Standard Operating Procedure for Undertaking Operations and … Documents/Operations... · in the PICU. This standard operating procedure (SOP) lays down what processes must be followed

Title: Operations and Invasive Procedures on PICU

Version: 2 Approved by PICU/CICU Clinical Practice Group: August 2018

Trust Ref: C162/2016 Next Review: August 2021

NB: Paper copies of this document may not be the most recent version. The definitive version is in the

UHL Policies and Guidelines Library.

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Standard Operating Procedure for Undertaking Operations and Invasive Procedures on PICU GGH 1. Introduction & Scope There are many operations and invasive procedures that are undertaken on patients in the paediatric Intensive Care environment. In most situations these procedures may be best undertaken in the operating theatre environment but in some cases due to severity of illness, lack of patient stability or the emergency situation they need to be undertaken in the PICU. This standard operating procedure (SOP) lays down what processes must be followed when undertaking operations and invasive procedures on PICU, with the aim of minimising risk and maximising patient safety.

2. Purpose This SOP applies to the following procedures on PICU:

Cardiac surgical chest opening, exploration and closure

Congenital Diaphragmatic hernia repair

Emergency laparotomy

Initiation of ECMO – Extra Corporeal Membrane Oxygenation

Balloon Septostomy

Flexible airway bronchoscopy

Skin and muscle biopsy

Chest drain insertion

Central/Arterial/PICC line/Vascath insertion






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2.1 Staffing Resource The following personnel must be present before the procedure is started, that is before administration of anaesthetic drugs or skin preparation is commenced.

The PICU Consultant on at the time of the procedure must be aware that it is

occurring.

PICU Registrar/ANP – it is the responsibilility of the PICU Consultant to

ensure that the PICU Registrar/ANP has sufficient experience to ensure anaesthetic and airway management is maintained. A Consultant Anaesthetist may be required for the more prolonged and complex cases.

Senior PICU Nurse/Bedside nurse Consultant Cardiac Surgeon/Surgical Registrar for cardiac

ECMO Consultant for ECMO cannulations/procedures

Consultant Surgeon for repair of diaphragmatic hernia/laparotomy

Theatre Scrub Nurse in cases of cardiac surgical chest opening, exploration,

closure, biopsies and the initiation of ECMO a theatre scrub nurse is essential. In an emergency ‘a competent person’ may take on this role until the arrival of the theatre scrub nurse.

Perfusionist – should be available for cannulation onto ECMO.

2.2 Minimum Monitoring

The minimum monitoring required in operations and invasive procedures undertaken on PICU:

Continuous ECG

Continuous Pulse Oximetry

Continuous End Tidal CO

Continuous invasive blood pressure monitoring or non‐invasive blood pressure monitoring at least every 5 minutes.

2.3 Minimum Vascular Access

A minimum requirement for any procedure undertaken on PICU is one working peripheral venous cannula.

Consider the need for central and arterial access

IO needle may be necessary






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2.4 Documentation

All patients undergoing surgical or invasive procedures in PICU should have the following documentation completed;

Consent form/Verbal consent documented

PICU Anaesthetic/Procedural Chart

Drug Prescription Chart

PICU Procedure Instrument checklist

Document procedure

Theatre team Documentation

WHO theatre checklist

Theatre Instrument checklist

Operation Record

Written documentation on green edged theatre sheet

2.5 Equipment Required

The equipment required will be specific to the procedure to be undertaken;

Surgical theatre packs/ theatre trolley – responsibility of Theatre Scrub Nurse

Diathermy – checked and appropriate pad applied by an appropriately trained personnel

Flip Chart Board

PICU Bedside Nurse is responsible for;

Suction

Appropriate Airway Management equipment

Temporary Pacing box attached to temporary pacing wires (cardiac patients)

2.6 Theatre Team

In all cases where a theatre team would be required, the procedure must be booked through the ‘Theatre Floor Control’ which is the responsibility of the surgical consultant or registrar.

Cardiac surgical chest opening, exploration or closure

Repair of diaphragmatic Hernia

Skin /Muscle biopsy

ECMO cannulation/decannulation (ECMO Coordinator)






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2.7 Individual Clinical Responsibilities

a. The PICU Consultant: is responsible for ensuring the PICU registrar/ANP attending the procedure is of sufficient experience to provide the clinical support required during the procedure being undertaken.

b. The PICU Registrar/ANP is responsible for ensuring the PICU consultant is

aware that the operation/procedure is occurring. To ensure that the patient is adequately monitored, to ensure that the airway is secure, the anaesthetic, drugs and fluid are correctly administered prior and during the procedure. The procedure should not commence until all these measures are in place. The registrar/ANP is responsible that all drugs and fluids used are correctly prescribed. The vital signs are correctly recorded. The PICU registrar/ANP MUST be present at the patient’s bedside throughout the procedure. The responsibility for the other patients on PICU must be delegated to other colleagues on PICU.

c. Consultant Anaesthetist should assume overall responsibility for actions

described above if required.

d. PICU Bedside Nurse should support the PICU Consultant/PICU Registrar/ANP Should ensure that the Procedure Instrument Checklist is completed

e. Theatre Nurse should ensure surgical equipment is available and theatre

WHO checklist is completed

f. Surgical Consultant and Registrar – following the procedure should ensure all appropriate paperwork is correctly completed






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3. Education and Training

No new education or training is required to implement this SOP. Training and raising awareness are on-going processes. On-going awareness is promoted through the induction and continuous bedside teaching. Training is provided for medical staff during lunchtime teaching (Wednesdays) and other sessions, and at junior doctors’ induction training. Nursing education supported by the Practice Development Teams and Nursing Educators. 4. Supporting References and Related documents

WHO guidelines for safe surgery : 2009 : safe surgery saves lives.

UHL Management of Surgical Swabs, Instruments, Needles and Accountable Items (Swab Policy) 2015, B35/2007.

UHL Sharps Management Policy. B8/2013.

UHL Infection prevention policy: B4/2005

UHL Safety Standards for Invasive Procedures Policy: B31/2016

5. Key Words

Operations, Invasive Procedures, Paediatric Intensive Care.

CONTACT AND REVIEW DETAILS

Guideline Lead (Name and Title)

Jenny Burgess – Senior Sister

Executive Lead:

Simon Robinson

REVIEW RECORD

Description Of Changes (If Any)

No content changes, format update and addition of sections2,4 & 5






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PICU Procedure Instrument Checklist

For use with procedures on PICU

Affix Patient Label Date:

Procedure:

DEVICE TYPE COUNTED

OUT

COUNTED

BACK IN

Observer

Signature

Operator

Signature

Guide wire

Cannulas

Needles

Suture Needles

Blades/Scalpels

Needle Holder

Artery Forcep

Forceps

Swabs

Scissors

Use the table above as a checklist to record all instruments used.


Version: 2 Approved by PICU/CICU Clinical: August 2018


NB: Paper copies of this document may not be the most recent version. The definitive version is in the UHL Policies and

Guidelines Library.

All instruments used must be accounted for at the end of the procedure and the operator and observer must sign to say this has been completed.

Have all the sharps been disposed of safely? YES NO

PLEASE FILE THIS FORM IN THE PATIENT NOTES ON COMPLETION

SOP for Operations /Procedures on PICU Flowchart

Does the procedure/operation require activation of the SOP?

Cardiac surgical chest opening, exploration & closure, Balloon Septostomy, ECMO

cannulation/decannulation, CDH Repair, Chest drain insertion, Skin & Muscle biopsy

Are the necessary personnel present?

PICU Consultant/Registrar, PICU nurse, Surgical Consultant/Registrar, Theatre Team,

ECMO Consultant/Coordinator, Anaesthetist, Perfusionist

Is there adequate monitoring?

Pulse oximetry, ECG, BP

Is there adequate Access?

Peripheral line, Central line and Arterial line

Is all the necessary equipment present and checked?

Surgical instruments, diathermy, suction, pacing box, surgical light

Complete WHO checklist ‐ Sign In Time Out

Proceed with agreement of all personnel involved

Procedure takes place

Complete Procedure Instrument Check listComplete Procedure Instrument Check list


Version: 2 Approved by PICU/CICU Clinical: August 2018


NB: Paper copies of this document may not be the most recent version. The definitive version is in the UHL Policies and Guidelines Library.

Procedure Date: Time: Ward: Indication: Operator: Assistant: Observer:

This checklist should be completed by an observer and filed in the patient’s medical notes.

If a significant breach of aseptic technique is observed the observer must stop the procedure.

Procedure Elective Emergency Re‐wire Ultrasound guided Landmark guided

Catheter type Size of lumen Number of lumens Batch Number Name

Insertion site Subclavian: Right Left Internal Jugular: Right Left Femoral: Right Left

Before the procedure

1 Indication checked Yes

2 Bed space isolated (close curtains around) Yes

3 Hands washed by operator and assistant Yes

4 Hat and mask worn by operator and assistant Yes

5 Sterile gloves and sterile gown worn by operator and assistant Yes

During the procedure

7 Chloraprep© applied procedure site and allowed to dry for 30 seconds Yes

8 Use a large drape to cover the patient in a sterile manner Yes

9 Continuous Sterile Zone maintained Yes

10 Sterile sheath and sterile gel used with ultrasound probe (if applicable) Yes

After the procedure

11 Injection site caps placed using ANTT Yes

12 Sterile dressing (Tegaderm) applied using ANTT technique Yes

13 Dispose of sharps including guide wire Yes

14 X‐ray confirmation of line position (except femoral lines) Yes

15 File this checklist in the patient’s medical notes Yes

16 Restock as per Paediatric Central Line Box/Tray Checklist Yes

Complications

Pneumothorax Arterial puncture Malposition Haemorrhage

Unable to cannulate Other (document in medical notes)

Number of attempts No complications

Date of catheter removal

Infection detected: Yes No If yes, date of positive culture

Reason for removal

Culture result