7 Practical procedures

Automated device or sterile lancet.

Appropriate sample bottles or capillary tubes.

Cotton wool or gauze swab.

Finger site in the older child.

In the case of foot, hold dorsiflexed.

Clean with an alcohol impregnated swab.

Gently massage area to improve blood flow and use your hand as a tourniquet.

Puncture skin with an automated device or sterile lancet.

‘Scoop’ droplets of blood into an appropriate sample container or on to blood glucose-measuring strip. Note that excessive squeezing leads to falsely high serum potassium and haematocrit levels, and bruising.

Once sample has been collected stop any residual bleeding by local pressure with a cotton wool ball or gauze swab.

In infants and small children use either a 23G butterfly needle and syringe or 21–23G butterfly needle without the normal tubing.

An alcohol impregnated swab.

Appropriate sample bottles or capillary tubes.

Cotton wool or an occlusive plaster.

Identify suitable vein and warm limb if necessary.

Topical local anaesthetic cream can be applied under an occlusive dressing for 30–60min reduces pain and may be appropriate in young children.

Apply a tourniquet proximal to the intended venepuncture site. In infants this is often best done using your own gloved fingers or asking an assistant to squeeze the limb. Also use your fingers to stretch the overlying skin to stabilize the vein. In young children an assistant may be required to keep the child’s limb steady.

Clean overlying skin with an alcohol impregnated swab.

Along the line of the vein and in a proximal direction, insert needle through overlying skin at 20–30° into the vein until blood flashes back into the needle.

Stabilize needle/butterfly with your fingers and then aspirate into syringe or, if using a butterfly with no tubing, allow blood to drip into sample bottles. Repeated gentle release and retightening of tourniquet often increases blood flow.

Once blood has been collected, release the tourniquet, remove needle and then apply gentle pressure to puncture site for a few minutes with cotton wool.

Once bleeding has stopped, an occlusive plaster is optional, but is often appreciated!

IV cannula: 24G in newborns, 21G in older children.

IV extension set and 3-way tap with Luer lock flushed with 0.9% saline.

Tourniquet (older children).

Fixing tape or transparent occlusive dressing to fix cannula in site.

Tip: transillumination of hand or foot with a ‘cold’ light source can be very useful for locating ‘hidden’ veins, particularly in the newborn. In an emergency, or if one or more normal sites have been used, scour the whole body and use whatever vein you can find!

Consider at least 45min of local anaesthetic cream applied under an occlusive dressing over the intended vein before starting. Remove the cream before starting.

Ensure good vein perfusion, e.g. warm extremity before cannulation.

If needed, ask an assistant to help with keeping the child’s limb steady. This may require wrapping a young child in a towel or sheet.

In older children, apply a tourniquet proximal to the vein. In infants, if attempting the hand dorsum, apply compression and immobilization by flexing the wrist, then grasping with the index and middle fingers over the dorsum, whilst the thumb is placed over the child’s fingers.

Clean site with an alcohol impregnated swab.

Insert cannula at an angle of 10–15° to the skin with the bevel upright, just distal and along the line of the vein.

When the stylet tip penetrates into the vein lumen blood will flash back (not always if the vein is small!).

Once vein lumen is entered advance 1–2mm, to ensure the cannula is also in vein, and then advance the cannula over stylet up into the vein.

Remove stylet, and collect any blood required from the cannula hub.

Flush cannula with 0.9% saline to confirm IV placement (fluid should infuse without resistance) and to prevent clotting, then connect IV line.

Secure cannula with appropriate adhesive tape or dressing leaving the skin over the cannula tip visible so that extravasation can be observed.

Splint extremity to prevent the cannula kinking.

This is a difficult procedure to master, particularly in the newborn. Do not be afraid to ask for senior help if unsuccessful after 2 or 3 attempts.

Heparinized arterial blood syringe, if blood gas analysis intended.

Identify artery by pulse or ‘cold’ light.

Partially extend limb, (e.g. extend wrist for radial artery sampling), and with a finger slightly stretch skin over artery to stabilize its position.

Clean overlying skin using an alcohol impregnated swab.

Insert needle through overlying skin at 15–30° angle into artery until blood flashes back; if after inserting needle there is still no flash back withdraw slowly as often blood will then appear.

Collect blood by aspirating into the syringe.

Remove needle and apply pressure with cotton wool or gauze swab to puncture wound for at least 5min and bleeding has stopped.

When blood flashes back into the hub, advance the cannula smoothly over the stylet and into the artery.

Remove the stylet and immediately stop the bleeding by applying pressure over the artery and the tip of the catheter with your finger.

Connect a 3-way tap that has been previously flushed with heparinized saline. Samples can be obtained from the unused ports.

Flush the arterial line with heparinized saline (1U/mL) and connect the saline infusion line at 1–2mL/h (1U heparin/mL).

A pressure transducer may be attached to continuously monitor arterial BP.

Sterile surgical instruments including fine forceps, blunt-ended dilator probe, scalpel, artery forceps, scissors, suture forceps, sutures.

Sterile drapes, gown, gauze swabs, and gloves.

Umbilical catheters: 3.5Fr if birth weight <1500g; 5.0Fr for newborns ≥1500g. Catheters with a terminal electrode can be used for continuous measurement of arterial O₂ and CO₂ concentrations.

3-way taps, IV extension sets, syringes, cord ligature.

5–10mL syringes, one containing heparinized saline (1Ut/mL).

BP transducer if monitoring is intended.

An assistant should hold the baby’s legs down with the infant supine.

Calculate the distance (cm) to insert the catheter from the umbilicus to the aorta at T8–10 level using the formula:

Insertion distance = 3 × weight (kg) + 9 + umbilicus stump length.

To control bleeding, tie a cord ligature around the umbilicus stump.

Catheter insertion should be performed using strict aseptic technique.

Wash hands and put on sterile gloves, gown, +/− surgical mask.

Connect a 3-way tap to catheter and prime with heparinized 0.9% saline (do not use heparinized saline if coagulation testing is required).

Clean cord and periumbilical area with antiseptic solution.

Surround periumbilical area with sterile towels to create sterile field.

Clamp the umbilical cord horizontally with artery forceps 0.5–1cm above umbilical skin. Using the artery forceps as a guide, cut the umbilical cord horizontally and immediately below with the scalpel.

Identify the two umbilical arteries and umbilical vein (see Fig. 7.2).

Dilate the end of one of the arteries with fine forceps or a probe until wide enough for the catheter tip to be easily introduced.

Gently advance catheter the calculated distance (see formula). If resistance is met put gentle traction on the umbilicus using artery forceps as this often eases insertion down the spiral umbilical artery.

Aspirate blood to confirm position and take required samples. Note: arterial blood should pulsate and still bleed if catheter hub is held above infant (unlike blood from the umbilical vein).

Secure catheter by fixing a zinc oxide flag around the catheter and then suture it to the stump (see Fig. 7.2). Ligate remaining vessels with a separate purse string suture. Remove cord ligature and check for bleeding.

Connect catheter to 3-way tap and IV infusion set. BP monitoring can be performed by connecting appropriate pressure transducer.

Confirm correct placement with a combined CXR/AXR. Catheter should loop initially downwards to the pelvis as it traverses the iliac arteries before ascending up the aorta.

Check perfusion of the perineum and lower limbs. If ischaemia occurs, this usually may be corrected by an IV bolus of 0.9% saline or albumin. If ischaemia remains, remove the catheter immediately.

Following insertion, the abdomen should remain exposed to allow immediate observation of any haemorrhage, e.g. from accidental removal of catheter.

As soon as the catheter is no longer required, it should be removed. Cut the surrounding suture, then slowly withdraw it, taking several minutes to remove the final few centimetres from the artery. Then apply pressure or suture to limit any bleeding.

Remaining equipment as for umbilical arterial catheter (  p.206).

Catheter insertion should be performed using strict aseptic technique.

Wash hands and put on sterile gloves, gown, +/− surgical mask.

Clean and prepare umbilical stump and create sterile field as detailed on  p.206.

Identify umbilical vein (see Fig. 7.2) and then dilate opening with fine forceps or a dilating probe.

Insert catheter the measured distance (see Procedure, first bullet point).

Aspirate blood to confirm insertion. Blood from the umbilical vein should not pulsate and, when the catheter hub is held open to the air above the infant, blood will slowly fall back to the infant. Do not do this for long or an air embolus will result!

If blood will not aspirate or resistance is felt before the catheter is inserted the measured distance, it is likely that the catheter tip has lodged in the hepatic portal veins or sinus. Withdraw the catheter and then reinsert as far as it will go while still allowing blood aspiration.

Flush umbilical catheter with heparinized saline (1Ut/Ml).

Secure catheter and ligate unused other umbilical vessels using method described for umbilical arterial catheter (  p.206).

Remove cord ligature and check for bleeding.

Confirm correct position by a combined CXR/AXR. UVC should only follow a direct course proximally through the liver (unlike a UAC) Ideally, tip should lie in the inferior vena cava (IVC) just above diaphragm.

The catheter can then be used for blood sampling, fluid or drug administration, or CVP monitoring (the later only if the catheter tip is above the diaphragm).

As soon as the catheter is not needed, remove it slowly and then gently compress umbilical stump until bleeding stops.

In an emergency (e.g. resuscitation at birth) the procedure is simplified. Simply, cut the umbilical cord with a scalpel blade 1–2cm distal to the umbilical skin and rapidly insert the umbilical catheter until blood can be aspirated. Resuscitation drugs and fluids can then be given safely. Don’t worry about haemorrhage as cardiac output will be minimal or absent in such an emergency! Besides, any bleeding can be easily controlled by squeezing the base of the umbilicus between the thumb and index finger. Note: Caution is needed as air embolism will occur if an umbilical catheter is left open to the air for any significant time.

Sterile gloves, gauze swabs, gown, and drapes.

Antiseptic solution, e.g. 0.5% chlorhexidine.

23 or 27G silastic long line catheter. 27G should only be used when a 23G line cannot be inserted.

2–5mL syringe and heparinized (1U/mL) saline solution.

Introducer, e.g. 19G butterfly needle, 20G IV cannula.

Sterile adhesive tape and transparent occlusive dressing.

Catheter insertion should be performed using strict aseptic technique.

Wash hands and put on sterile gloves, gown, +/− surgical mask.

Set out equipment and prime catheter with sterile heparinized saline.

Apply tourniquet proximal to selected insertion point.

Immobilize relevant limb, then clean insertion site with antiseptic.

Place sterile drapes around insertion point to create sterile field.

Insert introducer needle into the vein until blood flashes back. If using a cannula, remove stylet.

With fine forceps advance catheter through introducer needle/cannula.

Continue to advance catheter into vein until the desired distance is reached. Tip: often the catheter will meet resistance as it becomes wedged against a kinked vein or valve. Milking in a proximal direction with a finger over the catheter tip may facilitate further advancement.

Remove tourniquet and then flush catheter with heparinized saline.

Once fully inserted, withdraw introducer needle/cannula. Remove from line after unscrewing catheter hub. Reconnect hub to catheter.

Ensure haemostasis at puncture site by applying gentle pressure with sterile gauze swab. This may take some considerable time!

Secure line in place by using thin strips of sterile adhesive tape and sterile transparent occlusive dressing.

Start infusion of heparinized saline (1U/mL) to keep line patent.

Confirm catheter tip placement with CXR. This may be aided by the injection into the line of 0.5mL of contrast solution immediately before X-ray. Ideally, the catheter tip should lie just proximal to the right atrium. Withdraw the catheter before use if it is in the right atrium.

Chin lift: using 1 or 2 fingers apply forward pressure to just under the chin to pull the tongue forward.

Jaw thrust: apply forward pressure behind one or both angles of the jaw to pull the tongue forward.

Guedel oro-pharyngeal airway: slip the airway over the tongue until the flange reaches the lips. Be careful not to push the tongue back. To determine the correct size, hold the airway along the line of the jaw with the flange in the middle of the lips. The end of the correctly sized airway should be level with the angle of the jaw.

Endotracheal intubation: see  p.212.

Suction: not routinely required, especially in newborn resuscitation. However, if the methods described above are not successful in obtaining an adequate airway, check that the airway is not obstructed by secretions, vomitus, blood, meconium, etc. If there is obstruction on inspection, or it is obvious from the start, suction should be performed using an appropriate suction catheter connected to a suction source.

Tracheotomy: bypasses upper airway obstruction and when oral oro-nasal endotracheal intubation fails or is contraindicated. Perform only if already trained by a senior doctor. The description of this technique is beyond the scope of this book.

Select appropriate size mask. It should be big enough to be able to cover the face from the bridge of the nose to below the mouth, but not extend over the edge of the chin or over the orbits. In infants a round mask, e.g. Laerdal^® or Bennett’s mask, is most appropriate. In older children the Laerdal^® moulded mask is more suitable.

Connect face mask to an appropriate self-inflating bag or tubing with a ‘T’ piece and then to an oxygen or air supply at an adequate flow rate, e.g. 5–8L/min in the newborn.

In newborns, a pressure-limiting valve should used and initially be set at ˜25–30cmH₂O.

Apply mask to face over mouth and nose, and apply enough downward pressure to make an effective seal.

Give inflation breaths by either compressing self-inflating bag or occluding open aperture of ‘T’ piece.

Observe and ausculate chest wall for adequate inflation. Note whether condition of child is improving or deteriorating.

If inflation is poor or child deteriorating, check airway is not obstructed and use one or more techniques described on  p.210 to ensure patent airway.

ETT size: 2–2.5mm (internal diameter) in infant <1000g; 3mm when 1000–3000g; 3.5mm when >3000g. The appropriate size then increases as child size increases up to male adult size of 8–9mm. Cole (shouldered) ETTs are suitable for oral intubation in newborns. Straight (non-shouldered) tubes can be used for oral or nasal intubation.

Appropriately-sized introducer if required.

Lubricating jelly if attempting nasal intubation.

Magill forceps if attempting nasal intubation.

Suction catheter and tubing connected to suction source.

Appropriate ETT connection adaptors, tubing, and O₂ source.

Fixation device and tape.

Check laryngoscope light, O₂ supply, and suction.

Connect child to pulse oximeter and cardiac monitor.

Sedation or anaesthesia should be given prior to elective intubation.

Pre-oxygenate the child by hyperventilation with 85% O₂ for 15–30s prior to elective intubation.

Place the child in the supine position with the head in the neutral position and the neck slightly extended.

Stand immediately behind the child’s head.

If nasal intubation is being performed, a prelubricated ETT should be passed into one nostril as far as the nasopharynx prior to insertion of laryngoscope. If the ETT will not pass easily, do not try force, as this may lead to penetration of the cribriform plate.

Open the mouth and use suction to clear airway secretions.

Holding the laryngoscope in the left hand, initially insert the blade to the right side of the mouth and advance to the base of the tongue.

Once inserted move the laryngoscope blade into the centre of the mouth, thereby pushing the tongue to the left.

Advance the blade further until epiglottis is seen and then insert blade tip into the valleculla (space between base of tongue and epiglottis).

Vertically lift up the whole blade, thereby exposing the vocal cords (see Fig. 7.3). Apply cricoid pressure with the little finger of the left hand to see the vocal cords. Perform suction if needed.

If the vocal cords cannot be seen after 30s do not try to attempt blind intubation. Abandon the attempt, maintain patent airway (  p.210), and perform mask ventilation (  p.211), before trying again.

Once the vocal cords are seen, insert the ETT between the vocal cords. If difficult, or performing nasal intubation, use the Magill forceps with the right hand to advance the ETT tip.

If using a straight tube, the ETT should be advanced until the thick black line at the tip is level with the vocal cords. If using a Cole ETT, advance it until the shoulder just reaches the vocal cords.

If using a cuffed tube advance until the cuff is just below the vocal cords and no further. Then inflate the cuff with air using a syringe.

Once intubation is successful, connect tubing and ventilate.

Visually check chest movement and auscultate over each lung to ensure appropriate and equal bilateral air entry.

If this procedure is successful, SpO₂ and heart rate should improve.

Fix ETT in place appropriately following local institutional guidelines.

Perform a CXR to confirm position of ETT, which should ideally be 1–2cm above the carina, depending on the childs’ size.

Causes of failure to intubate include: poor visualization of vocal cords due to over extension of neck or advancement of laryngoscope too far into the oesophagus; spasm of vocal cords (wait, as almost certainly vocal cords will open eventually—do not attempt to force ETT through as this may cause damage); anatomical abnormalities, e.g. laryngeal atresia; vocal cord oedema.

Conditions that may give an impression of failed intubation (little or no chest movement on ventilation after intubation) include: thoracic pathology (e.g. tension pneumothorax, diaphragmatic hernia); intubation of the right main bronchus (detected by unequal air entry); and particulate obstruction of airway or ETT.

Local anaesthetic: e.g. 1% lidocaine, needle, and 10mL syringe.

Intercostal drain: size ranges from 8–12Fr for newborns up to 18Fr for young adults.

Straight surgical scalpel blade, artery forceps, and suture.

Sterile dressing pack (including gauze, gloves, drapes).

Underwater drainage system and suction pump.

Steri-Strips^® and plastic transparent dressing, e.g. Tegaderm^®.

Raise the arm towards the head.

Suitable sites are the fourth intercostal space in the mid-axillary line (be careful to avoid the nipple), and second intercostal space in mid-clavicle line.

Chest drain insertion should be performed using strict aseptic technique.

Wash hands and put on sterile gloves, gown, +/− surgical mask.

Clean skin over the insertion site with antiseptic solution.

Prepare sterile field, then infiltrate small amount of local anaesthetic into the tissues down to the pleura.

Wait 1–2min, then make a small skin incision with the scalpel just above and parallel to rib. Note: Blood vessels lie just below each rib.

Using artery forceps make a blunt dissection down to and through the parietal pleura.

Using forceps clamp chest drain and then insert into pleural space. Most clinicians remove the trocar before insertion.

Aim to push the chest drain tip towards the lung apex. In the event of a small pneumothorax aim the tip in the direction of the pneumothorax remembering to aim anteriorly (air rises in the ill child lying supine).

Connect the drain tightly to the underwater drainage system, unclamp drain, and apply negative pressure of 5–10cmH₂O. Bubbling should start to occur.

Using single sutures close skin wound closely around chest drain. Do not use a purse string suture as this will increase scarring.

Apply zinc oxide tape to chest drain and fix to skin using sutures.

Perform a CXR to check drain position and pneumothorax or effusion drainage.

Remove drain when confident it is no longer required, e.g. pneumothorax has resolved and there has been no bubbling for >24hr. This is done by releasing holding sutures, then rapidly removing drain followed by immediate pressure and gentle rubbing with a gauze swab to close the underlying tissues. Apply Steri-Strip^® across skin incision to provide air-tight seal. Perform a CXR to confirm that a significant pneumothorax has not re-accumulated.

Note: If pleural fluid is required for diagnostic purposes only, then simple needle aspiration at the above sites is the technique of choice.

Alcohol impregnated swab.

5mL syringe.

Local anaesthetic, e.g. 1% lidocaine, 2mL syringe and a small gauge needle if patient conscious and local anaesthetic appropriate.

Any age: medial malleolus of the tibia above the ankle.

Clean skin with an alcohol impregnated swab.

Insert at 90° to the skin. Advance into bone using a rotary action.

Advance trocar until bone cortex is reached, when a give will be felt.

Remove stylet, attach syringe, and aspirate to confirm position. Obtain any required blood samples.

Flush needle with 0.9% saline to again confirm position. Swelling outside the bone indicates needle displacement.

Infuse any required fluids (any fluid that can be given IV can be used).

Obtain conventional vascular access as soon as possible and then remove IO needle.

21G needle and syringe containing resuscitation drug.

Locate site: 4th intercostal space immediately lateral to the left sternal edge (immediately below the line joining the nipples).

Clean site with an alcohol impregnated swab.

Insert needle and aspirate syringe as needle is inserted.

Once blood flashes back, stop advancing.

Inject resuscitation drug(s).

21G needle or IV cannula and 10–20mL syringe.

Sterile gloves, drapes, gown, and adhesive plaster.

Sterile sample containers if pericardial fluid analysis intended.

Locate insertion site; this lies just below the angle between the sternum and the left costal margin.

Use sterile gloves and gown. Clean the site with antiseptic and place sterile drapes around insertion site.

Local anaesthetic infiltration may be appropriate.

Insert needle connected to syringe at an angle of 30° to the skin and advance slowly, aiming towards the left shoulder. Gently aspirate the syringe as needle is inserted.

Stop when pericardial fluid (usually straw-coloured) is aspirated and remove desired amount as indicated.

Once drainage is complete, remove needle and apply adhesive plaster.

Lay the child supine. If ascites is minimal also tilt towards the left side.

Except in emergencies, clean and prepare the site as described in  p.217, Pericardiocentesis.

Attach needle to the syringe and carefully insert it at 90° to the skin.

Aspirate fluid and place it in sample containers. If large amounts of fluid are to be drained use an IV cannula. Once inserted, remove the stylet, and leave the cannula in place to reduce the risk of bowel perforation. If prolonged drainage is needed, attach the cannula to the skin using adhesive tape or stitches.

Once complete, remove needle and apply sterile plaster to site.

If a large amount of fluid is withdrawn, drainage should be followed by IV infusion of albumin.

Anaesthetic lubricating gel, e.g. 0.1% lidocaine gel.

Water-based antiseptic solution, e.g. 0.5% chlorhexidine.

Sterile urine sample container.

Sterile gloves and adhesive tape.

Clean penile tip or vulval area with antiseptic solution.

Apply anaesthetic lubricating gel to catheter tip and urethral opening.

Partially withdraw foreskin in males. Part the labia in females.

Insert and advance catheter into urethra in a posterior manner until urine is obtained, indicating that the bladder has been entered.

Once in the bladder, inflate the catheter balloon with saline if the catheter is intended to be indwelling.

Use adhesive tape to secure the catheter to the thigh.

Connect catheter to the urine collection bag or aspirate urine for analysis.

2–5mL syringe.

An alcohol impregnated swab.

Sterile urine sample container.

Cotton wool or gauze swab and adhesive plaster.

If in doubt as to whether the bladder contains adequate urine, perform bladder US to confirm.

Place child supine (with an assistant holding hips abducted) and then identify site—midline anterior lower abdominal wall 1cm above the pubic bone.

Clean site with an alcohol impregnated swab.

Insert needle connected to the syringe at 90° to the skin, aspirating continuously until urine is obtained.

Insert to almost the depth of the needle. If no urine is obtained, partially withdraw it before inserting again at different angle.

Once required urine is aspirated, remove the needle, press on puncture site with cotton wool or gauze swab, and then apply an adhesive plaster.

Place urine in sterile container.

If unsuccessful, repeat the procedure 30–60min later.

Antiseptic solution, e.g. 0.5% chlorhexidine.

Sterile dressing pack (including gauze, gloves, drapes).

Sterile sample containers; usually 3 are needed for M,C&S, protein, and glucose, but sometimes also for virology, cytology, or immunology.

Adhesive plaster or aerosol plastic dressing spray.

Pressure manometer and 3-way tap if measuring CSF opening pressure.

Place child on their side with back along an edge of a firm surface.

Ask an experienced assistant to firmly, but gently, hold child with the spine maximally flexed. Beware compromising respiration!

Locate site. L4 spinous process lies on a line joining the iliac crests.

Using strict aseptic technique, clean the site with antiseptic solution and then create a sterile field by surrounding it with sterile drapes.

Inject local anaesthetic into site if child is ≥6mths old.

Insert spinal needle into intervertebral space slowly at 90° to the skin and aim in the direction of the umbilicus, i.e. slightly cephalad.

Advance needle slowly until there is a sudden give, which occurs as the dura is penetrated.

Remove stylet; wait for CSF to drain. If no CSF drains, advance needle very slowly and withdraw stylet every 1–2mm to check for drainage. If bone is struck or needle is fully inserted and no CSF obtained, remove the stylet and then withdraw cannula very slowly in case CSF appears.

Allow 10 drops of CSF to drain into each sample bottle.

If measuring CSF pressure, connect 3-way tap before collecting samples and direct fluid up attached manometer. Once opening pressure is measured, turn 3-way tap to allow CSF to drain.

If therapeutic CSF drainage is required, drain required amount.

Once drainage is complete, remove the needle and rub the puncture site with a sterile gauze swab while applying pressure.

Cover site with an adhesive plaster or aerosol plastic dressing.

The child should lie flat for the next 6hr and have hourly neurological observations and BP measurement.

Place the baby supine, with an assistant firmly holding the baby’s head.

Measure the necessary depth required for needle insertion.

Palpate and locate the lateral corner of the anterior fontanelle on the intended side to drain.

Shave a small area of the scalp at the needle insertion point if required.

Set out sample containers +/− CSF pressure manometer if needed.

Full aseptic technique should be used.

Wash hands and put on sterile gloves, gown, +/− surgical mask.

Clean area with antiseptic solution and create a sterile field with sterile drapes.

Insert needle into the lateral corner of the fontanelle in a direction slightly forward and inward, aiming toward the inner canthus of the ipsilateral eye.

After the needle is inserted to the predetermined distance, remove stylet and CSF should drip out.

If CSF pressure measurement is required, attach manometer and allow it to fill until measurement is complete.

If CSF drainage or sample is required, then allow fluid to drip out spontaneously into containers until required amount is drained.

Once required CSF has been drained, remove the needle and then cover with adhesive plaster or spray with plastic dressing to seal.

The child should lie flat for the next 6hr and have hourly neurological observations and BP measurement.

Cardiac failure secondary to severe anaemia (with normal or increased plasma volume), e.g. hydrops fetalis due to rhesus haemolytic disease.

Disseminated intravascular coagulation.

Polycythaemia with a venous haematocrit >70% and/or symptomatic.

Acute poisoning, including that due to metabolic disease.

Removal of toxins, e.g. bilirubin or ammonia, requires a double volume exchange, i.e. 160mL/kg in newborns. This replaces ˜90% of total blood volume and should be performed over a minimum of 2hr.

To treat polycythaemia, a dilutional exchange transfusion is performed. The required exchange volume depends on the haematocrit (Hct) and can be calculated using the formula:

Volume = [measured Hct – desired Hct] x blood volume measured Hct

In a dilutional exchange replace blood with 0.9% saline 0.45% albumin.

Two 20mL syringes and 3-way taps.

Blood administration set and warming coils.

Calibrated waste blood container.

+/− High flow rate infusion pump.

Appropriately cross-matched blood (see Indications).

ECG and BP monitor.

Sterile dressing pack (including gown, gauze swabs, drapes, and gloves).

Start continuous ECG and frequent BP monitoring.

As a baseline, measure serum FBC, U&E, Ca²⁺, glucose, and blood gases.

Prime blood administration set and warm blood to 37°C.

Arrange for an assistant to keep a constant accurate log of volumes removed and replaced throughout the procedure.

Use a full aseptic technique throughout the procedure.

Wash hands and put on sterile gloves, gown, +/− surgical mask.

Connect 3-way taps into the system (exact arrangement depends on choice of method; see the following bullet points).

If using a single central venous catheter, e.g. UVC, use two sequential 3-way taps to perform the following in order:

If using two catheters together, remove 5–20mL aliquots of blood from the central or arterial catheter over 5–10min and then turn a single 3-way tap to allow blood to be pushed into the waste bag. Simultaneously, the same volume of fresh warmed blood is infused into the patient via the other venous catheter using a high rate flow infusion pump.

A safe volume to remove each turn varies depending on size of infant. Remove 5mL aliquots for ELBW infants, increasing up to 20mL for full term infants.

Apart from continuously monitoring pulse, ECG, BP, and temperature, every 30–60min during the procedure measure blood gases, FBC, U&E, serum Ca²⁺, and glucose. Measure again at the end of the procedure, as well as a coagulation profile. Correct any abnormality found.

Once procedure is completed, leave catheters in place in case repeat exchange transfusion is required.

Haemodynamic compromise, e.g. cardiac arrhythmia or hypotension.

Metabolic, e.g. hypoglycaemia (transfused plasma often has a low blood glucose concentration due to red cell consumption), hypokalaemia, hypocalcaemia, hypomagnesaemia, acidaemia.

Coagulopathy or thrombocytopenia.

Hypothermia.

Infection: bacteraemia, HIV, CMV, hepatitis B or C. Blood must be screened prior to transfusion.

Graft vs. host disease: risk reduced by irradiation or leucocyte filtration.