A lumbar puncture is performed to diagnose or rule out meningitis in neonatal sepsis patients. It is also used to monitor the efficacy of antibiotic therapy through repeat cell counts and cultures. Possible contraindications include bleeding disorders, infection at the site, vertebral anomalies, or increased intracranial pressure. The technique involves restraining the patient, prepping the site, inserting a spinal needle between vertebrae to collect cerebrospinal fluid samples.

1. Wrr
4- Lumbar Puncture
I. Lumbar puncture (LP) should be performed for the following indications:
A. Diagnosing or ruling out sepsis in the neonatal period. Meningitis may be present
in as many as 25% of cases of neonatal sepsis. The choice and dose of antibiotics and
the duration of antibiotic therapy may be longer for patients with meningitis than with
sepsis.
B. To monitor efficacy of antibiotic therapy with repeat cell count and culture, or
occasionally drug levels of antibiotics.
C. LP is sometimes used as a treatment for communicating hydrocephalus.
II. Possible Contraindications:
A. Severe bleeding diathesis
B. Superficial infection at the LP site
C. Vertebral anomalies
D. Increased ICP with decreased communication of spinal fluid
E. Severe cardiorespiratory instability of patient
III. Technique:
A. Have assistant restrain patient in either lateral decubitus or sitting position with
spine flexed. The head need not be flexed too far, as some infants develop increased
respiratory difficulty with flexing of the head. Some people prefer the lateral
decubitus for the more unstable patients. Complete immobilization of the spine is
extremely important in larger and stronger infants.
B. Palpate the spinous process that is even with the iliac crests. This is L4. Locate one
interspace above (L3-L4) or one space below (L4-L5) as the site.
C. Glove.
D. Prep 3 times with alcohol and sponges from the LP tray. Drape with the drape in
the tray or with a Steridrape R.
E. Use 22-gauge short spinal needle from kit or one with a clear hub from the
cupboard. Hold needle/stylet with both hands, thumb on the hub and first fingers
guiding into the interspace, aiming for the umbilicus. Insert slowly. One may not feel
"pop" as is common with the larger children. Remove stylet and check for CSF.
Return stylet and advance if no return. One may need to rotate the needle slightly to
increase or initiate the flow. If unsuccessful repeat attempt in next interspace up or
down, but never go above the L2-L3 interspace.
F. When collecting for diagnostic purposes, the spinal fluid should be collected in the
tubes from the kit in the following order; Tube 1 - culture and STAT gram stain, Tube
2 - glucose and protein, Tube 3 - cell count.
G. The stylet should be replaced and the needle removed, covering the site with a 2 x
2 gauze until a bandage can be placed
5- Obtaining Blood via Heel Stick
I. Adequate quantities of serum may be obtained via heel stick in almost any neonate.
If done properly, hemolysis should not be a significant problem. The skin's blood
supply is located at the junction of the dermis and subcutaneous tissue, 0.35 to 1.6
mm from the skin surface.

2. II. Prewarming with the commercially-available heel warmers or with a diaper which
has been warmed under a warm faucet and taped around the heel often increases the
blood supply and arterializes the sample. The area should be cleaned thoroughly with
alcohol swab. The person performing the procedure should wear appropriately fitting
gloves.
III. The heel puncture should be done on the most medial or lateral portions of the
plantar surface of the heel, not on the posterior curvature, to avoid the calcaneous.
The lancets are designed to enter no deeper than 2-3 mm. If using a scalpel blade, the
blade should enter the skin no more than 2-3 mm. After the puncture, wipe the first
small drop off to rid the skin of the tissue juices that may increase clotting at the site.
IV. Hold the ankle area with the 3 fingers on your ulnar side while placing your
thumb behind the heel and your second finger just below the ventral surface of the
toes. By alternately pressing the lateral three fingers , followed by a milking motion of
the second finger, blood can be expressed. The fingers should be relaxed for a few
seconds periodically to allow refilling. To prevent bruising, caution should be used to
limit squeezing with the finger tips. To prevent hemolysis, allow large droplets to
form, collecting the drops as they form into the microtube, not scraping the blood into
the tube.
V. Fingerstick sampling is used for capillary blood gas analysis in our NICU and may
be used for additional laboratories as well. The technique is similar to heelstick in that
only the medial and lateral aspects of the finger are stuck. The milking motion
includes the whole finger and even portions of the hand.
6- Collection of Arterial Blood Gas Samples
I. Due to the persistent, continuing incidence of retinopathy of prematurity (ROP),
any infant in an increased ambient oxygen concentration must have his arterial
oxygen tension or saturation monitored. Retinal changes have been noted in children
whose PaO2s have not been higher than 100 mm Hg.
II. An ill infant without an indwelling arterial catheter should have arterial O2 tension
monitored by arterial puncture, or PO2 catheter, or transcutaneous PO2 monitor. An
acceptable alternative would be continuous pulse oximetry with upper limits of
saturation in the low 90's, but caution should be used to prevent exposure to high
amounts of oxygen. If questions arise regarding the appropriate level of oxygen
saturation, peripheral arterial puncture should be performed.
III. Frequency of sampling depends on the clinical situation and the reliability of the
other monitoring devices. Generally, a change in respirator or CPAP setting should be
followed by a capillary or arterial sample within 15 minutes to an hour. If performing
a peripheral arterial puncture for blood gas purposes, note should be made of the
location, as many infants have shunting through the ductus arteriosus that may effect
the interpretation.
IV. Blood gas sampling with peripheral arterial puncture or indwelling arterial
catheter requires 0.1 ml of blood. If electrolytes, ionized calcium and hematocrit are
also run in the NICU laboratory, 0.3 ml of blood are obtained. Generally, the
tuberculin syringe should be heparinized by withdrawing 0.1-0.2 ml of 100 U/ml
heparin solutions, coating the surfaces and disposing of the remainder. Excessive
heparin left in the syringe will dilute the sample, decrease the pH value and lower the
PaCO2. If using blood in the syringe for other labs, including spun hematocrit in the

3. NICU lab, heparin cannot be used and one must notify the blood gas technician to run
the sample immediately.
V. Arterial puncture, although not as commonly used in NICU's as other methods of
monitoring, can be performed with relative ease, using the radial temporal, posterior
tibial, or dorsalis pedis artery. The brachial and femoral artery should be used only in
emergency situations, because of the risk of complications at those sites. Indwelling
catheters may be placed in the radial, posterior tibial or dorsalis pedis artery but
should not be placed the temporal or brachial artery.
VI. Prep the site with 3 alcohol swabs and wear appropriately fitting gloves. Goggles
or eyeglasses are also recommended. The artery should be easily palpable or visible
with transillumination. If using the radial artery, an Allen test should be performed
prior to puncture. An arm board may be useful to prevent extreme dorsiflexion of the
wrist which makes the procedure more difficult. A 25 gauge butterfly needle, with TB
or 3 ml syringe should be used. The bevel up position should be used, except in the
most superficial arteries. The angle of insertion should be 25o for a superficial and
45o for a deep artery, against the flow of the artery. Blood should flow spontaneously
or with gentle suction.
VII. After the needle is removed, continuous pressure should be applied for 5 minutes,
with care not to squeeze with the fingertips. If hematoma formation is prevented, the
artery may be used multiple times. Observe the extremity for 15-20 minutes after the
procedure for arterial spasm.
7- Technique for Insertion of an Endotracheal (ET) Tube
I. Indications.
A. Provide airway for mechanical ventilatory support.
B. Relieve critical upper airway obstruction.
C. Provide route for selective bronchial ventilation.
D. Assist in pulmonary hygiene when secretions cannot be otherwise cleared.
E. Obtain direct tracheal cultures.
II. The correct Endotracheal tube (ETT) size and length of insertion (tip to lip
distance) can be estimated from the infant's weight.
Weight ETT Depth of Insertion (cm)
1 kg 2.5 7
2 kg 3.0 8
3 kg 3.5 9
4 kg 4.0 Add 1 cm for each additional kg of body weight.
Insertion Depth (cm) = 6 + wt (kg)
The tube should not fit tightly between the vocal cords in order to minimize upper
airway trauma.
III. In most cases an infant can be adequately ventilated by bag and mask so that
endotracheal intubation can be done as a controlled procedure. The ONE
IMPORTANT EXCEPTION is in cases of known or suspected congenital
diaphragmatic hernia.

4. Preparation is important to performing successfully. Check availability of following
equipment prior to procedure - suction, laryngoscope with functioning light source,
appropriate laryngoscope blade size (Miller 0 or Miller 1), supply of ETTs,
stethoscope, tape and adhesive. Use of oxyscope blade (laryngoscope blade with port
built-in for blow-by oxygen) may allow patient to tolerate procedure better.
IV. Technique.
A. Prior to attempting insertion of ETT and as indicated by clinical condition,
ventilate the infant with bag and mask using 80-100% oxygen. If unable to insert the
ETT within 30 seconds, ventilate the infant again for 30-60 seconds before
reattempting intubation.
B. Infant's head should be slightly extended (in the sniffing position) with the body
aligned straight.
C. The laryngoscope is held with the thumb and first 1-2 fingers of the left hand.
Pushing down gently on the larynx with the fifth finger (or leaving an assistant do it)
may help to visualize the vocal cords. Avoid extreme tension or tilt of the
laryngoscope.
D. The ETT is held in the right hand and inserted between the vocal cords so that the
tip is 1-2 cm below the vocal cords.
E. Check tube position by auscultation of the chest (and abdomen) to ensure equal
aeration of both lungs and observation of chest movement with positive pressure
inflation.
F. Secure ETT by applying adhesive (Hollister spray) to upper lip followed by two
pieces of 1/4 inch adhesive tape placed on lip and securely around ETT.
G. Verify ETT position by chest x-ray.
V. Intubation should be attempted without the use of a stylet. If a stylet is necessary,
be sure the stylet tip does not extend beyond the end of the ETT.
VI. If the infant will require intubation for greater than 7 days, consider use of palate
plate to prevent formation of a palatal groove. Palate plates can be obtained by
requesting a consultation from Pediatric Dentistry.
8- Suctioning of Endotracheal Tubes
I. Indications.
A. To clear airways of secretions.
B. To keep artificial airway patent.
C. To obtain material for analysis of culture.
In-line suctioning preferred for indications other than obtaining material for culture.
II. Pre-assemble suction equipment. Recommended suction catheters are 5 or 6
French for 2.5 mm ET tube, 6 French for 3.0 ET tube and 8 French for 4.0 ET tube.
The amount of suction applied to the catheter should be between 40-80 mmHg.
III. Suction between feedings or discontinue feedings for period of treatment.
IV. Auscultate chest prior to suctioning. Oxygenation prior to suctioning will be done
with an FiO2 no greater than 0.10 above that being used to ventilate the infant.
Monitor heart rate continuously. Suction should not be applied while the catheter is
being inserted down the ET tube. The tip of the suction catheter will not be inserted
beyond the end of the tube. When withdrawing the catheter, continuous suction is
applies. The procedure should not take longer than 10 seconds. Following suctioning,
ventilate the infant with an FiO2 no greater than 0.10 above that used prior to
suctioning. The PaO2 should be raised to a level comparable to that prior to
suctioning.

5. V. Do not add saline unless necessary. Saline may be used if the infant has thick
tenacious secretions which cannot be extracted by using suctioning alone. Normal
saline for secretions for Respiratory Therapy use is instilled into ET tube and 3-5
ventilated breaths performed prior to suctioning as above.
VI. Vibration and percussion (CPT) will not be performed routinely prior to
suctioning. If the need for CPT is documented, it must be ordered by a physician
describing the area to be treated and the frequency of treatments.
9- Suprapubic Bladder Tap
I. Indications: bladder aspiration is performed to obtain sterile urine for culture. A
suprapubic bladder tap is not necessary for Group B strep latex antigen studies (i.e., a
bag specimen is adequate).
II. Be certain that voiding has not occurred within the previous hour so that the
bladder has an adequate amount of urine. The infant is restrained in the frog leg
position. The pubic area is prepped 3 times with an alcohol swab. A 25-gauge needle
attached to a 3-ml syringe is directed perpendicularly to the skin just superior (0.5 cm)
to the symphysis in midline and advanced to its hub. Full-term infants sometimes
require a 22-gauge needle (which need not be inserted to the hub). The needle is
withdrawn, slowly, with slight pressure pulling back on the syringe.
III. A minimal amount of hematuria may be seen after an attempt, but otherwise the
risks are minimal. Rare complications include bladder wall hematoma, lacerated
vessel on anterior bladder wall, perforation of hollow viscus, and osteomyelitis of
pubic bone or abdominal wall abscess.
IV. If no urine is obtained, the infant should have a U-BagR placed with repeat
attempt in 1 hour. If unable to obtain a specimen, a catheterized specimen may need
to be obtained but this procedure is more difficult to perform and may be riskier.

6. 10- Technique for Insertion of a Chest Tube
Pulmonary air leak is an anticipated risk of mechanical ventilation. Drainage of air or
fluid accumulation in the thorax is an important and necessary skill and is often
performed emergently.
I. Indications.
A. Evacuation of pneumothorax
B. Evacuation of large pleural fluid collections
1. Chylothorax
2. Empyema
3. Hemothorax
A small spontaneous pneumothorax in the absence of lung disease will most likely
resolve without intervention.
II. When evaluating a suspected pneumothorax, auscultation and transillumination of
the chest should be performed. Note that false positives may result from subcutaneous
edema or air. If positive, consider needle aspiration performed with a 20 or 22 gauge
needle connected to a 30 cc syringe via a 3-way stopcock. After prepping with
alcohol, insert needle 3-5 mm into the chest wall in the fourth or fifth intercostal space
in the anterior axillary line. If the infant is supine, air may be easier to access via the
second intercostal space in the mid-clavicular line.
III. If pneumothorax is under tension or reaccumulates following needle aspiration,
the insertion of a chest tube (CT) will be necessary. Appropriate insertion sites
include the fourth, fifth or sixth intercostal spaces in the anterior axillary line. The
nipple is a landmark for the fourth intercostal space.

7. IV. Insertion. (See figure on next page)
A. A 8, 10 or 12 French CT used depending on the size of the infant.
B. Position infant supine or with the affected side elevated 45-60 degrees off the bed
using a towel or blanket as back support. This has an advantage of allowing air to rise
to the point of entry and of encouraging the correct anterior direction of the CT.
C. The skin is prepped with alcohol and sterilely draped.
D. A 1 cm incision is made through the skin on top of the rib to facilitate entry of the
CT. Using a small curved forceps, separate the tissue down to the pleura.
F. Grasping the end of the CT with the tips of curved forceps, apply pressure until the
pleural space is entered. Do not use the trocar. Direct CT toward apex of thorax
(midclavicle) and advance CT assuring that side holes are within thorax. Observe for
cloudiness, vapor or bubbling in CT to verify intrapleural location.
E. The chest tube should be inserted 2-3 cm for a small preterm infant and 3-4 cm for
a term infant. (These are approximate guidelines only.)
V. After CT insertion connect the tube's distal end to a water seal system such as a
PleurevacR. To apply suction, use 15-20 cm of water in the PleurevacR column. If
multiple CTs are placed, each CT should be connected to it's own water seal system
and suction source.
Secure CT to skin with suture and cover incision site with Vaseline gauze and/or
TegadermR dressing.
VI. After thoracentesis or CT insertion a chest x-ray, A/P and lateral should be
obtained.
VII. If there is a persistent pneumothorax despite a properly placed CT, consider
increasing the column of water by 5 cm increments up to 30 cm before inserting a
second CT.
IX. Prior to removal, the CT should be clamped for 2-4 hours or longer. If there is no
reaccumulation of air, the CT can be removed.
X. Complications.
A. Misdiagnosis with inappropriate CT placement
B. Malpositioned CT
C. Trauma
1. lung laceration or perforation
2. Laceration and hemorrhage of major vessel (axillary, intercostal, pulmonary,
internal mammary)
3. Puncture of viscus with path of tube
D. Infection

8. 11- Percutaneous Placement of Central Venous Catheters
I. Background and General Information:
A. Percutaneously placed, central intravenous catheters have become an important
part of neonatal patient management over the past several years at the University of
Iowa and elsewhere. They have proved of value in helping to provide adequate long-
term nutritional support as well as providing long-term vascular access for the
administration of medications such as antibiotics and prostaglandin E1. The risks of
percutaneous and intravascular central catheters are lower than those of catheters
placed surgically. These include local or systemic infection, and thrombosis with or
without infiltration. Manifestations of the latter include redness or swelling of an
extremity, the chest wall, and/or the neck.
B. When used for nutritional purposes, glucose concentration up to 25% may be used
to provide adequate calories if the catheter has been successfully placed in the vena
cava or right atrium. However, in doing so one should try to use less concentrated
dextrose solutions since the risk of thrombosis goes up with the use of increasingly
hyperosmolar solutions. Attempts should be made to fully utilize other less
hyperosmolar means of providing calories. This might include using lipid solution to
provide additional calories and/or to use a faster rate of infusion with a less
concentrated dextrose solution. These considerations should be evaluated on a
continuing basis.
II. Catheterization Procedure:
Commonly used sites for catheterization include the basilic, cephalic, saphenous
popliteal, external jugular, and temporal veins. (The vessels with the highest success
rate of catheterization are those which have not been previously used for peripheral
IV's.) Cap, mask, sterile gloves and sterile gown are worn by the operator (mask only
by nurse assistant), and the procedure is performed aseptically. Ideally the catheter tip

9. should lie a few centimeters from the right atrium. This can be estimated by knowing
the catheter length and how far from its insertion site it needs to be threaded. To
confirm this, a post-insertion AP x-ray will be taken and the tip identified. The x-ray
to be ordered for most catheters is a single AP view of the lower chest and upper
abdomen.
III. Care of Percutaneous Central Catheters:
A. IV fluids need not contain heparin if the flow rate is 5 ml/hr or greater; if flow rate
is < 5 ml/hr fluid should contain heparin, usually at a concentration of 0.25 - 0.5
unit/ml, but at a rate not to exceed 100 U/kg day; (50 U/kg/day in infants <1000 g).
B. Initial IV fluids should contain dextrose at a concentration not greater than 10%; if
the catheter tip is positioned in a central vein, the dextrose concentration may be
advanced slowly to as high as 25% (see A above).
C. IV rates should be kept at 3 ml/hr or greater, and less than that recommended by
the catheter manufacturer (generally <20 ml/hr for a 27 or 28-gauge catheter)
D. 24-gauge silastic catheters may be repaired by cutting the hub and cannulating the
catheter with a 28-gauge blunt needle. This should be done with sterile technique. 27
and 28-gauge catheters cannot be repaired. The dressing is not routinely changed.
E. Blood samples should not be drawn through the catheter. If suspicions occur
regarding the need to remove the catheter or if other questions about the catheter
arise, consult a nurse or physician member of the Neonatal Percutaneous Central
Catheter Team.
F. More detailed nursing instructions for the placement; care and handling of the
catheter are available on the NICU in the Policy and Procedure Manual.
G. Removal of a percutaneous central catheter should be performed by a nurse or
physician member of the Percutaneous Central Catheter Team, if possible.
H. At the time of its removal, the length of the catheter from its tip to entry point into
the plastic hub should be measured and recorded on the special form in the patient's
chart.
IV. Requesting Placement of Central catheters by Patient's Physician:
A. Requests for central line placement can be made by consulting a member of the
Neonatal Percutaneous Central Catheter Team. (This needs to be followed by a
written order.) A Catheter Team member will inspect the patient's veins for suitability
of catheter placement and report his/her impression to the resident, fellow or staff
physician making the request. If the patient appears suitable the following need to be
done by the patient's physician in coordination with the physician placing the
catheter:
1. schedule the date and time of the procedure with a Catheter Team member;
2. Order IV solution and have present on unit.
3. Discuss procedure with patient's parent(s).
B. Responsibilities of the Percutaneous Catheter Team include:
1. Answering additional questions parents may have after their discussion with their
baby's primary physician;
2. Order and examine chest x-ray following catheterization procedure
3. Put procedure note in Progress Notes and fill out Percutaneous Line Consult Sheet.
4. Discuss results of procedure with baby's primary physician

10. should lie a few centimeters from the right atrium. This can be estimated by knowing
the catheter length and how far from its insertion site it needs to be threaded. To
confirm this, a post-insertion AP x-ray will be taken and the tip identified. The x-ray
to be ordered for most catheters is a single AP view of the lower chest and upper
abdomen.
III. Care of Percutaneous Central Catheters:
A. IV fluids need not contain heparin if the flow rate is 5 ml/hr or greater; if flow rate
is < 5 ml/hr fluid should contain heparin, usually at a concentration of 0.25 - 0.5
unit/ml, but at a rate not to exceed 100 U/kg day; (50 U/kg/day in infants <1000 g).
B. Initial IV fluids should contain dextrose at a concentration not greater than 10%; if
the catheter tip is positioned in a central vein, the dextrose concentration may be
advanced slowly to as high as 25% (see A above).
C. IV rates should be kept at 3 ml/hr or greater, and less than that recommended by
the catheter manufacturer (generally <20 ml/hr for a 27 or 28-gauge catheter)
D. 24-gauge silastic catheters may be repaired by cutting the hub and cannulating the
catheter with a 28-gauge blunt needle. This should be done with sterile technique. 27
and 28-gauge catheters cannot be repaired. The dressing is not routinely changed.
E. Blood samples should not be drawn through the catheter. If suspicions occur
regarding the need to remove the catheter or if other questions about the catheter
arise, consult a nurse or physician member of the Neonatal Percutaneous Central
Catheter Team.
F. More detailed nursing instructions for the placement; care and handling of the
catheter are available on the NICU in the Policy and Procedure Manual.
G. Removal of a percutaneous central catheter should be performed by a nurse or
physician member of the Percutaneous Central Catheter Team, if possible.
H. At the time of its removal, the length of the catheter from its tip to entry point into
the plastic hub should be measured and recorded on the special form in the patient's
chart.
IV. Requesting Placement of Central catheters by Patient's Physician:
A. Requests for central line placement can be made by consulting a member of the
Neonatal Percutaneous Central Catheter Team. (This needs to be followed by a
written order.) A Catheter Team member will inspect the patient's veins for suitability
of catheter placement and report his/her impression to the resident, fellow or staff
physician making the request. If the patient appears suitable the following need to be
done by the patient's physician in coordination with the physician placing the
catheter:
1. schedule the date and time of the procedure with a Catheter Team member;
2. Order IV solution and have present on unit.
3. Discuss procedure with patient's parent(s).
B. Responsibilities of the Percutaneous Catheter Team include:
1. Answering additional questions parents may have after their discussion with their
baby's primary physician;
2. Order and examine chest x-ray following catheterization procedure
3. Put procedure note in Progress Notes and fill out Percutaneous Line Consult Sheet.
4. Discuss results of procedure with baby's primary physician