=Green cap
• Anticoagulant= EDTA
• Mechanism of Action of Anticoagulant=The Na+ or K+ salt of EDTA chelates Ca2+
making it unavailable to partake in the coagulation cascade, thus impeding clotting.
• Preservative: EDTA
• Mechanism of Action of Preservative= Maintains membrane integrity.

• Uses:
1. Full Blood Count
2. Reticulocyte Count (for hemolytic and aplastic conditions).
3. Packed Cell Volume.
4. Red cell enzymes.
5. Red cell membrane protein.
6. Peripheral Blood film.
7. Erythrocyte Sedimentation rate.
8. Hb Electrophoresis (Hb Genotype).

• Contraindications:
• Not used in the Measurement of Ca2+ because it chelates calcium.
• Not used in the measurement of K+ because it contains potassium and would
give pseudohyperkalemia.
2) LITHIUM HEPARIN BOTTLE.
• Bottle Cap= Blue/yellow
• Anticoagulant= Heparin
• Mechanism of Action of Anticoagulant= Heparin potentiates
the effect of Antithrombin III (a natural anticoagulant), which
inhibits clotting factors II, X, XI and XII. Its anticoagulant effect
is not associated with any change in composition hence, it is
the best anticoagulant.
• Uses:
• Mainly for electrolytes Electrolyte analysis (Na2+, K+, CI,
HCO3-, Ca2+, PO4, Mg2+).
• Plasma Urea and Creatinine .
• Plasma Uric acid assay.
• Plasma AST and ALT Hormone assay.
• Plasma Total Albumin and Protein estimation.
• Contraindications:
• Serum tests.
• Plasma glucose because blood cells still metabolise the
glucose & even if you measure glucose, it wouldn’t be
accurate.
• Measurement of Lithium because it contains lithium.
(especially in psychiatric patients e.g schizophrenia whose
drugs for treatment contains lithium).
 3) Fluoride oxalate.
• Bottle Cap= Yellow
• Anticoagulant= Oxalate
• Mechanism of Action of Anticoagulant= It chelates calcium
• Preservative: Fluoride
• Mechanism of Action of Preservative= inhibits the enolase, a glycolytic enzyme
(2- phosphoglycerate to phosphoenolpyruvate) in the glycolysis pathway, thus
inhibiting further breakdown of Glucose and glucose level

• Uses:
• Fasting Blood Sugar
• Random Blood Sugar
• CSF Biochemistry
• Serous Fluid Biochemistry (Pleural, pericardial and peritoneal fluid)

• Contraindications:
• Calcium measurements.
• Urea level (Fluoride inhibits urease).
• Serum test.
4) ORDINARY PLAIN BOTTLE.

• Bottle Cap= Red

• Anticoagulant= None; hence it allows the blood to clot within 2 -
7minutes which results in the production of serum (not plasma)
• Uses:
• Cirrhosis, Multiple Myeloma, Nephrotic syndrome etc).
• Combs' Test -Antibody assay (Immunoglobulin assay)
• Blood Grouping and cross matching.
• Serum Bilirubin (Total and Conjugated).
• Enzyme assay e.g. Liver enzymes like ALT, AST, ALP and others like -
Serum Lipase and Amylase.
• Serum protein electrophoresis (Liver

• Contraindications:
• Plasma Tests
5) UNIVERSAL BOTTLE

• Bottle Cap= White

• Uses:used for other body samples asides blood.

• Urine sample for microscopy, culture and
sensitivity(MCS)
• Stool sample for MCS
• CSF sample for MCS
• Serous fluid sample for MCS
• Skin eruption fluid sample for MCS
• Gastric washout sample for Acid Fast Bacilli

• Contraindications:
• Plasma tests.
6) CRYOBOTTLES
• Uses:
• Used to store samples for a long time.

• Advantage:
• They can withstand extreme cold
temperatures.
BLOOD CULTURE BOTTLE
• Bottle Cap=
• Preservative = Thioglycate salts
• Mechanism of Action of Preservative = This bottle contains thioglycate
salts, which facilitate the growth of aerobic organisms at the top and
anaerobic organisms at the bottom

• Uses:
• Used in the diagnoses of certain conditions like Septicaemia
Osteomyelitis Typhoid and Enteric fever Infective endocarditis

• False Negatives
• Prior use of antibiotics
• A non-bacterial infection e.g. fungal endocarditis
• A bacterial infection due to slow growing organisms or anaerobes
 INSTRUMENTS IN RESPIRATORY SYSTEM

1. Suctioning Machine
2. Nebulizer
3. Spacer Device
4. Metered Dose Inhaler (MDI)
5. Peak Flow Meter
6. Endotracheal Tube
7. Oropharyngeal Airway
Suctioning Machine

Parts:
• Pump
• Vacuum and a container made up of two
underwater seal jars.
• Rubber tubing and nozzle.

Indications
• For suctioning in Paediatrics.
• To clear the airway of secretions especially
during resuscitation.
• To empty gastric contents.
 Definition: is a compartment in which liquid drugs can be acted upon
by a driving force, converting it into aerosol which can be inhaled into
NEBULIZER respiratory tracts through a face mask. It is used to deliver higher doses
of a drug to the airways than is usual for standard inhalers.

Parts:
• Nebulizer chamber.
• Mouth piece or face mask.
• Compressor unit.

Indications
1. To deliver a beta agonist or ipratropium bromide to a patient with
acute exacerbation of asthma or chronic airway obstruction.
2. To deliver a beta agonist on a regular basis to a patient with severe
asthma who has been shown to benefit from higher doses.
3. To deliver prophylactic medication in asthma such as sodium
cromoglycate or a corticosteroid to a patient unable to use other
inhalation devices (esp. in a young child).
4. To deliver antibiotics such as colistin in chronic purulent infections
like bronchietasis.
5. To deliver salbutamol in treatment of hyperkalemia.
METERED DOSE INHALER (MDI)

Definition: These are devices that produce aerosols under

pressure in Puffs, with each puff containing a specific quantity of
the drug e.g. 1puff = 100ug

Indications
1. Relievers are indicated when the following features of acute
exacerbation of asthma are present:
• Too breathless to talk.
• Too breathless to feed.
• Respiratory rate more than 40 breaths/min.
• Pulse rate more than 140 beats/min.
• Use of accessory muscles of respiration.
• Peak flow rate of 50% of the best or predicated by the
height.
2. Preventers are indicated in moderately severe
asthma where the peak flow rate is < 60% of the
expected.

Contraindications: It is not used when there're life

threatening features of severe asthma such as:
• Cyanosis
• A silent chest.
• Poor respiratory effort.
• Fatigue or exhaustion.
• Agitation or reduced level of consciousness
• Peak flow rate < 33% of predicted value
SPACER DEVICE

Definition: These are materials used together with the MDI.

Use: They provide a space between the inhaler and the mouth.

Parts:
• Spacer chamber- the larger the volume, the more effective it.
• There's a unidirectional valve which allows a one sided flow of the aerosol
and prevents dilution by the breath of the patients.
• There are two openings one for the MDI and the other for a face mask.

Indications for spacer:

• Young children
• Poor inhalation technique
• Higher doses of drug required
• Nocturnal asthma
Peak Flow Meter

Uses:
• Measures the Peak Expiratory Flow Rate (PEFR).

• Useful in asthmatics to Assess disease progression.

• Measures response to treatment.

• It can be used in diagnosis.

Endotracheal Tube
Parts and Functions

• Tube: Connected to oxygen source.

• Cuff: Prevents aspiration of fluid into the lungs. Non-cuffed
tubes are used in paediatric patients (to prevent subglottic
stenosis post intubation).
• Pilot: For inflating the cuff.
• Murphy's Eye: Alternative air opening.

Indication
• Resuscitation tool.
• In poisoning with volatile liquids to prevent aspiration.
• Anaesthesia.
 Uses:
OROPHARYNGEAL • Used to alleviate upper airway obstruction caused by tonsillar or adenoidal
hypertrophy.
AIRWAY • Used to alleviate normal pharyngeal tissue obstruction, as often occurs in small
infants.

Indications:
• For unconscious patients in the setting of: Bag-valve-mask ventilation.
• Spontaneously breathing patients with soft tissue obstruction of the upper
airway who are deeply obtunded and have no gag reflex.

Contraindications:
• Absolute contraindication.
• Consciousness or presence of a gag reflex.
• Relative contraindications.
• Insertion of an oropharyngeal airway may not be feasible in some settings, such
as Oral trauma, Trismus (restriction of mouth opening including spasm of
muscles of mastication).
Note: Nasopharyngeal airways may be used instead.

Complications:
• Airway obstruction by an improperly sized or improperly inserted oropharyngeal
airway.
• Gagging and the potential for vomiting and aspiration.
INSTRUMENTS IN CARDIOVASCULAR SYSTEM
Parts
• Manometer gauge.
1. Mercury Sphygmomanometer • Mercury Reservoir.
• Rubber tubing.
• Bladder-Cuff.
• Metal casing.
• Bulb/Inflator.
• Knob
• Valve
Uses:
• To measure blood pressure.
• To elicit physical signs. e.g. Pulsus paradoxus: which can occur in many
conditions such as cardiac tamponade and bronchial asthma, Korotkoff
sounds.

STEPS
• Ensure the child is comfortable and seated for about 5 minutes.
• Measure the UAL and circumference.
• Ensure the cuff is at least 2/3 of UAL and the internal bladder encircles
80-100% of the upper arm circumference.
• Palpate the brachial artery pulsation.
• Apply the cuff about 2.5 inches above the antecubital fossa ensuring
that the arrow on the cuff is placed over the brachial artery.
• The first BP reading should be estimated by placing fingers over the radial pulse
and pumping up the cuff, when the pulse sound disappears this is your estimated
BP (usually about 10mmHg less than that obtained by ascultation), now deflate
the cuff quickly.
• Now palpate for the brachial pulsation at the antecubital fossa.
• Place the diaphragm of stethoscope over the brachial pulsation, pump the cuff up
to a pressure 30mmHg higher than the estimated BP.
• Reduce the pressure slowly.
• The 1st repetitive sound is recorded as the SBP
• The last sound/ muffled sound is the DBP.
• If you need to repeat the BP you should wait 1 minute to give the vessels a chance
to refill.
• Record the BP measurement immediately in the nearest 2mmHg
• Measure on both upper limbs, and use the limb with higher pressure for
reference.
• Take 3 measurements at least 15 minutes, and take the average reading.
1. Take in the BP in 2 contiguous positions (sitting to standing, lying to sitting).
2. Take the height of the child and get percentile using the CDC chart Read off the BP percentile
on the BP percentile chart
3. Crude estimate of SBP= 90 + n, where n is age in years. 2/3rds of SBP obtained is DBP.

Other Methods of Measuring Blood Pressure:

• Flush method
• Palpation method
• Doppler method
• Oscillometric method
• Intraarterial catheterization.
 Definition: is a device used to measure the oxygen level (oxygen saturation) of
2. Pulse Oximeter the blood.

Indications
• Endotracheal intubation
• Cardiac arrest
• Procedural sedation
• Asthma /chronic obstructive pulmonary disease (COPD)
• Respiratory complaints
• Acute respiratory distress syndrome (ARDS)
• Sleep disorders/sleep apnea
• Shunts in cyanotic heart diseases

Limitations
• Poor circulation
• Skin pigmentation
• Skin thickness
• Skin temperature
• Current tobacco use
• Use of fingernail polish
INSTRUMENTS AND PROCEDURES IN UROGENITAL SYSTEM
FOLEY CATHETER & URINE BAG

Indications:

• Peri operative use in selected surgeries.

• Acute urinary retention or obstruction.
• Hospice/comfort care/palliative care.
• Accurate measurement of urinary output in critically ill
patients.
• Required strict immobilization for trauma or surgery.
• Assistance in healing of severe perineal and sacral wounds in
incontinent patients.
 INSTRUMENTS IN CENTRAL NERVOUS SYSTEM

Tendon Hammer
Uses :
• Deep tendon reflexes.
• Plantar reflexes.
• Abdominal Reflex.
 INSTRUMENTS AND PROCEDURES IN ENDOCRINE SYSTEM

1. GLUCOMETER (A GLUCOSE METER )

Uses:
• Used to measure the amount of glucose in blood.
• Regular monitoring of blood sugar levels.

Types
• Standard Glucose Monitors (SGMs).
• Continuous Glucose Monitors.
 SOME PROCEDURES IN PAEDIATRICS

1. Intraosseous Cannulation
2. Lumbar Puncture
3. Chest Tube Drainage
4. Oxygen Delivery
5. Thoracocentesis
6. Urine sampling
7. Ambu Bag and Mask ventilation
8. Nebulization
Lumbar Puncture Definition: is the act of inserting in a needle in the lumbar
region of the sub arachnoid space.

Indications
• Diagnostic:
• CNS infections especially in meningitis
• CNS Haemorrhage
• CNS Tumours
• Contrast myelography

Therapeutic:
• Intrathecal drug administration
• Communicating hydrocephalus

Monitoring:
To monitor CSF pressure
Contraindications
• Signs of raised intracranial pressure such as anisocoria (Unequal pupils), rigid
posture, unilateral or bilateral motor posturing, papilloedema, headache and
projectile vomiting .
• Pathologies at the site of puncture such as skin infection, neural tube defects, low
lying spinal abscess or tumour.

General state of the child:

• Severe respiratory distress
• Cardiopulmonary instability
• Thrombocytopenia/coagulopathy
• Brain abscess

Complications :
• Traumatic tap
• Needle fracture
• Coning
• Implantation dermoid
• Cord trauma
• Infection
• Back pain
• Headache
• Cardio- respiratory depression.
INTRAOSSEOUS INFUSION Introduction
It is a safe, simple and dependable emergency technique used for
parenteral fluid and drug administration.

Sites
• Distal femur
• Proximal tibia

Indications
• Failure of peripheral IV access in circulatory collapse.
• Contraindication to setting a central venous line despite peripheral
IV access failure.
• Initial rehydration in a severely dehydrated child (to increase the
intravascular volume and open collapsed veins).
Contraindications
• Local sepsis at the site to be used
• Fracture at the site of puncture

Disadvantages
• Expertise is limited - Painful procedure
• Limited duration of use

Complications
• Necrosis and sloughing of overlying skin
• Cellulitis at puncture site
• Obstruction of needle by marrow
• Inadequate or excessive penetration of the bony cortex
THORACOCENTESIS Definition:
This is a closed thoracotomy drainage system which
involves insertion of a chest tube and drainage of material
from the pleural cavity through the catheter whose
external opening is kept in a dependent position
underwater i.e. the underwater seal.

Components of the Chest Tube Drain

• Chest tube (catheter)
• Clamp
• Graduated collection bottle
• Underwater seal

Indications:
• Tension pneumothorax
• Pleural effusion
• Empyema thoracis
• Haemothorax
• Chylothorax
Signs Of A Functioning Chest Tube:
• Rhythmic swinging of oscillatory movement of fluid in the tube with respiration.
• Progressive rise in fluid level in the collection bottle over time.
• The bubbling phenomenon visualized in the collection bottle in a pneumothorax.
• Accumulation of fluid within the tube after it has been clamped for a while.
• Lung re-expansion associated with fall in the volume of fluid or air in the pleural
cavity. This is visible on serial chest radiographs.

Complications:
• Pneumothorax
• Haemothorax secondary to trauma
• Empyema thoracic
• Pulmonary edema following drainage of large volumes of fluid
• Damage to intercostal nerves

Differentials Of A Non-draining Tube:

• Wrong placement of the tube in the pleural cavity.
• Kinking of the tube.
• Obstruction of the tube e.g. by clots.
• Completion of the drainage process i.e. resolution of the underlying pathology.
 AMBU Stands for Ambulatory Manual
Breathing Unit

Ambu Bag & Mask Ventilation Parts:

• Face mask (which is transparent to control the delivery of
(Bag, Valve and Mask) gas visualization of vomitus is secondary)
• Unidirectional valve (to prevent back flow of gas)
• A self inflating bag
• Oxygen inlet, Gas inlet
• Oxygen reservoir
• Pressure control valve to prevent over inflation of the
lungs

Indication:
• Cardiopulmonary resuscitation in the following settings:
• New born with no respiratory effort or low APGAR score
• Apneic patients (Apnea is defined as the cessation of
respiration for more than 15secs in duration or less than
15 seconds if associated with cyanosis, bradycardia,
hypotension or vascular collapse.)
• Congestive cardiac failure with severe ventilation -
perfusion mismatch
• Near drowning
Precaution Before Use:
• Proper positioning of the patient by placing supine on the back with the neck extended to keep a patient
airway and prevent gastric distension (please rule out neck trauma first!)
• Clearing the airway by suctioning the mouth and the nostrils.
• Ensure that the face mask covers the nose, mouth and chin and form a seal between a mask and the face
with the palm of your hand.
• For neonates and small infants, prevent hypothermia by resuscitating on a resuscitaire or beneath a
radiant warmer.

Signs of Effective Ventilation:

• Presence of chest movement with each ventilation
• Improvement in the colour of the patient will indicate effectiveness of the ventilation.

Complication:
Infection, Gastric distension, Air-leak syndromes

Contraindication:
• Cleft palate
• Suspected meconium aspiration syndrome (intubate and suction lungs before bag and mask ventilation)

Other components of the resuscitator bag apart from the AMBU bag include:
Needles and syringes, Drugs like adrenaline, naloxone, Mucus extractor, laryngoscope, Endotracheal tube, IV
Fluids including normal and dextrose saline, Nasogastric tube, Stop clock, Defibrillator.
 Techniques and diagnostic values for significant bacteria:
• Mid-stream urine (Clean catch) (10x5/hpf)
• IN urine bag (10x5/hpf)
URINE SAMPLING • Suprapubic aspirate (any + ve culture)
• Urethral catheterization (10x3 /hpf)

Suprapubic Aspiration:
The bladder is punctured in the midline, just above pubic
symphysis.

Indications:
• An ill child for urgent screening before commencement
of antibiotics therapy
• Clinical UTI
• When repeated urine bag samples show signs of UTI
• To decompress the bladder when there is urethral
obstruction, e.g., PUV

Contraindications:
• Bleeding diathesis
• Urine passage per urethra possible
• Bowel obstruction
• Infected skin
Complications:
• Infections
• Bowel perforation
• Brief haematuria
• Predisposition to bladder rupture

Indications for Urethral Catheterization

• UTI
• To relieve urinary retention
• Retrograde urethrocystography (RUCG)
• Measurement of residual bladder volume

Complications:
• Infection (urethritis, cystitis, pyelonephrifis, septicemia)
• Urethral trauma

Causes of False Negative Finding on UrineCulture:

• Previous antibiotic treatment
• Dilution of urine from over hydration
• The contamination of specimen by antiseptic solution
• Wrong culture medium.
 Sources of Oxygen include:
• The Oxygen Cylinders (Liquid Oxygen)
Oxygen Delivery • The Oxygen Concentrators
• Piped oxygen (Oxygen Plant)

Oxygen Cylinder
Parts
• Oxygen Tank which contains the gas (the white color oxygen).
• The pressure Gauge which measures the partial pressure of oxygen in
the tank.
• Flow Meter which measures the rate at which oxygen is being delivered
in litre / min. (0.5l/min for young infants and 1-2l/min for older
children). Up to 2L/min can be delivered to neonates.
• Bubble Humidifier contains water which humidifier dries oxygen from
the tank and thus prevents irritation of the Respiratory mucosa.

Advantage:
It doesn't require electricity to function and so it is ideal in rural settings.

Disadvantages:
• The oxygen available is limited to the number of tanks available.
• There's a risk of fire hazards from explosion if flame is brought too
close.
Methods of Oxygen Administration/Delivery Devices:
I) Nasal Prongs
II) Nasal catheter
III) Nasal pharyngeal catheter
IV) Face Mask
V) Oxygen hood
VI) Oxygen tent
VII) Head boxes

Indications:
A) Clinical signs that indicate the need for oxygen therapy such as signs of respiratory distress. E.g.
• Central Cyanosis
• Chest in drawing
• Tachypnea
• Grunting
• Tracheal tug

B) Clinical conditions requiring oxygen therapy.

Pneumonia, Bronchial asthma, Bronchiolitis, Pertussis, Diphtheria, Pleural effusion, Heart failure, Severe
anemia, Ascites with splinting of the diaphragm, Raised intracranial pressure, Congenital heart disease,
Pulmonary oedema, Foreign body aspiration.
Complications:
A) Those due to oxygen toxicity:
• Spasm of cerebral blood vessels with 2° CNS manifestations
• Adsorption atelectasis
• Air leak syndromes.
• Retinopathy of prematurity
• Respiratory center depression
• Brochopulmonary dysplasia (chronic lung disease)

B) Those due to the procedure of oxygen administration

• Trauma to the respiratory tract.
• Transmission of infection
• Oesophageal trauma (nasopharyngeal catheter)
• Gagging and vomitting (nasopharyngeal catheter)
• Gastric distension (nasopharyngeal catheter)
• Obstruction of the tool for oxygen administration by mucus plugs may increase Hypoxaemia
 Indications:
Nasogastric Intubation • Gavage (NGT) feeding .
• Administration of fluids such as ORS and other flulds in dehydration.
• Administration of feeds in an unconscious patient..
• Gastric aspirate for sputum analysis of AAFB (early morning samples).
• Gastric washout/lavage following poisoning.
• Cold saline lavage as part of management of fever.
• Drug administration
• Used for abdominal decompression in patients with obstruction, or
during resuscitation (to prevent aerophagia).
Improvised uses include:
• Umbilical catheterization
• Venous cut down
• Urethral catheterization

Application
• Determining the safe length of NG tube to be inserted.
• The tip of the tube is held against the child's nose and the distance
between the nose and the ear lobe as well as from the ear lobe to the
xiphisternum is measured and marked on the tube.
• The tube Is lubricated with water or petroleum jelly and is passed directly but slowly
through one nostril with extension of the neck.
• It passes without resistance to the stomach and when the measured distance is reached, the
NG tube is fixed with a plaster to the face.

How to Confirm The Position of The Tube in The Stomach

• Air bubbles in a bowl of water when the free end of the tube is placed in it suggests tracheal
intubation.
• Presence of respiratory distress when the tube is passed inadvertently into the trachea.
• Presence of an aspirate of stomach content using a syringe.
• Using a litmus test on the aspirated material (turns blue litmus paper pink - acid)
• Push air down the tube, with a syringe, and listen over the left hypochondrial region of the
abdomen with a stethoscope for air entering the stomach.

Complications:
• Trachea intubation
• Trauma to the pharynx
• Infections such as sinusitis secondary to gram negative bacilli .
• Risk of Aspiration
• Risk of triggering cough in certain respiratory diseases like pertussis
• Obstruction of nasal cavity.
NEBULIZATION
Nebulizer: is a device used to convert liquid medications to aerosol and is used for
delivering medications to lower parts of the respiratory tract.
Types:
• Jet nebulizer.
• Ultrasonic nebulizers.
Benefits:
• It delivers a larger dose of medication than would be received from several puffs of
inhale.
• It is useful in patient too ill to handle the inhaler e.g. in acute severe asthma
• It is useful in patient too young to use the inhaler e.g. infants
• It is useful when drugs are not available in hand held inhalers e.g. Pentamidine.
How to use the jet nebulizer:
• Place the prescribed quantity of drugs into the nebulizer chamber.
• Connect the nebulizer to tubing and attach it to the compressor unit.
• Attach the face mask or mouth piece to the nebulizer with the patient positioned
thus: Younger child sits comfortably in mother's lap Older child sits comfortably in
upright position.
• Use a mouth piece or face mask while the child breathes using the mouth.
• Compressor is switched on for 10 to 15 minutes.
Care of equipment: This is necessary to limit introduction of infection.
• Disconnect the tubing from the face mask and mouth piece and from the nebulizer.
• Unscrew the nebulizer, wash the nebulizer's face mask and mouthpiece in a soapy,
warm water and rinse under warm running water.
• Dry thoroughly before reassembling.
• A damp tube is attached to the compressor to dry it out.

Nebulized drugs: These are examples of drugs that are commonly nebulized, this list is
not exhaustive .
• Bronchodilators e.g. salbutamol used in asthma Ipratropium bromide used in
asthma .
• Corticosteroids for asthma
• Morphine as analgesic for bronchial carcinoma
• Antibiotics e.g. ceftazidime and colistin (for suppurative lung diseases)
• Pentamidine used for the treatment and prophylaxis of Pneumocystis pneumonia
• Oxygen for patient with pneumonia.
• Normal saline for acute bronchiolitis Salbutamol in treatment of hyperkalemia