Connected Care Quick Hits Volume 3

Connected Care Quick Hits are up to date and evidence based recommendations for the care of children with medical complexity & technology dependence, from hospital to home.


HINT: To Instill Or To Not Instill?

SITUATION: 

This QuickHiT! came from a consult initiated by a home care nurse who texted Connected Care Live! for clarification about the use of normal saline drops via tracheostomy. In this situation, the child's family had previously learned to routinely instill saline prior to suctioning but this practice differed from the nurse's employer's policy.

Current best practice guidelines cite that saline does not mix well with mucous, and as a result, does not typically help loosen secretions for tracheal suctioning. In addition, saline has demonstrated a negative effect on oxygenation after suctioning and may pose an increased risk of infection(Halm & Krisko-Hagel, 2008)

Halm, M. A. & Krisko-Hagel, K. (2008). Instilling normal saline with suctioning: Beneficial technique or potentially harmful sacred cow? American Journal of Critical Care. 2008, 17(5), 469-472. http://ajcc.aacnjournals.org/content/17/5/469.full.pdf

 

RECOMMENDATION:

For routine suctioning of a child's tracheostomy:

 

DO NOT instill normal saline for routine tracheostomy suctioning.

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DO lubricate the catheter by suctioning a small amount of sterile water or saline through the catheter to wet it and to make it easier to insert.

DO consider other ways to thin secretions like systemic hydration and airway humidification

Sickkids Staff. (2017). Available at https://www.aboutkidshealth.ca/Article?contentid=2469&language=English

Additional Hints and Recommendations: 

Are the secretions dry? Are they thick? Difficult to suction?

  • For trouble shooting when secretions are difficult to clear, the instillation of normal saline drops (2-3 drops of 0.9% NaCl solution/nebules) may be tried in combination with other troubleshooting strategies (like chest physiotherapy and increased humidity, see full list here)

  • If this practice is needed more than very occasionally (more than once a week), be sure to review this practice with the child’s family caregivers and point of care team - as a change in the child’s secretions may suggest a change (decline) in their health status that needs further assessment.

  • Also, consider partnering with a child's family and initiating a joint consult via Connected Care Live! to chat/talk/video with a Connected Care Resource Nurse and Respiratory Therapist to review practice updates including approaches to improve airway clearance!