• The laryngoscope consists of a handle (which also contains the batteries), blade and light source.
• The blade can be either a straight blade (Miller) or a curved blade (Macintosh).
• Straight blade is preferred for infants and toddlers since it provides better visualization of glottis but a curved blade is preferred for older children since its broader blade facilities displacement of tongue and visualization of the glottis.
• Laryngoscope is designed to be held in left hand – by both right and left handed persons. If held in right hand, the closed covered part of blade will block your view of glottis, as well as make insertion of ET tube impossible.
• Turn on the laryngoscope light and hold the Laryngoscope in your left hand, between your thumb and first two or three fingers, with the blade pointing away from you. One or two fingers should be left free to rest on baby's face to provide stability.

 

• Zero (Preterm neonate)
• One (Term neonate and infant)
• Two (Children)
• Three (Adolescent)

 

• Autoclaving

 

• Injury like dislodgement of tooth
• Bradycardia
• Hypoxia

 

• An endotracheal tube of uniform internal diameter is preferrable to a tapered tube.
• 15 mm adapter is firmly affixed to the proximal end for attachment to a ventilating device.
• The distal end of the endotracheal tube may provide an opening in the sidewall (Murphy eye) to reduce the risk of right-upper-lobe atelectasis. The Murphy eye also reduces the likelihood of complete endotracheal tube obstruction if the end opening is occluded.
• The endotracheal tube should have distance markers (in centimeter) for use as reference points during placement and to facilitate detection of unintentional endotracheal tube movement. 1 cm graduation markings are to ascertain insertion depth while 2 cm indicator mark assists positioning of tube past the vocal cord.
• Vocal cord guide: Most ET tubes for neonates have a heavy black line set back from the tip which is meant to be aligned with the vocal cords during tube insertion. This should position the tip of the tube above the bifurcation of the trachea.
• A cuffed endotracheal tube is generally indicated for children aged 8 to 10 years or older. In children younger than 8 to 10 years the normal anatomic narrowing at the level of the cricoid cartilage provides a functional cuff and so uncuffed tube is indicated.
• Inflation is appropriate if an audible air leak is present when ventilation to a pressure of 20 to 30 cm H₂O is provided. The absence of an air leak may indicate that the cuff is inflated excessively, that the endotracheal tube is too large, or that laryngospasm is occurring around the endotracheal tube.
• Simple visual estimates of appropriate endo-tracheal tube size can be made by choosing a tube with an outside diameter approximating the diameter of the child's little finger (Table 1.1.)

Table 1.1   Size of ET tube Tube size (mm) Weight (gm) Gestation Age (weeks) 2.5 <1000 Below 28 3.0 1,000-2,000 28-34 3.5 2,000-3,000 34-38 3.5-4.0 Above 3,000 Above 38

• Depth of insertion in cm (alveolar ridge to midtrachea) for children older than 2 years can be approximated by:
  
  Alternatively, the distance of insertion (in cm) can be estimated by multiplying the internal diameter of the tube by 3. For example if i.d. = 4 mm
  Depth of insertion = 4 × 3 = 12 cm

 

• Epinephrine
• Atropine
• Naloxone
• Isoproteronol
• Lignocaine

 

• Hypoxia/apnea
• Injury
• Pneumothorax
• Bradycardia
• Obstruction

 

1. Air inlet and attachment site for oxygen reservoir
2. Oxygen inlet
3. Patient outlet
4. Valve assembly
5. Oxygen reservoir
6. Pressure release (pop-off) valve
7. Pressure manometer attachment site

• As the bag re-expands following compression, gas is drawn into the bag through a one way valve called air inlet.
• Every self-inflating bag has an oxygen inlet, which is a small nipple or projection to which oxygen tubing is attached.
• The patient outlet is where gas exits from the bag to the baby and where the mask or endotracheal tube attaches.
• When the bag is squeezed during ventilation, the valve opens, releasing oxygen/air to the patient. When the bag reinflates the valve is closed. This prevents the patient's exhaled air from entering the bag and being re-breathed.
• Most self-inflating bags have a pressure-release valve (pop-off valve) which is generally set to 30 to 40 cm H₂O. If pressure greater than this is generated, the valve closes.
• Concentration of oxygen actually received by the patient without reservoir is 40%. High concentrations of oxygen can be achieved by using an oxygen reservoir. The concentration of oxygen achieved with a self-inflating bag with an oxygen reservoir attached will be between 90% and 100%.
• Current recommendations are that a baby who requires resuscitation should be given a high concentration of oxygen (90 to 100%).

 

• Resuscitation masks have thin rims that are either cushioned or noncushioned.
• The rim on a cushioned mask makes it easier to form a seal. It requires less pressure on newborns face to obtain a seal. There is less chance of damaging the newborn's eyes.
• A mask with noncushioned rim, makes more difficult to obtain a seal, can damage the eyes, and can bruise the newborn's face.
• Two shapes are available—Round and Anatomically shaped.
• For the mask to be of correct size, the rim will cover the tip of the chin, the mouth, and the nose but not the eyes. Too large may cause possible eye damage. Too small will not cover the mouth and nose and may occlude the nose.

 

• It has elongated design for visual patient assessment (cyanosis, regurgitation) with adjustable nose clip and elastic head strip which helps in proper positioning of mask on mouth and nasal area.
• It also has exhalation ports in the side and between mask and face.
• Lumen tube is provided to ensure continuous flow of oxygen.
  7
• Proximal end of tube is fitted with soft funnel shaped connector for easy connection to oxygen source.
• It should have low under mask volume (dead space) which will decrease the chances of rebreathing of exhaled gases.

 

• Interference with feeding and suction procedures
• If oxygen flow rate is less than 6 L/min, rebreathing of exhaled CO₂.
• Tightly fitted mask is not accepted by children and poorly fitted mask provide only 30-40 percent oxygen.
• Variable FiO₂ delivery.

 

• It contains soft twin prong nasal tips to ensure equal volume of oxygen to both air passages and has star lumen main tube to avoid accidental blockage.
• Prongs are inserted into anterior nares and oxygen is delivered into nasopharynx.
• Sizes available: Adult and paediatric.

 

• CPAP
• Leaves mouth free for nutritional purpose.

 

• Does not provide humidified oxygen
• Frequent displacement of prongs
• Nasal mucosa injury.
• Contraindicated in chonal atresia, deviated nasal septum, nasal polyp.
  8

 

• Oxygen mask
• Oxygen hood
• Nasal cannula
• Nasopharyngeal catheter.

 

• Clinical assessment by color.
• Pulse oximetry:
  • Recommended levels of oxygen saturation-89-95%.
  • Pulse oximetry is based on measurement of the proportion of light transmitted by oxy-genated forms of hemoglobin; a sensor is placed over a finger, toe, earlobe, or the bridge of the nose, and a numerical output is produced.
  • Pulse oximetry is generally accurate only for oxygen saturations greater than 80%; therefore, arterial blood gas analysis is recommended for oxygen saturations less than 80%.
• PaO₂ estimation by arterial blood gas analysis
• Transcutaneous oxygen measurement for SpO₂ monitoring
• Estimation of tissue oxygenation by estimation of serial lactate.

   

• Humidification decreases the size of oxygen molecule, therefore, reaches alveoli easily.
• Humidification prevents drying of secretions as dried secretions may block the airway.
• Well tolerated by infant.
• Allows easy access to rest of body.
• No risk of airway obstruction and gastric dilatation.

 

• Prolonged exposure to humidified oxygen increases the risk of cutaneous fungal infections.
  9
• Low temperature within enclosure system may result in cold stress injury.
• Inadequate oxygen flow rate, may result in hypoxia or hypercapnia.
• Any opening in the enclosure may result in decrease in the concentration of oxygen.
• Difficulty in feeding and suction procedures.
• Carbon dioxide build up can occur.

 

• It has closed distal end with two lateral eyes and soft and rounded tip to prevent trauma during application.
• Length is 52 cm and is marked at 25 cm from the tip for accurate placement.
• Radiopaque line is provided throughout the length for X-ray visualization.
• Proximal end is fitted with mount for easy connection to feeding funnel or syringe.
• Color coding is done for size identification.

 

• Always measure the length of the tube. The length of the inserted tube should be equal to the distance from the Bridge of the nose to the tragus and from the tragus to the Xiphoid Process (the lower tip of the sternum).
• Insert the tube through the mouth rather than the nose. The nose should be left open for ventilation. Ventilation can be resumed as soon as the tube has been placed.
• Once the tube is inserted the desired distance, attach a syringe and gently remove the gastric contents.
• Remove the syringe from the tube and leave the end of the tube open to provide a vent for air entering the stomach.
• A large tube may cause difficulty in making a seal. A smaller tube can be occluded by secretions.

 

• Atraumatic, soft and rounded open tip with two lateral eyes
• For removal of secretion from oropharynx and trachea
• Length: 52 cm.

 

• Designed for intermittent or continual access to the umbilical artery or vein of the newly bornor premature baby
• Tube with radiopaque line, marked at every cm from 5 to 25 cm from the open distal tip for accurate placement:
  • 1st marking: Under surface of liver
  • 2nd marking: Hepatic vein
  • 3rd marking: Inferior venae cava
• Open distal end without lateral eyes eliminates the chance of clot formation in the blind spaces

• Has female flexible mount and luer lock
• Color coded funnel end connector for easy identification of size
• Length: 40 cm
• Sizes available: FG 4, 5, 6, 8
• Optimal length for umbilical vein catheterization: 20 percent of crown heel length or 50 percent of shoulder umbilicus length.

 

• Bleeding
• Thromboembolism
• Infection.

• Portal hypertension (extrahepatic)

 

• It has atraumatic, soft and rounded, open tip with two lateral eyes and clear transparent container permiting visual examination of aspirate.
• Spare screw top lid is provided to seal the container for safe transportation of specimen to the laboratory or aseptic disposal of container
• Suction tube lengths available: 40 cm, 50 cm
• Capacity: 25 ml.
• Pressure: 100 mm Hg.

       

• Most commonly used device
• Cannister with drug (1%), surfactant, preservatives and propellent (80%) (CFC/HFA)
• Metered dose chamber (finite volume released)
• A metering valve that dispenses a constant volume of a solution or suspension of the drug in the propellant.

 

• β₂ agonist
• Ipratropium bromide
• Inhaled steroids—beclamethasone, budesonide. fluticasone
• Mast cell stabilizers—cromolyn sodium, nedocromolyn.

 

• Tremors
• Oral thrush
• Ankle edema
• Tachycardia
• Hypokalemia.

 

• Portable
• Quick delivery
• Precise and constant dose
• Light, compact, resistant to moisture
• No drug preparation
• No contamination of contents.
  13

 

• Needs hand breath coordination
• Cold Freon effect (inability to breath when propellent is released in mouth)
• Contains CFC
• Used with spacer (increases cost)
• Time consuming to teach
• Oropharyngeal deposition

• Remove cap and shake inhaler in vertical direction
• Breathe out gently
• Put mouthpiece in mouth and at start of inspiration which should be slow and deep, press canister down and continue to inhale deeply
• Hold breath for seconds or as long as possible then breathe out slowly
• Wait for few seconds before repeating above steps.

• Remove cap, shake inhaler and insert into spacer device
• Place mouthpiece of spacer in mouth
• Start breathing in and out gently and observe movements of valve
• Once breathing pattern is established press canister and continue to breath 5-10 times (tidal breathing)
• Remove the device from mouth and wait for 3 minutes before repeating above steps

• Attach baby mask to the mouth end of spacer
• Shake MDI and insert it in the MDI end of spacer device
• Cover baby's mouth and nose with baby mask
• Press canister and encourage the child to take tidal breathing with mouth open (if possible) 5-10 times
• Remove baby mask and wait for 30-60 seconds before repeating above steps.

     

• If a new inhaler OR if you have not used the MDI for one week spray two doses into the air before use to mix properly and check it working.

• MDI: Metered dose inhalers
• DPI: Dry powder inhalers
• Nebulizers

 

MMAD	: Mass median aerodynamic diameter
MMAD <1μm	: Exhaled out
MMAD 1~5μm	: Target particle that reaches lung
MMAD >5 μm	: Deposited in oropharynx

 

• Rotahaler is used in children above 4-5 years of age
• Contains mouthpiece and reservior
• Drugs administered: Salbutamol, Beclo-methasone, Budesonide, Fluticasone, Sodium cromoglycate
• They have the advantage of being portable and eliminate the need to co-ordinate actuation with breathing environmental friendly, as they do not contain CFC
• There may be a problem in high humidity environment (agglutination of particles), and high oropharyngeal deposition of drugs.

   

• Contains CFC
• High velocity aerosols
• Requires hand breath co ordination
• Delivery of medicines independent of external factors
• Time consuming to teach
• Requires deep and slow breathing only.

• No CFC
• Aerosol velocity depends on inspiratory flow rate
• No hand breath coordination needed
• Delivery of medication largely dependent on external factors
• Easy to teach
• Requires high inspiratory flow >28 L/min.

 

• Nebulizers are used for delivering nebulized P-agonist in acute severe asthma.
• Dose of salbutamol used in nebulizers is 0.15 mg/kg/dose at 0, 20 min and 40 min and then depending on the response of patient 2 hourly or 4 hourly.

 

1. Calculate the dose of medicine (0.15 mg/kg/dose; minimum dose: 1.25 mg)
2. Add saline to make a fill volume of 3-5 ml.
3. Switch on the compressor and give aerosol for 8-10 minutes.
4. As many patients are hypoxic, oxygen from central supply or a oxygen cylinder should be given, at a flow rate of 6-8 L/minute in place of compressed air.
5. Nebulization is given over 8-10 minutes, till you hear a spluttering sound.

• Avoid combining steroids with other medications
• Can combine salbutamol and ipratropium

• 3-5 ml

• 8-10 minutes.

• The total fill volume should be about 3-5 mL
• Tapping the sides
• The optimal flow rate is 6-12 L/min, 30-50% of aerosol are in the respirable range of 1-5 μm
• Slow deep inhalations and breath holding can improve delivery:

 

• Holding chamber/resevoir types:
  • Small volume/large volume
  • With/without valve
  • Polyamide/polycarbonate.

 

• No need to actuate with inspiration
• Increased drug deposition in lungs
• Less deposition in mouth
• Eliminates ColdFreon effect: (inability to breath when propellent is released in mouth)
• Decreased chance of oral thrush
• As effective as nebulizer.

 

• Initiation can be more complex
• More expensive than MDI alone
• Less portable than MDI alone
• Can reduce dose if not correctly given.
  16

   

• Stillete
• Thick body with nail
• Guard 2 cm from the tip (guard prevents through and through penetration of the bone).

   

1. Posterior iliac crest (both aspiration and biopsy)
2. Sternum (aspiration only in adults)
3. Anterior iliac crest (both aspiration and biopsy).

 

• Coagulation disorders like hemophilia
• Infection at biopsy area.

 

• Infection
• Bleeding
• Cardiac injury (if deep penetration occurs in sternal aspiration).

   

• In children, ordinary needle is often used for lumbar puncture.
• The advantage with the lumbar puncture needle is that the stilette helps to keep the lumen of the needle patent.

   

• Trocar
• Cannula
• Bifid needle.

       

• Neonatal hepatitis
• Biliary atresia
• Galactosemia.

• Chronic hepatitis
• Cirrhosis
• Metabolic: Wilson's disease, Tyrosinosis, Hemochromatosis
• Malignancy Staging: Wilms' tumor, Hodgkin's lymphoma, Neuroblastoma
• Diagnosis of malignancy: Hepatoma, hepato-blastoma.

 

• Age <1 year or > 8 years
• Persistent microscopic or gross hematuria, low serum C3
• Sustained hypertension (>3 weeks)
• Suspected secondary causes of nephrotic syndrome.

• Proteinuria persisting despite 4 weeks of daily corticosteroid therapy
• Before starting treatment with cyclosporine A
• Frequently relapsing or steroid dependant nephrotic syndrome (discretion of the pediatric nephrologist).

 

• Systemic features: Fever, rash, joint pain, heart disease.
• Absence of serologic evidence of streptococcal infection; normal levels of C3.
• Mixed picture of AGN and nephrotic syndrome
• Severe anemia, very high levels of blood urea or anuria requiring dialysis.
• Delayed resolution.
  • Oliguria, hypertension and/or azotemia persisting past 2 weeks.
  • Gross hematuria persisting past 3-4 weeks.
  • Low C3 levels beyond 6-8 weeks.
  • Persistent hematuria or proteinuria beyond 6 to 12 months.

 

• Three way is a T-shaped instrument with two inlets and one outlet. By a screw, either of the inlets can be connected to the outlet.
• Transparent polycarbonate main body facilitates observation of flow. Arrow on the handle indicates the direction of flow.
• Minimum priming volume required for accurate drug administration.

 

• Clear, soft, cylindrical and calibrated measured volume chamber with bold graduation.
• Chamber injection port allows medication to be injected into burette chamber for medication mixture.
• Chamber vent allows air to enter chamber through hydrophobic membrane to prevent solution contamination.
• Burette sizes available: 110 ml, 150 ml.
• 1 ml of it contains 64 drops.
• It contains Murphy chamber through which it is possible to regulate the number of drops falling per minute. A fluid level must be maintained in the Murphy's chamber. If the chamber gets full, it has to be reset.
• If you want to give 40 ml/hr fluid through microdrip set, adjust it to set at just 40 drops/min.

   

• Suitable for maintaining an unobstructed oropharyngeal airway during general anesthesia and in unconscious patients. It has rounded atraumatic edges with smooth airway path for easy cleaning
• Length of Guedel airway used is 2/3rd of distance between angle of mouth and temporomandibular joint.

 

• Contains transparent flash back chamber for easy visualization of blood to confirm veni-puncture.

 

Phase I	: First appearance of clear, tapping sound. It represents the systolic blood pressure
Phase II	: Tapping sounds are replaced by soft murmurs
Phase III	: Murmurs become louder
Phase IV	: Muffling of sounds
Phase V	: Disappearance of sounds

   

• It has penile sheath/External catheter
• Male catheter is specially designed for urine incontinence for day and night use in male patient
• Proximal end is designed for easy connection to urine bag, making it simple to use
• Provided with self-adhesive coated strip for proper fixing on to the penis

 

• Provided with finger grip for safe and convenient handling
• Security lock to prevent accidental opening after clamping
• Grooved clamping area to prevent slipping of umbilical cord.

 

• It consists of three balls
• It helps the patient to recover normal respiration after a chest or abdominal surgery

 

• Bag graduated in ml to measure urine output
• Contains non-return valve
• Conical inlet connector with cap

     

1. Comparator: It contains Sahli tube. Comparator has brown tinted glass pieces on either side for color matching an opaque white glass is present at back to provide proper illumination.
2. Sahli tube: Calibrated in gram% hemoglobin (2 to 24) on one side and in percentage (20 to 140) on other side. 100 percent being equivalent to Hb 17.3 g/dl blood.
3. Sahli pipette Graduated to .02 ml (20 mm³) mark with rubber tubing and mouthpiece.
4. Glass rod stirrer

 

• Fill the Sahli tube to the 20 mark (3 g%) with N/10 HCl
• Draw blood to the 0.02 ml mark of Sahli pipette
• Wipe out any blood stick to the pipette from outside with cotton
• Blow the blood from pipette into Sahli tube containing N/10 HCl
  23

• Mix the content quickly by gently shaking the tube
• Keep the Sahli tube back into comparator for 10 min
• Acid reacts with hemoglobin and converts it into acid hematin (brown color)
• Compare it with color of standard com parator
• If the color of blood is darker than that of standard continue to dilute by adding distilled water drop by drop and stir it after adding each drop of distilled water till the color of solution matches with standard.
• Note the reading in gram percent. It gives reading with error of 10%.

 

• Cyanmethemoglobin method—Best method
• Alkaline haematin method
• Oxyhemoglobin method
• Carboxyhemoglobin method
• Copper sulfate specific gravity method.

   

• Length 11 cm, diameter 2.5 cm
• It is open at top end and closed distally

 

• Fill the Wintrobe tube from oxalate blood with pipette up to zero mark.
• Keep the Wintrobe tube in Wintrobe stand in a vertical position for 1 hr and take the reading.
• Express the reading in mm 1st hour. Normal ESR value: 1 to 10 mm in 1st hour.

 

• Fill the Wintrobe tube with EDTA blood.
• Centrifuge the tube for 20 min at 2500 rpm. Take the reading in percent.
• Centrifuge the tube again for 5 min and note the reading.
• Final reading is recorded when 3 consecutive readings are identical.
• After centrifugation blood is separated into 3 layers, tall bottom layer of packed red cells, thin middle layer of WBCs and platelets and top layer of clear plasma.
• Percentage of height of red cell volume is hematocrit (PCV).

   

• Draw the EDTA sample into clean dry Westergren tube.
• Adjust the rack so that the tube rests in an exactly vertical position.
• Leave undisturbed for 60 min.
• At the end of the hour read the height of clear plasma above the upper margin of the column of sedimenting cells to the nearest millimetre.
  25
• A poor delineation of the upper layer of red cells, so-called ‘stratified’ sedimentation, has been attributed to the presence of many reticulo-cytes.
• Report this measurement as the ESR (Westergren) in units of mm in 1 hour.

     

• Glass stem has 3 marking 0.5,1 and 101 (volume)
• Glass capillary tube opens into wide bulb containing red glass bead
• Red bead helps in mixing the contents of bulb.

   

• Fill the RBC pipette exactly upto 0.5 mark with blood
• Now fill RBC diluting fluid (formal citrate solution) up to mark 101 (dilution 1 in 200)
• Mix the content thoroughly for 2 minutes. Discard first 2-3 drops of diluted blood
• Adjust the chamber and put coverslip in such a manner that both the ruled platforms are evenly covered by it
• Now charge the chamber (improved Neubauer chamber)
  26
• Wait for 2 min for settling of cells and then count
• In erythrocyte count central double-ruled square is used. Red cells lying in 80 very small squares have to be counted.

 

• Glass stem has 3 marking 0.5,1 and 11 (volume)
• Glass capillary tube opens into wide bulb containing white bead
• White bead helps in mixing the contents of blood

   

• Fill the WBC pipette exactly up to 0.5 mark with blood.
• Now fill WBC diluting fluid upto mark 11 (dilution 1 in 20).
• Mix the content of pipette thoroughly for 2 minutes.
• Expel first 3 drops of diluted blood.
• Adjust the chamber under microscope.
• Wait for 2 minutes for settling of cells.
• Cells lying in 4 large corner squares are counted.

   

• For purposes of comparison, growth charts are provided with reference curves. The WHO reference curves are based on extensive cross sectional data of well nourished healthy children, assembled by the National Centre for Health Statistics which are considered the best available for international use.
• 50th percentile of NCHS weight for age chart normally corresponds to the reference median. It gives the value of the 50th child of a group of 100 when they are arranged in ascending or descending order and where equal number of children will have measurements smaller or larger than the 50th value.
• When we say 3rd percentile it means that only 3 percent (3 in each 100) of children weighed had values which fall below that line. The 3rd percentile corresponds approximately to 2 standard deviations below the median of the weight for age reference value (2 SD below 50 percentile of NCHS chart). It is considered as the conventional lower limit of normal range.

 

• The WHO growth chart has 2 reference curves. The upper reference curve is the median (50th percentile NCHS) for boys (slightly higher than that for girls), and the lower reference curve is the 3rd percentile for girls (slightly lower than that for boys)
• The space between the two growth curves has been called the “road to health”, i.e. road to normality.

• Identification and registration
• Birth date and weight
• Chronological age
• History of sibling health
• Immunization
• Introduction of supplementary foods
• Episodes of sickness
• Child spacing and reasons for special care.
  27

 

• There are 49 different types of growth charts in use in India.
• Growth chart recommended by the government of India has four reference curves.
• Topmost curve corresponds to the median (50th percentile of WHO reference standard) which represents the level of optimum growth.
• Second line represents 80 percent of the median weight (3rd percentile) which is approximately equivalent to 2 SD below the median which is the conventional lower. limit of normal range.
• 3rd and 4th line represents 70 and 60 percent of the median weight.
• 1st degree malnutrition: Weight is between 80 and 70 percent line
• IInd degree malnutrition: Weight is between 70 and 60 percent
• IIIrd degree malnutrition: Weight is below 60 percent line
• IVth degree malnutrition: Weight below 50 percent.

   

• There are 3 patterns of curves
• Direction of the growth curve is more important than the position of the dots on the line at any time
• If child is growing normally, growth line will be above the 3rd percentile and run parallel to the road to health curves.
• Flattening of the weight curve shows persistent failure to gain weight. It is the earliest sign of malnutrition.
• Falling of the weight curve shows definite malnutrition.
• When there is increase in the rate of weight gain after a flattening or a falling curve that is the earliest evidence of recovery (catch up growth)
• Weight chart can be misleading in Kwashiorkor. The weight increases due to edema and the weight can go above 50th percentile also.