CLINICAL PROCEDURE MUHCmuhcnicu.weebly.com/uploads/2/4/3/...nasopharyngeal... · Clinical Procedure...
Transcript of CLINICAL PROCEDURE MUHCmuhcnicu.weebly.com/uploads/2/4/3/...nasopharyngeal... · Clinical Procedure...
Clinical Procedure – Peds Oro & Nasopharyngeal Suction – Final Update April 6, 2017 1
CLINICAL PROCEDURE – MUHC
Medication included No Medication included
THIS IS NOT A MEDICAL ORDER
Title: Oropharyngeal and nasopharyngeal suction for neonatal and pediatric patients
This procedure is attached to:
Interprofessional protocol: Ventilator associated pneumonia in the neonatal and pediatric population: Prevention, surveillance, diagnosis and treatment
Interprofessional protocol: Installation and maintenance of bubble continuous positive airway pressure (CPAP)
MUHC Infection Control Guidelines
MUHC Hand Hygiene Policy
MUHC Policy: Patient Double Identification
Routine Practices for Acute Care In-patient Settings and the Emergency Room – Adults and Pediatrics
Collective order: Initiation of Oxygen Pediatric Site
1. DEFINITION AND PURPOSE
The purpose of this protocol is to describe the procedure for oropharyngeal and nasopharyngeal suction for the neonatal and pediatric population.
Note: For guidelines for oropharyngeal and nasopharyngeal suction for patient on bubble CPAP, refer to the interprofessional protocol: Installation and maintenance of bubble CPAP
2. PROFESSIONALS INVOLVED
Nurses, physiotherapists and respiratory therapists who care for neonatal and pediatric patients requiring oropharyngeal and nasopharyngeal suctioning and have reviewed the protocol
Candidate to the Practice of Nursing (CPNs) and licensed practical nurses (LPNs) who meet the above criteria, working within the limits of their role and in collaboration with a nurse
Clinical Procedure – Peds Oro & Nasopharyngeal Suction – Final Update April 6, 2017 2
3. INDICATIONS
Note: Suctioning should be performed only when clinically indicated due to invasiveness of the procedure
and the potential to cause harm.
A patient may require suction when:
Unable to clear their own secretions or cough effectively
Oxygen saturation is below acceptable level for patient’s condition as per collective order or
individual order
Presence of visible or audible secretions
Increased respiratory effort
Poor or difficult feeding secondary to nasal congestion
Change in skin color compatible with poor oxygenation (Note: Cyanosis is a late sign of hypoxia)
4. CONTRAINDICATIONS
Absolute contraindications:
Suspected epiglottitis or croup
Basal skull fracture
Head injury until basal skull fracture is ruled out
Relative contraindications:
Oesophageal fistulae
Occluded nasal passage
Severe bronchospasm
Stridor at auscultation
High intracranial pressure (ICP)
Leakage of cerebral spinal fluid
Severe epistaxis
Post-tonsillectomy/post-adenoidectomy
Post-operative period for surgeries involving the nose, throat or palate
Neutropenia
* Consult physician prior to initiating the procedure in the presence of a relative
contraindication
5. PRECAUTIONS
For patients with a platelet count less than 30 000 (30 X 109) or with a bleeding disorder (such as
hemophilia) proceed with caution and be aware that suctioning may provoke bleeding. Ensure appropriate monitoring.
Clinical Procedure – Peds Oro & Nasopharyngeal Suction – Final Update April 6, 2017 3
6. POTENTIAL COMPLICATIONS
Infection
Hypoxia
Trauma to pharynx or bleeding
Cardiovascular disturbances (hypertension, arrhythmia, bradycardia)
Laryngospasm/bronchospasm
Increased ICP
Vomiting
7. PROCEDURE
Procedure for oro or nasopharyngeal suctioning using a suction catheter:
Equipment needed:
Sterile suction catheter or suction kit containing the required size suction catheter. Refer to the
Table 1 for guidance in selecting the appropriate catheter size. Note: Catheter must not exceed
more than 50% of the internal diameter of the nostril.
Table 1: Guidelines for selecting suction catheter size
Age of child Catheter size
Premature baby 6 French
Neonate 6 to 8 French
Child 1 month to1 year of age 8 to10 French
Child 1 to 8 years of age 10 French
Child greater than 8 years old 10 to 14 French
Clinical Procedure – Peds Oro & Nasopharyngeal Suction – Final Update April 6, 2017 4
Sterile water or sodium chloride 0.9% (NS) to rinse catheter
Suction source with suction gauge and suction canister
Oxygen source and appropriately sized equipment to administer oxygen available if required
Mask, protective eyewear, and gown
Lubricant
Eye protection for the patient (for example glasses) if required
If not using suction kit the following additional equipment is required:
A clean container such as a disposable cup in which to pour sterile water or NS
used to rinse suction catheter
Non-sterile gloves
Procedure:
General principles:
Nasopharyngeal suction is performed as a “clean” procedure but a sterile catheter should be
used. The use of sterile gloves is not necessary.
Normal saline does not mix with mucus so does not thin or mobilize secretions. The practice of
instilling normal saline (NS) to facilitate secretion removal is not supported in the literature so has
not been included in this procedure.
1. Explain procedure to the patient and/or family.
2. Assemble necessary equipment. Ensure that oxygen is available at the bed side; equipment must
be checked to ensure it is fully operational.
3. Consider having a second person to assist if required
4. Set wall suction to the appropriate setting as per guidelines below.
Age of child Suction gauge setting
Neonate/Infant 80-100 mmHg
Child 100-120 mmHg
Adult 100-150 mmHg
5. Wash hands according to MUHC infection control guidelines.
6. Don gown, gloves, mask and protective eyewear.
7. Position patient appropriately to provide ease of access for the procedure and promote patient
comfort.
8. If there is a risk of secretions falling into the patient’s eyes during the procedure, consider
covering the patient’s eyes
9. Using a clean technique, open suction kit or suction catheter and prepare equipment for
suctioning. Pour sterile water or normal saline into sterile container provided in suction kit or a
clean container.
Clinical Procedure – Peds Oro & Nasopharyngeal Suction – Final Update April 6, 2017 5
10. Test suction level by occluding thumb port. Suction should be adjusted if it exceeds
recommended level.
11. The length of catheter to be inserted is determined by the distance from the tip of the nose to the
angle of lower jaw. (see image 1)
Image 1: Length of catheter to be inserted
Nose Suctioning
#1948 December 2013 Page 2 of 2
Steps (Continued)
9. Test the suction. Put the tube in the bowl of water. Put your finger over the suction
port. Suction a small amount of water with the tube. This will check the suction. It will
also make the suction tube e
10.
This may help loosen thick mucous.
11. Measure for correct suction depth. Put the tube
face. Measure from the tip of the nose to the tip of the ear lobe with the tube.
Keep your fingers on this spot so you do not suction too
far.
12. Gently put the tip of the tube into the nostril.
13. Point the suction tube straight back toward the ear, not up
toward the eye.
Do not:
Go any deeper than the length you measured.
Suction as you put in the tube.
Force the tube. If the tube does not go in easy,
pull back, adjust your angle and try again.
14. After the tube is in, out. open and close the port often as you pull the tube out of the
nose. Do not do suction longer than 10 seconds each time you enter the nose.
15. After you are done suctioning your child, suction a small amount of water into the tube
to clear it of mucous. The mucous and water will go into the storage jar of the suction
machine. Empty this storage jar every day. Teaching sheet #1462- Portable Home
Suction will teach you how to clean the machine.
Repeat steps #11 to 15 until most of the mucous is gone from
are clear. When suctioning is done, rinse the tube one last time. Turn the suction machine off
and take out the tube. Store the tube in the original container. You may re-use the same tube
for one day (24 hours).
ALERT: your child has special health care needs not covered by this information.
This teaching sheet is meant to help you care for your child. It does not take the place of medical care. Talk with your healthcare provider for diagnosis, treatment, and follow-up.
Measure tip of nose to ear lobe
12. Lubricate catheter by aspirating sterile water or NS. This also permits verification of catheter
patency and adequacy of negative pressure. Lubricant can also be used if required.
13. Catheter should be inserted gently into the nostril. Hold the catheter so that its natural curve is
aligned with the child’s trachea. Without applying suction, insert catheter into child’s nostril, using
an upward motion until the nasal septum is passed and then using the downward motion until the
epiglottis is felt or you have reached the pre-measured distance. Do not proceed if resistance is
felt. Remove catheter and attempt using other nostril.
14. During withdrawal, apply constant suction limited to no more than 10-15 seconds. Catheter must
not be rotated on removal but withdrawn straight out of airway. Always withdraw the suction
catheter away from (not over) the patient’s eyes.
15. Suction sterile water or normal saline through the catheter to rinse in between suction passes and
at the end of suction procedure.
16. Proceed to suction the other nostril using the same technique allowing a few seconds between
passes for the patient to recover.
Clinical Procedure – Peds Oro & Nasopharyngeal Suction – Final Update April 6, 2017 6
17. While performing the procedure, the child must be continuously observed for signs of
deterioration. Monitor respiration rate and quality, colour, heart rate, SpO2 (if already monitored),
and aspirate obtained (quantity, colour, viscosity, and odour).
18. Discard used equipment and wash hands. See page 5 for recommendations for the management
of equipment used for oral or nasopharyngeal suction.
Clinical Procedure – Peds Oro & Nasopharyngeal Suction – Final Update April 6, 2017 7
Procedure for oral or nasal suctioning using an oral/ nasal suction device (such as Little
Sucker®):
Equipment needed:
Oral and nasal suction device such as Little Sucker®
Non-sterile gloves
Sterile water or NS to rinse catheter
Mask, protective eyewear and gown if required
Oxygen source
Clean container such as a disposable cup in which to pour sterile water or NS to rinse catheter
Procedure:
1. Explain procedure to patient and/or family
2. Assemble necessary equipment. Ensure oxygen is available at the bedside. Check equipment to
ensure it is fully operational prior to initiating procedure.
3. Consider having a second person assist if required.
4. Set wall suction to the appropriate setting as per guidelines below.
Age of child Suction gauge setting
Neonate/Infant 80-100 mmHg
Child 100-120 mmHg
Adult 100-150 mmHg
5. Wash hands as per MUHC infection control guidelines
6. Don gloves and personal protective equipment if required.
7. If suctioning both the oropharynx and the nasopharynx, the nasopharynx should be suctioned
first. Avoid returning to the nasopharynx after having suctioned the patient’s mouth.
8. Test suction level by occluding thumb port. Suction should be adjusted if it exceeds
recommended level.
9. Insert suction device without applying suction.
10. Block thumb port with thumb to begin suctioning. Unblock thumb port to stop suctioning. Suction
mouth or nares with intermittent suction.
Clinical Procedure – Peds Oro & Nasopharyngeal Suction – Final Update April 6, 2017 8
11. Suction sterile water or NS through the catheter to rinse in between suction passes and at the
end of suction procedure.
12. Discard used equipment and wash hands. See below for recommendations for the management
of equipment used for oral or nasopharyngeal suctioning.
Clinical Procedure – Peds Oro & Nasopharyngeal Suction – Final Update April 6, 2017 9
Procedure for oral suctioning using an oral suction device:
Equipment needed:
Oral suction device such as a Yankauer suction tip
Non-sterile gloves
Sterile water or NS to rinse catheter
Mask, protective eyewear and gown if required
Clean container such as a disposable cup in which to pour sterile water or NS to rinse catheter
Procedure:
1. Explain procedure to patient and/or family
2. Assemble necessary equipment. Ensure that oxygen is available at the bed side; equipment must
be checked to ensure it is fully operational.
3. Consider having a second person to assist if required
4. Set wall suction to the appropriate setting as per guidelines below.
Age of child Suction gauge setting
Neonate/Infant 80-100 mmHg
Child 100-120 mmHg
Adult 100-150 mmHg
5. Wash hands as per MUHC infection control guidelines.
6. Don gloves and personal protective equipment if required
7. Suction oropharyngeal secretions as required. Never use an oral suction tip to suction the nasopharynx. Intermittent suction is not available when using this device and could result in mucosal injury.
8. Suction sterile water or NS through the catheter to rinse in between suction passes and at the
end of suction procedure.
9. Discard used equipment and wash hands. See below for recommendations for the management of equipment used for oral or nasopharyngeal suctioning.
Clinical Procedure – Peds Oro & Nasopharyngeal Suction – Final Update April 6, 2017 10
Recommendations for the management of equipment used for oro or nasopharyngeal suction
Suction catheters, suction kits and clean container used to rinse catheter are single use and must
be discarded after use
The suction canister lining should be changed when ¾ full
The suction tubing must be changed at least every 7 days and when visibly soiled to prevent
growth of bacteria according to unit practice
Oral/nasal suction devices (Little Sucker®) and oral suction devices (Yankauer suction tip) should
be changed every 24h or when visibly soiled to prevent growth of bacteria. In between changes,
the suction device should be kept in its protective sheath or packaging or in a clean plastic bag.
8. DOCUMENTATION IN CHART
Document procedure in the patient’s medical record: describe quantity, color, viscosity, and odour of
secretions as applicable; report any abnormal findings and adverse clinical reactions (such as
desaturation, bradycardia, hypertension, apnea or laryngospasm).
MAIN AUTHOR:
Vincent Ballenas, MSc, NPDE pediatric medicine
Eren Alexander, MSc, Nursing Practice Consultant
CONSULTANTS:
Johanne Boyer, Technical Coordinator Respiratory Therapy
Marco Bianchi, Nurse clinician ENT clinic
NPDQM Committee
Martine Lafond, Infection control nurse
Caroline Foucault, Interim NPDE Pediatric ER
Stephanie Lepage, NPDE pediatric surgery
Margaret Powell, NPDE PICU
Deborah Meldrum, NPDE Hem Onc
Manon Ranger, PhD, Evidence-Informed Decision Making Advisor
Clinical Procedure – Peds Oro & Nasopharyngeal Suction – Final Update April 6, 2017 11
9. APPROVAL PROCESS
Committees Date
[yyyy-mm-dd]
Clinical Practice Review Committee (if applicable) 2017-01-19
Updated
2017-04-06
Adult Pharmacy and Therapeutics (if applicable) N/A
Pharmacy and Therapeutics Pediatrics (if applicable) N/A
MUHC Pediatric Medication Administration Policy (PMAP) (if applicable) N/A
10. REVIEW DATE
To be updated in maximum of 4 years (2021) or sooner if presence of new evidence or need for practice change.
11. REFERENCES
1. Advanced Paediatric Life Support Group (2011). Advanced Paediatric Life Support- The Practical
Approach (5th Ed.). BMJ books. Oxford, UK: Wiley-Blackwell publishing.
2. Carsten, J. (2010). Evidence Summary: Pharyngeal Suction- Clinician Information. The Joanna
Briggs Institute. Accessed online: 21/02/2012
http://www.jbiconnectplus.org/ViewDocument.aspx?0=3927
3. Day T., Farnell, S., and Wilson-Barnett, J. (2002). Suctioning: a review of current research
recommendations. Intensive and Critical Care Nursing 18(2), 79-89.
4. Glass, CA, Grap, MJ. (1995). Ten tips for safer suctioning. American Journal of Nursing 5, 51-53.
5. Griggs, A. (2008). Oral/Nasal-pharyngeal suctioning. Royal Free Hampstead, National Health
Service (NHS) Trust. Accessed online: 13/02/2012 http://www.royalfree.nhs.uk/
6. Hayes, JS and Czarnecki, CL. (1999). Infant Nasal-Pharyngeal Suctioning: Is it Beneficial?
Pediatric Nursing 25(2),193-198.
7. Little Sucker® Oral and Nasal Suction Device, Neotech Products Inc. Directions for use.
8. Macmillan, C. (1995). Nasopharyngeal suction study reveals knowledge deficit. Nursing Times
91(50), 28-30.
9. Matthews, PJ. (1994). Six Steps for Safe Suctioning. Nursing 24(2), 18.
10. Simpson, S. (2011). Airway Suction. Clinical Guidelines/Health professionals/Great Ormond
Street Hospital. Accessed online: 13/02/2012 http://www.gosh.nhs.uk/health-
professionals/clinical-guidelines/airway-suction/
11. Western Sydney Health Service (2003). Oropharyngeal & Nasopharyngeal Suctioning. Intensive
Care. Evidence Based Practice Guidelines. Accessed online: 13-02-2012.
http://intensivecare.hsnet.nsw.gov.au/five/doc/suctioning_upper_airways_V_swahs.pdf
Clinical Procedure – Peds Oro & Nasopharyngeal Suction – Final Update April 6, 2017 12
Appendix 1
Comparative table of different suction equipment used for oral or nasal suctioning
Type of suction equipment Type of suction
Indication
Suction catheter
Intermittent
Oropharyngeal and nasopharyngeal suction
Little sucker™
Intermittent
Oral and nasal suction
Oral suction device
Continuous
Oral suction