Word: Ventriculoperitoneal Shunt Tap



ApplicabilityOccurs within the Neonatal Intensive Care UnitPractice Level/CompetenciesVentricular access devices (VAD) are tapped by Physicians and Nurse Practitioners (referred to as providers throughout the document)VAD tapping is a two person procedureEstablishment of competency for tapping VAD: Teaching sessions related to VAD tapping will be offered to NICU providers (fellows, CAs, NPs) during routine educational opportunities or ad hoc If a provider has not performed the procedure on a patient before, the provider should first observe a trained provider demonstrating the procedure. Subsequently, the provider can be observed by a trained provider while performing the procedure. If a provider has performed the procedure on a patient before, they should first be observed by a trained provider while performing the procedure.Residents may perform this procedure under supervision by a NICU provider, if competency ascertained through training and supervision by a NICU providerNote: reservoir tapping is not a core competency in PediatricsEquipment & SuppliesSterile GownBedside TrayGlovesSterile GlovesCapMaskDressing Tray and/or drapesDexidin swab sticksSterile butterfly needle (23 or 25 Gauge)Sterile Luer Lock Syringe(s) (5 ml) 3-way stop-cockSterile CSF collection tube (as applicable)Gauze dressingSmall bandage as requiredProcedureAssessmentReservoir tapping to be performed by Neonatology after head ultrasound images obtained if:Levene Index remains >97th centileNot necessary to confirm with Neurosurgery unless there are issues below or if clinical circumstances have changedContraindications: Head ultrasound demonstrates new intracranial bleedingAnterior fontanelle is sunken before start of procedure Local hematoma or area of infection suspectedLevene Index < 97th centileIf any of these conditions exist; hold tapping and review with NeurosurgeryIn the event of difficulty with this procedure; notify the Neurosurgery team for assistanceStepsNotesPerform Hand HygienePerform Hand hygiene at the beginning of procedure and any time throughout when hands may have been soiled.Verify Infant with two patient identifiers.RN and ProviderProvider to explain VAD tap procedure to infant’s family.Assess the desire of family members to be present during the procedureRN to assess and document infant’s current neurological status and vital signs.This assessment will provide information about infant’s baseline RN to update provider with assessmentRN and provider to assess infant’s skin integrity on the VP shunt reservoir.Avoid puncture sites with skin integrity issuesRN to document skin assessmentRN and provider to assess infant’s pain management planIf indicated, apply local anesthetic cream to the site and administer prescribed pain medications.Measure pain scoreRN and provider to don cap and maskRN to clean work space (silver bedside tray) with disinfectant wipeProvider to assess the infant’s current laboratory profile and most recent CSF results. If CSF samples due to be sent, document in orders. Complete blood count (CBC)Prothrombin time (PT)Partial thromboplastin time (PTT)CSF culture at least weeklyProtein, glucose, cell count at least weeklyAll CSF studies if procedure planned (e.g. conversion to ventriculoperitoneal shunt) within next weekRN to open sterile tray on the bedside tray and add the supplies listed aboveCheck orders to see if CSF samples need to be sent Provider to palpate the infant’s reservoir to ascertain position and ability to tap before the procedure. Review most recent head ultrasound and ensure Levene Index > 97th percentile (Refer to post-hemorrhagic hydrocephalus protocol) RN to ensure developmentally supportive care is provided during procedure.Involve family as appropriateThis will help manage the infant’s response to an invasive procedure.Offer analgesia as appropriate.RN to ensure that the infant’s vital signs and indicators of adequate oxygenation and ventilation are monitored and airway’s patency is maintainedRT may be required to assist if infant is receiving invasive or non-invasive respiratory supportRN and Provider to ensure the shunt reservoir area is accessible Ensure that the shunt reservoir is accessible.Elevate the head, if necessary.Provider to perform hand hygiene and don clean glovesProvider to palpate the scalp for the reservoir close to the scalp incision used to insert the shunt. Sizes and shapes of tapping resevoir vary by manufacturer and that some infants have multiple scars from other surgical proceduresProvider to remove clean gloves and perform hand hygiene. Don mask, sterile gown and gloves.Provider to clean/prepare site with Dexidin swab for 30 seconds using a side-to-side motion. Allow to air dry for 60 secondsFor infants ≤ 1000 grams remove residual Dexidin solution from skin using sterile NS or sterile water after drying is completeProvider to attach 3-way stop-cock and 5mL syringe to the end of a butterfly needle Use a 5mL syringe as the pressure generated is lower than with larger syringesA stop-cock allows temporarily stopping decompression the empty syringeProvider to introduce a butterfly needle (23 or 25G) into the tapping resevoir.To avoid damage to the shunt, enter at a 20- to 45 -degree angle25G is typically sufficientProvider to advance the needle slowly and observe the tubing for spontaneous cerebrospinal fluid (CSF) flow. Allow CSF to flow into the distal catheterAllow CSF to flow spontaneously into sterile specimen containers (if specimens required) Aim to remove 10 ml/kg Withdraw CSF at maximum rate of 1 ml/kg/min (Approximately 10 minutes)Stop if increased resistance felt in syringe as fluid is being withdrawnProvider to remove the needle from the shunt and apply pressure briefly with a sterile gauze padRN to apply gentle pressure to puncture site with gauze for few minutes post-procedure. Observe for oozing from site. Dress as necessary.Continuous oozing may result in decreased volume of cerebrospinal fluid and electrolyte disturbances.RN to assess and document infant’s post-procedure neurological status, pain and vital signs. RN to label specimens and send to lab as required.Discard used supplies and remove personal protective equipment, perform hand hygiene.Document infant’s response, volume of fluid removed, specimens sent, skin integrity, details of procedureProvider to document procedure in progress notesRN to document in Nurses’ NotesDocumentationRN to document in Nursing FlowsheetProvider to document in progress notesAppendixPost-hemorrhagic hydrocephalus protocol Demo videos ReferencesMosby’s Clinical Skills (2017). Ventriculoperitoneal Shunt Tap (Pediatric). Retrieved from: San Diego Health (2014). Standardized Procedure: Withdrawing Cerebrospinal Fluid from a Ventricular Shunt or Resevoir (Adult, Neonatal, Peds). Retrieved from: (Adult,%20Neonatal,%20Peds).pdfVersion HistoryDATEDOCUMENT NUMBER and TITLEACTION TAKEN01-Dec-2018C-06-12-60002 Ventriculoperitoneal Shunt TapApproved at: Neonatal Leadership Committee28-Feb-2020“Approved at: Neonatal Leadership CommitteeDisclaimerThis document is intended for use?within?BC Infantren’s and BC Women’s Hospitals only. Any other use or reliance is at your sole risk. The content does not constitute and is not in substitution of professional medical advice. Provincial Health Services Authority (PHSA) assumes no liability arising from use or reliance on this document.?This document is protected by copyright and may only be reprinted in whole or in part with the prior written approval of PHSA.? ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download