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OSCE PEDIATRICS
OBSERVED SPOTS
PROCEDURES
www.dnbpediatrics.com

DON’T FORGET TO WISH PATIENT, EXPLAIN
THE PROCEDURE AND TALK ABOUT
CONSCENT PRIOR TO BEGINNING OF
PROCEDURE.

1.LIVER BIOPSY
NEEDLE USED
(1) VIM SILVERMANN”S NEEDLE
TROCAR
CANNULA
BIFID NEEDLE
(2)TRU-CUT BIOPSY NEEDLE (DISPOSABLE)
OUTER HOLLOW NEEDLE
INNER SOLID NEEDLE WITH
A GUTTER

PRE REQUISITE:
PT/APTT
PLATELET COUNT
BLOOD GROUP –CROSS MATCH
LFT BASELINE

INDICATIONS:
• CIRRHOSIS OF LIVER:
CRYPTOGENIC CIRRHOSIS
BILIARY CIRRHOSIS
• STORAGE DISORDER:
HEMOCHROMATOSIS
GLYCOGEN STORAGE DISEASE
WILSON’S DISEASE

MALIGNANCY: LEUKEMIA
LYMPHOMA
WILM’S TUMOR
HEPATOBLASTOMA
NEPHROBLASTOMA
INFILTRATION:TUBERCULOSIS
SARCOIDOSIS
INFECTIONS : CMV
HERPES
UNEXPLAINED FEVER WITH HEPATOMEGALY/JAUNDICE

PROCEDURE:
• PREMEDICATION : ATROPINE
SEDATION
• SUPINE WITH ARMS BEHIND HEAD AT
EDGE OF TABLE.
• STERILISATION & LOCAL ANESTHETIC
• SITE:9th OR 10th SPACE-MIDAXILLARY
AREA
• BIOPSY WITH NEEDLE
• LIVER TISSUE TO BE PUT IN FORMALIN
• T.B. SEAL
• VITALS FOR 4 Hrs & NBM TILL 4 Hrs

CONTRAINDICATIONS:
• BLEEDING DIATHESIS
• SEVERE HEPATOCELLULARE JAUNDICE
• INFECTION OF LIVER,PERITONEUM,BILLIARY TRACT
RIGHT LUNG BASE, Rt. SUBHEPATIC ABCESS
• HYDATID CYST OF LIVER
• HEMANGIOMA OF LIVER
• CHRONIC PASSIVE CONGESTION OF LIVER
• GROSS ASCITES

COMPLICATIONS:
• HEMORRHAGE
• INFECTION
• INJURY TO LIVER
,GALLBLADER, COLON, KIDNEY, BLOOD
VESSELS & NERVES
• PRECIPITATION OF HEPATIC COMA

2.LUMBER PUNCTURE
• NEEDLES: L-P NEEDLE
SHORT 21-23 GAUGE FOR
INFANTS
LONG 21 GAUGE FOR
CHILDREN
• INDICATIONS:DIAGNOSTIC
THERAPEUTIC
CHEMOTHERAPY
• ANTIBIOTICS

PROCEDURE:
• POSITION: KNEE DRAWN UP & HEAD FLEXED
RESTRAIN IN LATERAL RECUMBANT POSITION
• SITE:INTERSPACE BETWEEN L3-L4 OR L4-L5
• SMALL INFANTS:SITTING WITH LEANING FORWARD POSITION
• STERILISATION & LOCAL ANESTHESIA
• ‘GIVE UP’ SENSATION – DURA PIERCED.
• T.B.SEAL
• HEAD LOW POSITION POST PROCEDURE.
• VITAL MONITORING

PREREQUISITE
• Fundus examination (NOT IN NEWBORNS)
• Rule out bleeding diasthesis

PROBLEMS
• Dry tap
• Blood stained
Trauma
Subarachnoid hemorrhage

COMPLICATIONS
• Headache (reduced by keeping head low or
plenty of fluids)
• Backache
• Infection
• Medullary herniation
• Injury to blood vessels,spinal cord or
intervertebral disc

CONTRA-INDICATIONS
• Increased ICT (GAURDED LP CAN BE DONE)
• Bleeding diasthesis
• Local infection

• POSITION ---- sitting with leaning forward
supine in small infants
• SITE----Fifth to sixth intercostal space in posterior axillary line
• PREMEDICATION----atropine and sedation
• Sterlization and local anesthesia
• Large 18-22 G Needle for centesis and mallecot or ICD tube
for drainage
3.THORACOCENTESIS

continue
• Underwater seal
• X ray after procedure
• Vitals monitoring

COMPLICATIONS
• Pleural shock due to vagal stimulation
• Pnemothorax
• Intercostal vessels and nerve injury
• Infection
• Hemoptysis
• Subcutaneus emphysema
• Air embolism
• Pulmonary edema
• Circulatory collapse

4.ABDOMINAL PARACENTESIS

INDICATIONS
• DIAGNOSTIC
• THEURAPTIC
- Marked abdominal distension with respiratory distress
-edema refractory to medical therapy
4.ABDOMINAL PARACENTESIS

CONTRAINDICATIONS
• Bleeding diathesiS
• Severe jaundice with impending hepatic coma

PROCEDURE
• SUPINE or SEM RECLINED position with back rest
• SITE-midway between umblicus and anterior
superior iliac spine
• Evaluate bladder
• PREMEDICATION – atropine and sedation
• Sterlisation and local anesthetic
• Large bore needle or IV canula using ‘Z’ technique

continue
• Don’t remove large volume or too rapidly-will
precipitate shock
• Tincture Benzoin seal

complications
• SHOCK-if too rapid removal or large volume is
tapped
• Acute liver cell failure and precipitation of
hepatic coma
• INFECTION –peritonitis
• Perforation of visceral organ
• Protein depletion

5.PERICARDIAL EFFUSION

INDICATION
• Diagnostic
• Theuraptic- cardiorespiratory embarresment
or tamponade

PROCEDURE
• SITE
ANTERIOR-fifth ICS outside apex but inside
outer edge of dullness
EPIGASTRIC(PREFERRED) - between
ensiform cartilage and left costal margin
POSTERIOR- near inferior angle of scapula
STERNAL-fourth left ICS lateral to sternum

continue
• SUPINE POSITION
• PREMEDICATION- atropine and sedation
• Sterlisation and local anesthetic
• Epigastric lateral to xiphoid cartilage at 45degree
posteriorly towards MCL with negative suction
• Cardioscope should be attached
• Seal with tincture Benzoin

COMPLICATIONS
• ARRYTHMIAS- ventricular tachycardia
• Penetration of cavity of heart
• Hemopericardium
• Infection
• shock

6.BONE MARROW ASPIRATION

DIAGNOSTIC INDICATIONS
ESSENTIAL--- Aplastic anemia
megaloblastic anemia
aleukemic leukemia
myelofibrosis, myelosclerosis
multiple myeloma
HELPFUL BUT NOT ESSENTIALLY DIAGNOSTIC
-Refractory anamia
-iron deficiency anemia(to diferrentiate from other hypochromic
anemia)
- ITP,agranulocytosis,hypersplenis
- infilterative disease-gaucher ds,niemann pick
-leukemia, to differentiate type of leukemia
UNDIAGNOSED FEVER

PROGNOSTIC INDICATIOJN
• Aplstic anemia
• Leukemia
• Agranulocytosis
THEURAPTIC INDICATION
Bone marrow transplantation

• CONTRAINDICATION
Blood dyscrasia
PREREQUISITE
PT/PTT, Platelet count, BT/CT

SITES
• ILIAC CREST
- 1 cm below iliac crest about 1-2cm posterior
to mid axillary line
-prone or side position
-PREFERRED OVER TWO YEARS
TIBIA
-Upper third of medial shaft
-PREFERRED LESS THAN 2 YRS
STERNUM
LUMBAR SPINOUS PROCESS

PROCEDURE
• Position
• Pre medication
• Local upto periostium
• Nick with screwing motion
• NEEDLES-21G LP needle for infants
18-19G marrow needle for older children
loss of resistance after entering cavity
attach to 10-20cc syringe with negative suction
Immediately make slide

Post procedure
• LOCAL PRESSURE FOR 5 MINS
• Seal
• vitals monitoring

COMPLICATIONS
• DRY TAP Faulty technique
Pathological marrow
- myelofibrosis
-myelosclerosis
-leukemia
-hyper or hypoplasia
Bone pain
Hematoma
Infection(osteomyelitis)

WHAT TO LOOK FOR IN MARROW
• Number and type of
erythropoietic, megakaryocytic and
leucopoietic cell linenage
• Cellularity
• Myeloid erythroid ratio(normal 3:1 to 4:1)
• Tumor and plasma cells
• Parasites,LD bodies,malarial parasites

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