Editors: MacDonald, Mhairi G.; Ramasethu, Jayashree
Title: Atlas of Procedures in Neonatology, 4th Edition
Copyright ©2007 Lippincott Williams & Wilkins
> Front of
Book >OFEditors
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Editors
Mhairi G. MacDonald MBChB, FRCPE, FRCPCH, FAAP, DCH
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Professor of Pediatrics
George Washington University, School of Medicine and Health
Sciences, Washington, DC, The Accreditation Council of Graduate
Medical Education, Chicago, Illinois
Jayashree Ramasethu MBBS, DCH, MD, FAAP
Associate Professor of Clinical Pediatrics, Associate Director
Neonatal - Perinatal Medicine Fellowship Program, Division of
Neonatology, Georgetown University Hospital, Washington, DC

Secondary

Editors

Sonya Seigafuse
Acquisitions
Editor
Ryan Shaw
Managing Editor

Alicia Jackson
Production Editor
Benjamin Rivera
Senior Manufacturing
Kimberly

Manager

Schonberger


Marketing

Manager

Doug Smock
Creative Director
Mark Flanders
Art Director for Media Services
TechBooks
Compositor
R. R. Donnelley-Asia
Printer

Contributing

Authors

M. Kabir Abubakar MBBS, FAAP
Associate Professor of Clinical Pediatrics

Division of Neonatology, Department of Pediatrics, Georgetown
University Hospital, Washington, DC
Monisha Bahri MBBS
Fellow in Neonatal-Perinatal Medicine
Division of Neonatology, Department of Pediatrics, Georgetown
University Hospital, Washington, DC
Aimee M. Barton MD, FAAP
Fellow in Neonatal-Perinatal Medicine
Division of Neonatology, Department of Pediatrics, Georgetown
University Hospital, Washington, DC
Alan Benheim MD
Pediatric Cardiology

Associates,

P.C.


Fairfax, Virginia; Assistant Clinical Professor, Inova Fairfax Hospital for
Children, Falls Church, Virginia
A. Alfred Chahine MD
Associate
Professor
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Department of Pediatric Surgery, The George Washington University
School of Medicine; Chief, Department of Pediatric Surgery,
Georgetown University Hospital, Washington, DC
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Robert D. Christensen MD


Medical Director
Neonatology, Urban
Utah

North

Region,

Intermountain

Healthcare,

Ogden,

Linda C. D'Angelo RN, BSN, CWOCN
Wound, Ostomy, and Continence Nurse, Nursing Department,
Georgetown University Hospital, Washington, DC
William F. Deegan MD
Associate Clinical Professor
Department of Ophthalmology, George Washington University School
of Medicine, Attending Surgeon, Department of Ophthalmology,
Children's National Medical Center, Washington, DC
Jennifer A. Dunbar MD
Assistant Professor of Ophthalmology
Department of Ophthalmology, Loma Linda University School of
Medicine; Attending Physician, Department of Ophthalmology, Loma
Linda University Medical Center, Loma Linda, California
Martin R. Eichelberger MD
Professor of Surgery and Pediatrics
Department of Surgery, The George Washington University School of



Medicine; Attending Pediatric Surgeon, Department of Pediatric
Surgery, Children's National Medical Center, Washington, DC
Rebecca J. Eick MD
Fellow in Neonatal-Perinatal Medicine
Division of Neonatology, Department of Pediatrics, Georgetown
University Hospital, Washington, DC
Laura A. Folk RNC, BSN, Med
Clinical Educator
Neonatal Intensive Care Unit, Georgetown University Hospital,
Washington, DC
Chrysanthe G. Gaitatzes MD, PhD
Neonatology Fellow
Department of Pediatrics, George Washington University Hospital,
Neonatology Fellow, Department of Neonatology, Children's National
Medical Center, Washington, DC
Harold M. Ginzburg MD, JD, MPH
Clinical Professor
Department of Psychiatry, Tulane University Health Sciences Center,
LSU Health Sciences Center, New Orleans, Louisiana; Adjunct
Professor, Psychiatry, Uniformed Services University of the Health
Sciences School of Medicine, Bethesda, Maryland
Allison M. Greenleaf RN, MSN, CPNP
Pediatric Nurse Practitioner
Department of Pediatrics, Division of Neonatology, Georgetown
University Hospital, Washington, DC
Leah Greenspan-Hodor DO
Neonatal-Perinatal
Fellow



Department of Neonatology, Children's National Medical Center,
Washington, DC
Gary E. Hartman MD
Clinical Professor of Surgery
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Division of Pediatric Surgery, Stanford University School of Medicine;
Director, Regional Surgical Services, Lucile Packard Children's
Hospital, Stanford, California
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Hosai Hesham MD

Resident Physician
Department of Otolaryngology, Head and Neck Surgery, Georgetown
University Hospital, Washington, DC
Pamela Jakubowicz MD
Assistant
Professor
Department of Medicine, Albert Einstein College of Medicine, BronxLebanon Hospital Center, Bronx, New York
Margaret Mary Kuczkowski MSN, CPNP
Clinical Educator
Neonatal Intensive Care Unit, Georgetown University Hospital,
Washington,

DC

Naomi L. C. Luban MD
Professor
Departments of Pediatrics and Pathology, George Washington

University School of Medicine and Health Sciences; Chairman,
Laboratory Medicine and Pathology; Director, Transfusion Medicine;
Vice Chairman, Academic Affairs, Department of Laboratory Medicine,
Children's National Medical Center, Washington, DC
Mhairi G. MacDonald MBChB, FRCPE, FRCPCH, FAAP, DCH


Professor of Pediatrics
George Washington University, School of Medicine and Health
Sciences, Washington, DC, The Accreditation Council of Graduate
Medical

Education,

Chicago,

Illinois

Secelela Malecela MD
Fellow in Neonatal-Perinatal Medicine
Division of Neonatology, Department of Pediatrics, Georgetown
University Children's Medical Center, Washington, DC
Kathleen A. Marinelli MD, IBCLC,
Associate Professor of Pediatrics
Department of Pediatrics, University
Farmington, Connecticut; Attending
Neonatology, Connecticut Children's
Connecticut

FABM, FAAP

of Connecticut School of Medicine,
Neonatologist, Department of
Medical Center, Hartford,

Nicholas J. Marsh DO
Attending
Anesthesiologist
Department of Anesthesiology, INOVA Loudoun Hospital Center,
Leesburg, Virginia
An N. Massaro MD
Adjunct Instructor in Pediatrics
Department of Pediatrics, George Washington University; NeonatalPerinatal Fellow, Department of Neonatology, Children's National
Medical Center, Washington, DC
Marijean Miller MD
Associate
Professor
Departments of Ophthalmology and Pediatrics, George Washington
University; Attending, Department of Ophthalmology, Children's
National Medical Center, Washington, DC


Gregory J. Milmoe MD, FAAP
Associate
Professor
Department of Otolaryngology - Head and Neck Surgery, Georgetown
University

Hospital,

Washington,


DC

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Susan H. Morgan MEd
Instructor, Director of Audiology and Hearing Research
Department of Otolaryngology-Head and Neck Surgery, Georgetown
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University VERSION
Hospital,OFWashington,
DC
Robert J. Musselman DDS
Clinical Professor of Pediatric Dentistry
Louisiana State University School of Dentistry, New Orleans, Louisiana
Sepideh Nassabeh-Montazami MD
Assistant Professor of Pediatrics
Division of Neonatology, Department of Pediatrics, Georgetown
University Hospital, Washington, DC
Khodayar Rais-Bahrami MD
Professor of Pediatrics
Department of Pediatrics, The George Washington University School of
Medicine; Attending Neonatologist, Department of Neonatology,
Children's National Medical Center, Washington, DC
Jayashree Ramasethu MBBS, DCH, MD, FAAP
Associate Professor of Clinical Pediatrics; Associate Director
Neonatal - Perinatal Medicine Fellowship Program, Division of
Neonatology, Department of Pediatrics, Georgetown University

Hospital, Washington, DC
Majid Rasoulpour MD


Professor
Department of Pediatrics, University of Connecticut School of Medicine,
Farmington, Connecticut; Chief, Pediatric Nephrology, Connecticut
Children's

Medical

Center,

Hartford,

Connecticut

Mary E. Revenis MD
Assistant
Professor
Department of Neonatology/Pediatrics, The George Washington
University School of Medicine and the Health Sciences; Attending
Neonatologist, Department of Neonatology, Children's National Medical
Center, Washington, DC
Lisa M. Rimsza MD
Associate
Professor
Department of Pathology, University of Arizona, Department of
Pathology, University Medical Center, Tucson, Arizona
Dora C. Rioja-Mazza MD

Fellow in Neonatal-Perinatal Medicine
Division of Neonatology, Department of Pediatrics, Georgetown
University Hospital, Washington, DC
Priyanshi Ritwik BDS, MS
Assistant
Professor
Department of Pediatric Dentistry, Louisiana State University, Baton
Rouge, Louisiana; Clinical Director, Special Children's Dental Clinic,
Children's Hospital of New Orleans, New Orleans, Louisiana
Jeanne M. Rorke RNC, NNP, MSN
Neonatal Nurse Specialist
Neonatal Intensive Care Unit, Georgetown University Hospital,
Washington, DC


Thomas T. Sato MD
Staff Surgeon
Division of Pediatric Surgery, Children's Hospital of Wisconsin,
Milwaukee,

Wisconsin

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Billie Lou Short MD

Professor
Department of Pediatrics, George Washington University School of
Medicine; Chief, Division of Neonatology, Department of Neonatology,
UNREGISTERED VERSION OF CHM TO PDF CONVERTER PRO BY THETA-SOFTWARE
Children's National Medical Center, Washington, DC

Martha C. Sola-Visner MD
Associate
Professor
Department of Pediatrics, Drexel University, Attending Neonatologist,
Department of Pediatrics/Neonatology, St. Christopher's Hospital for
Children, Philadelphia, Pennsylvania
Rachel St. John MD
Assistant Professor, Director
Kids Clinic for the Deaf, Department of Pediatrics, Georgetown
University Hospital, Washington, DC
Cynthia J. Tifft MD, PhD
Associate
Professor
Department of Pediatrics, The George Washington University School of
Medicine and Health Sciences; Chief, Division of Genetics and
Metabolism, Children's National Medical Center, Washington, DC
Dawn M. Walton MD
Associate Clinical Professor of Pediatrics
George Washington University School of Medicine, Washington, DC,
Neonatologist, Community Neonatal Associates, Holy Cross Hospital,
Silver Spring, Maryland


Smitha Warrier MD
Resident
Department of Otolaryngology,

Louisiana

State


University-New

Orleans, New Orleans, Louisiana
S. Lee Woods MD, PhD
Clinical Associate
Department of Pediatrics, Johns Hopkins University School of Medicine;
Medical Director, Nursery, Nursery, Johns Hopkins Hospital, Baltimore,
Maryland
Brett M. Wortham MD
Assistant
Professor
Department of Pediatrics, George Washington Medical Center; Fellow,
Department of Neonatology, Children's National Medical Center,
Washington, DC


Editors: MacDonald, Mhairi G.; Ramasethu, Jayashree
Title: Atlas of Procedures in Neonatology, 4th Edition
Copyright ©2007 Lippincott Williams & Wilkins
> Front of
Book >
UNREGISTERED
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OFDedication
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Dedication
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“This book is dedicated to my mother, Jane Graham MacDonald, for


her steadfast support, love, and encouragement.â€
Mhairi G. MacDonald MBChB,FRCPE,FRCPCH,DCH


Editors: MacDonald, Mhairi G.; Ramasethu, Jayashree
Title: Atlas of Procedures in Neonatology, 4th Edition
Copyright ©2007 Lippincott Williams & Wilkins
> Front of Book > Preface

Preface
It has been over a quarter of a century since the first edition of the
Atlas of Procedures in Neonatology was published. The basic
philosophy and purpose of the Atlas, as reflected in the preface to
editions one through three, has not changed as the field of neonatalperinatal medicine has matured.
This fourth edition has undergone a significant facelift, and the
majority of illustrations are now in color. Color photographs of
procedure complications proved comparatively difficult to obtain; it is
tempting to hope that this reflects a decline in their incidence. The
new, fold-over cover continues to allow the book to open flat and also
offers easy identification on a bookshelf.
In the preface of the third edition, we noted that some promising
technologies, such as transcutaneous bilirubin measurement, required
further field testing. A chapter on transcutaneous bilirubin
measurement has been added in this edition, plus one on auditory
screening, and three other new chapters.
With the exception of Aseptic Preparation, the procedures included on
the DVD fall into two categories:
Commonly performed procedures, such as peripheral and umbilical
line placement and endotracheal intubation.

Vital emergency procedures that trainees may have infrequent
opportunity to perform, such as chest aspiration/placement of a


thoracostomy tube, or rare opportunity to perform, such as
exchange
transfusion.
Particularly in the case of exchange transfusion, there is now a
generation of neonatologists who have graduated from training with
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limited practical
experience
theCONVERTER
procedure PRO
but BY
who
now have the
responsibility to teach it to trainees. We hope that the
video—animation will prove a valuable teaching resource.
Mhairi G. MacDonald MBChB, FRCPE, FRCPCH, DCH
UNREGISTERED VERSION OF CHM TO PDF CONVERTER PRO BY THETA-SOFTWARE
Jayashree Ramasethu MD, FAAP


Editors: MacDonald, Mhairi G.; Ramasethu, Jayashree
Title: Atlas of Procedures in Neonatology, 4th Edition
Copyright ©2007 Lippincott Williams & Wilkins

> Front of Book > Preface to the Third Edition

Preface to the Third Edition
Almost two decades have passed since the publication of the first
edition of Atlas of Procedures in Neonatology. We have seen our
patients become progressively smaller, less mature, and more
susceptible to iatrogenic morbidity. The increasing fragility of our
patient population and the escalating complexity of care continue to
make neonatology challenging. These challenges have necessitated not
only innovations in technology and equipment but also increased
familiarity with and proficiency in procedures.
This revised edition of Atlas of Procedures in Neonatology reflects
changes that have come about in the management of neonates since
the second edition was published in 1993. Reliable monitoring
techniques and therapeutic modalities have been developed or refined
since then for some aspects of care; however, other promising
technologies, such as noninvasive transcutaneous bilirubin monitoring,
require additional field testing and validation.
The passing of the era of the mercury thermometer deserves special
note. The prototype of the widely used clinical mercury thermometer
was designed over 130 years ago, an admirable track record for a
medical device. Technical advances in thermometry have rendered the
risk of mercury toxicity from broken thermometers unacceptable. As a
result, in July 2001, the Committee on Environmental Health of the
American Academy of Pediatrics recommended that mercury
thermometers no longer be used for pediatric patients.
Advances in the prevention and intrauterine management of


alloimmune hemolytic disease, along with the liberal use of

phototherapy, have resulted in a significant decrease in the need for
postnatal exchange transfusions—to the point that fellows in
neonatal–perinatal medicine now occasionally complete training
programs without ever performing the procedure. The reappearance of
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kernicterusVERSION
in wellOFfull-term
neonates
underscores
importance of
retaining the chapter on exchange transfusions in this edition.
Cryotherapy for retinopathy of prematurity has been replaced by laser
therapy. A chapter on ostomy care has been added. Expanded chapters
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on the management
of extravasation
injuriesPRO
andBYvascular
spasm and
thrombosis are acknowledgments of the all-too-common iatrogenic
problems in neonatal intensive care. A new chapter on perimortem
sampling provides guidelines for testing in the event of sudden or
unexpected death.

Updated
provided
informed
in order

information regarding the complications of each procedure is
to facilitate risk-versus-benefit considerations and the
consent process. Complications are listed whenever possible
of frequency of occurrence or of importance.

At the request of those who used the previous editions of Atlas of
Procedures in Neonatology, we have modified the binding to allow the
book to lie flat when open. As in previous editions, commercial
products listed in the text are intended for illustrative purposes only;
no endorsement is implied. Commercial availability of some equipment
may change subsequent to the publication of this edition.
Acknowledgment of the fact that invasive procedures are currently
unavoidable in the care of sick neonates must come with the
recognition that there is responsibility to reduce potential iatrogenic
morbidity to the minimum possible. The latter may be achieved by
strict adherence to basic principles of asepsis, careful monitoring and
maintenance of patient homeostasis, and by ensuring that procedures
are performed or supervised by those with the requisite expertise.
Mhairi G. MacDonald MBChB, FRCP(E), DCH


Jayashree

Ramasethu


MD


Editors: MacDonald, Mhairi G.; Ramasethu, Jayashree
Title: Atlas of Procedures in Neonatology, 4th Edition
Copyright ©2007 Lippincott Williams & Wilkins
> Front of
Book >OFPreface
the
Second Edition
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Preface to the Second Edition
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There is nothing more gratifying to editors than to see their book lying

open and dog-eared during a bedside visit to another facility. We have
been pleased to find the first edition of the Atlas of Procedures in
Neonatology used not only by trainees and staff in neonatology but
also by other members of the neonatal–perinatal health care team,
including radiologists and respiratory therapists.
The primary purpose of the Atlas is to provide a detailed, step-by-step
approach to procedures, most of which are performed by
neonatologists, pediatricians, and nurses within the nursery. Some
procedures—such as extracorporeal membrane oxygenation

cannulation, operative tracheotomy, gastrostomy, and
cryotherapy—are usually performed by surgical specialists but are
included to promote understanding by those who are responsible for
the perioperative care of the neonate.
On the advice of our readers, we have selected a binding that will
allow the book to open flat so as to facilitate bedside use during
procedures. The organizational format of the first edition remains. We
recommend studying an entire procedure before starting it, not only to
review the technique but also to better weigh benefits against risks by
understanding the complications and precautions. As in the first
edition, we have emphasized the anatomical differences between the
neonate and older patients that influence the performance of certain
procedures. After every procedure, we have attempted to include a
comprehensive list of complications in order to heighten awareness of


their potential impact on both morbidity and mortality. The order of
listing does not necessarily reflect the frequency or severity of any
single
complication.
It is sobering to observe that a significant number of complications,
some of them not previously recognized, continue to be reported for
procedures that have been standard in neonatal nurseries for more
than two decades. For example, since the first edition of the Atlas was
published, reports in the literature on complications of umbilical artery
catheterization have approximately tripled. With every new procedure
there is a learning curve, but one would expect the incidence of
complications to decrease as experience and expertise increase.
Clearly, the number of reported complications does not represent their
true incidence. An optimistic view might be that increased reporting of

complications reflects a more universal respect for the possibility of
their occurrence and attempts to find ways of preventing or minimizing
them.
When any procedure is applied to smaller and more immature infants,
it is not only technically more difficult but also more likely to be
accompanied by side effects or complications. For all procedures
performed in the newborn there is a baseline morbidity; no procedure
will be absent complications. For example, placement of a peripheral
intravenous line is a basic procedure essential for the survival of sick
newborn babies. There have been significant improvements in the size
and quality of i.v. cannulas and pumps specifically to allow for
pressure obstruction alarms, low flow rates, and so forth. However, no
matter how good the care of the infant and the i.v., there will always
be incidents of infiltration and chemical skin burns. It behooves each
clinician to carefully weigh the risks versus the benefits of every
procedure before beginning it, while any piece of equipment remains in
place, and even in the months and years after completion.
One cannot possibly practice good medicine and not
understand the fundamentals underlying therapy.


Few if any rules for therapy are more than 90%
correct. If one does not understand the
fundamentals, one does more harm in the 10% of
instances to which the rules do not apply than one
does good in the 90% to which they do apply.
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—Fuller Albright
Mary Ann Fletcher MD
G. MacDonald

MBChB,
FRCP(E), DCH
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Editors: MacDonald, Mhairi G.; Ramasethu, Jayashree
Title: Atlas of Procedures in Neonatology, 4th Edition
Copyright ©2007 Lippincott Williams & Wilkins
> Front of Book > Preface to the First Edition

Preface to the First Edition
The rapid advances in neonatology in the last 15 years have brought
with them a welter of special procedures. The tiny, premature, and the
critically ill term neonate is attached to a tangle of intravenous lines,
tubes, and monitoring leads. As a result, more and more procedures
are done at the bedside in the intensive-care nursery, rather than in a
procedure room or operating room. With these technical advances has
come the opportunity for more vigorous physiologic support and
monitoring. With them also has come a whole new gamut of sideeffects and complications. The old dictum to leave the fragile
premature undisturbed is largely ignored. It is therefore the
responsibility of those who care for sick newborns to understand the
complications as well as the benefits of new procedures and to make
systematic observations of their impact on both morbidity and
mortality. Unfortunately, the literature on outcome and complications
of procedures is widely scattered and difficult to access. Manuals that
give directions for neonatal procedures are generally deficient in
illustrations giving anatomic detail and are often cursory.

We are offering Atlas of Procedures in Neonatology to meet some of
these needs. A step-by-step, practical approach is taken, with
telegraphic prose and outline form. Drawings and photographs are
used to illustrate anatomic landmarks and details of the procedures. In
several instances, more than one alternative procedure is presented.
Discussion of controversial points is included, and copious literature
citations are provided to lead the interested reader to source material.
A uniform order of presentation has been adhered to wherever


appropriate. Thus, most chapters include
contraindications, precautions, equipment,
complications, in that order.

indications,
technique, and

The scope of procedures covered includes nearly all those that can be
performed VERSION
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an CONVERTER
intensive-care
nursery.
Some are
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within the traditional province of the neonatologist or even the
pediatric house officer. Others, such as gastrostomy and
tracheostomy, require skills of a qualified surgeon. Responsibility for
proceduresVERSION
such asOFplacement
of CONVERTER
chest tubesPRO
andBYperformance
of
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vascular cutdowns will vary from nursery to nursery. However, some
details of surgical technique are supplied for even the most invasive
procedures to promote their understanding by those who are
responsible for sick neonates. We hope this will help neonatologists to
be more knowledgeable partners in caring for babies and will not be
interpreted as a license to perform procedures by those who are not
adequately
qualified.
The book is organized into major parts (e.g., “Vascular Access,â€
“Tube Placement,â€
“Respiratory Care†), each of which
contains several chapters. Most chapters are relatively self-contained
and can be referred to when approaching a particular task. However,
Part I, “Preparation and Support,â€
is basic to all procedures.
Occasional cross referencing has been used to avoid repetitions of the
same text material. References appear at the end of each part.
Many persons have contributed to the preparation of this atlas, and we

are grateful to them all. Some are listed under Acknowledgments, and
others have contributed anonymously out of their generosity and good
will. Special thanks is due to Bill Burgower, who first thought of
making such an atlas and who has been gracious in his support
throughout this project.
If this atlas proves useful to some who care for sick newborns, our
efforts will have been well repaid. Neonatology is a taxing field:
strenuous, demanding, confusing, heartbreaking, rewarding,
stimulating, scientific, personal, philosophical, cooperative, logical,


illogical, and always changing. The procedures described in this atlas
will eventually be replaced by others, hopefully more effective and less
noxious. In the meantime, perhaps the care of some babies will be
assisted.
Mary Ann Fletcher MD
Mhairi G. MacDonald MBChB, FRCP(E), DCH
Gordon B. Avery MD, PhD


↑
Table of Contents
[-]

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1 - Preparation and Support
[+]

1 - Informed VERSION
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2 - Maintenance of Thermal Homeostasis
[+]

3 - Methods of Restraint
[+]

4 - Aseptic Preparation
[+]

5 - Analgesia and Sedation in the Newborn
[-]

2 - Physiologic Monitoring
[+]

6 - Temperature Monitoring
[+]

7 - Cardiac/Respiratory Monitoring
[+]


8 - Blood Pressure Monitoring
[+]


9 - Continuous Blood Gas Monitoring
[+]

10 - Capnography
[+]

11 - Transcutaneous Bilirubin Testing
[-]

3 - Blood Sampling
[+]

12 - Vessel Transillumination
[+]

13 - Venipuncture
[+]

14 - Arterial Puncture
[+]

15 - Capillary Heelstick Blood Sampling
[-]

4 - Miscellaneous Sampling
[+]

16 - Lumbar Puncture