Atlas of Procedures in Neonatology, 4th Edition
Central Venous Catheterization
Jeanne M. Rorke
- Alfred Chahine
Central venous catheters provide stable intravenous (IV) access to sick or low-birthweight infants who need long-term IV nutrition or medications (1).
A percutaneous central venous catheter, also known as a peripherally inserted central catheter (PICC), is a soft, flexible catheter that is inserted into a peripheral vein and threaded into the central venous system. Central venous lines may be placed by surgical cutdown when percutaneous access is not possible. Totally implantable vascular access devices (ports) are rarely used in neonates and are thus not included in this chapter.
Regardless of the method employed to obtain secure and reliable venous access, the clinician should be familiar with the technique and anatomic considerations unique to the approach. Some form of analgesia and sedation is generally required, with general anesthesia being reserved for more complex access cases. The majority of venous access procedures in the critically ill neonate are performed at the bedside rather than in the operating room.
- Common Indications
- Total parenteral nutrition
- Long-term IV medication administration
- Administration of hyperosmolar IV fluids or irritating medications that cannot be administered through peripheral IV cannulas.
- Fluid resuscitation
- Repetitive blood draws (usually a secondary indication; catheters are not usually inserted primarily for this indication in neonates; only larger-lumen catheters may be used for blood draws without risk of clotting).
- Relative Contraindications
There are no absolute contraindications, as the clinical situation dictates the need for venous access.
- Skin infection at insertion site
- Uncorrected bleeding diathesis (not a contraindication for percutaneous catheters inserted in distal peripheral venous sites)
- Ongoing bacteremia or fungal infection (which may cause catheter colonization and infection)
- The patient can be treated adequately with peripheral IV access. Central venous catheters have significant risks of complications and must not be used when peripheral venous access is possible and adequate.
- General Precautions
- Central venous catheterization must be performed by trained individuals.
- Obtain informed consent prior to performing the procedure.
- Plan ahead: Success with PICC placement is higher if the catheter is inserted electively before peripheral veins are “used up” by frequent cannulations.
- Infant should be on a cardiorespiratory monitor during the procedure.
- Follow the manufacturer's instructions for catheter use.
- Follow strict sterile technique, because sepsis is the most common complication.
- Never leave a catheter in a position where it does not easily and repeatedly withdraw blood during the insertion procedure, to ensure that the tip is not lodged against a blood vessel or cardiac wall (2).
- Always confirm the position of the catheter tip by radiography prior to using it. This is especially true for catheters placed at bedside.
- If the catheter is used for hyperalimentation:
- If possible, avoid use for any other purpose (such as medication administration or transfusion), because catheter manipulation increases the risk of sepsis (3).
- Avoid using a stopcock in the line (increased potential for infection).
- If possible, the line should be cared for by specifically trained personnel. Central line teams have
been shown to decrease the frequency of catheter-related infections (4).
TABLE 31.1 Vessels Amenable to Central Venous Access
Upper extremity: cephalic, basilic, median cubital, or axillary vein
Percutaneous or surgical
May be done at bedside
Lower extremity: saphenous vein or femoral vein
Percutaneous or surgical
May be done at bedside
Percutaneous technique, amenable only to PICC lines
External jugular vein
Percutaneous or surgical
May be done at bedside
Internal jugular vein
Common facial vein
May be done at bedside
Percutaneous technique, may be done at bedside
- Vessels Amenable to Central Venous Access
Table 31.1 lists the sites usually used for central venous catheterization in the newborn. When venous access is extremely difficult because of superior vena cava or inferior vena cava occlusion, alternative sites such as the azygos system or the hepatic vein may be used for prolonged access, but there is little information about these approaches in neonates (5, 6).
- Position of Catheter Tip (Fig. 31.1)
FIG. 31.1. Chest radiograph with PICC tip in appropriate position, just above junction of superior vena cava and right atrium.
- The catheter should be placed in as large a vein as possible, ideally outside the heart, and parallel with the long axis of the vein such that the tip does not abut the vein or heart wall (7). The recommendations for appropriate position of a central venous catheter tip vary, but there is general agreement that the tip should not be within the right atrium (8, 9, 10, 11). However, one large retrospective audit of 2,186 catheters showed that catheters with their tips in the right atrium and not coiledwere not associated with pericardial effusions (2).
Recommendations for appropriate position of the catheter tip are as follows.
- The catheter tip should be within the superior or inferior vena cava, outside the pericardial reflection, a distance estimated to be about 1 cm outside the cardiac silhouette in preterm neonates and 2 cm outside the cardiac silhouette in term neonates (8).
- When inserted from the upper extremity, the catheter tip should be in the superior vena cava, outside the cardiac reflection and above the T2 vertebra (12).
- When inserted from the lower extremity, the catheter tip should be above the L4/ L5 vertebrae or the iliac crest, but not in the heart (12).
- The tip of the catheter should be at the junction of the vena cava and the right atrium (7, 13).
- Confirmation of catheter tip placement
- The tip of the radio-opaque catheter is usually seen on a routine chest radiograph (Fig. 31.1), but there can be significant interobserver variability in assessing the position (14). Digital enhancement of the radiograph may improve visualization but does not prevent interobserver variability (15).
- Two radiographic views (anteroposterior and lateral) help to confirm that the catheter is in a central vein. This is particularly important for catheters placed in a lower extremity, where the catheter may inadvertently be in an ascending lumbar vein and may appear to be in good position on an anteroposterior view (16).
- The use of radio-opaque contrast improves localization of the catheter tip, particularly when the catheter is difficult to see on a standard radiograph (17, 18). A 0.5-mL aliquot of 0.9% saline is instilled into the catheter to check patency, followed by 0.5 mL of iohexol. The radiograph is taken, and the line is flushed again with 0.5 mL of 0.9% saline. With this technique, there is no need to inject the contrast material while the radiograph is being taken (17). Other authors recommend injecting a 2-mL bolus of nonionic water-soluble contrast medium into
the catheter during radiographic exposure, but this technique results in a larger volume of iodine-containing contrast being injected (18).
- Ultrasonography may also be useful in localizing the catheter tip (19).
- Chest radiographs obtained for any reason should be scrutinized for appropriate catheter position. Routine weekly radiographs taken for this purpose do not appear to reduce the risk of complications (13).
- Methods of Vascular Access
- Percutaneous technique
- Simpler to perform and relatively rapid procedure
- May not require sedation
- Vessel is not ligated as in open cutdown methods
- Decreased potential for wound infection/dehiscence complications
- Beyond the initial insertion into the peripheral vein, further passage of the catheter into its final position is essentially a blind technique.
- Smaller-caliber catheter may preclude use for blood transfusions
- Potential for injury to adjacent anatomic structures (20)
- Cutdown or open surgical technique
- Allows for insertion of larger silicone catheter (3- or 4.2-French [Fr])
- The catheters can be tunneled under the skin away from the venotomy site, so they can remain in place longer with a lower risk of infection.
- Requires general anesthesia/intravenous sedation
- Requires surgical incision
- Vein is often ligated, so it cannot be reused in the future.
- Potential for injury to adjacent anatomical structures
- Increased potential for wound infection
- An operating room is the ideal setting for the procedure, so risks of transport of critically ill neonates need to be taken into consideration.
- Types of Central Venous Catheters
TABLE 31.2 Catheter Materials
Type of Catheter
Lower risk of vessel perforation
Reported to be thromboresistant
May be more difficult to insert percutaneously
Fragile material: less tolerance to pressure
Poor tensile strength: can tear or rupture
May be less radio-opaque
Easier to insert percutaneously
Stiffer on insertion but softens within body
Some catheters are more radio-opaque
Tensile strength: more tolerant to pressure
Reported to be thromboresistant
Increased risk of vessel perforation during insertion
Easier to insert
Very high tensile strength
High degree of stiffness may increase vessel perforation during insertion or throughout catheter dwell
Polyvinyl chloride (PVC)
Easier to insert percutaneously
Stiff on insertion but softens within body
May leach plasticizers into body
High incidence of thrombosis
- Catheter materials: See Table 31.2.
- Types of catheters
- Percutaneous (PICC) catheters/introducers
PICC catheters and kits are available commercially. PICCs are generally made of silicone or polyurethane. Sizes include 1.2, 1.9, 2, and 3 Fr. Larger sizes are generally not used in the neonatal population. Most catheters are single-lumen. Recently, a 1.9-Fr double-lumen catheter has become available. Double-lumen catheters can decrease the need for maintaining concurrent IV access when more than one site is required. PICC introducers/needles are available in 19, 20, 22, and 24 gauge. Choice will depend on the size of the vein to be cannulated.
- Surgically placed central venous catheters
Surgically placed central venous catheters for neonates are available in sizes 2.5, 2.7, 3, 4.2, and 5 Fr. Catheters are usually silicone or polyurethane, with tissue in-growth cuffs that adhere to the subcutaneous tract, anchoring the catheter. Recently, antimicrobial cuffs have become available. Most catheters are single-lumen, but a few manufacturers make double-lumen catheters in sizes 5 Fr and larger.
Percutaneous Central Venous Catheterization (See Procedure DVD for Video)
- Insertion sites (Fig. 13.1)
- Antecubital veins: basilic and cephalic veins
- Scalp veins: temporal and posterior auricular veins
- Saphenous veins
- Axillary vein
- External jugular vein
Right-sided and basilic veins are preferred because of the shorter and more direct route to the central vein. The cephalic vein may be more difficult to thread to the central position because of narrowing of the vessel as it enters the deltopectoral groove and the acute angle at which it joins the subclavian vein. The axillary and external jugular veins are the last choices because they are close to arteries and nerves.
- Insertion Variations
- Breakaway needle: Needle is inserted into the vein. Next, the catheter is advanced through the needle. The needle is then retracted, split, and removed (Fig. 31.2). Disadvantage: There is a potential for shearing or severing the catheter if it is retracted while the needle is in the vein.
- Peel-away introducer: A needle introducer is used to place a small cannula or sheath into the vein. The needle is then removed and the catheter is threaded through the cannula. The introducer cannula or sheath is then retracted from the vein, split or “peeled” apart, and removed from the catheter (Fig. 31.3).
- Intact cannula: This technique is now rarely used because most commercially available catheters have a hub and introducer needles. A regular IV cannula is used to obtain venous access. The needle is removed. The catheter is threaded through the cannula to its final position. The cannula is then retracted and slipped off the end of the “hubless” catheter. A blunt needle with hub is connected to the end of the catheter (Fig. 31.4). Disadvantage: The blunt needle attachment must be secured well, otherwise leakage can occur.
- Placement of PICC Using the Break-Away or Peel-Away Introducer Needle
All equipment used, except the mask, head cover, and tape measure, must be sterile. Commercial kits contain many of the necessary items.
- Radio-opaque central venous catheter
- Break-away or peel-away needle introducer
- Tourniquet (optional)
- Gauze pads
- Skin prep: 10% povidone–iodine or 0.5% chlorhexidine solution (as per institutional policy)
- Transparent dressing
- Sterile tape strips
- Sterile heparinized saline solution (1 U of heparin/mL or per institutional policy)
- 5- to 10-mL syringe with needle
- Tape measure
- Sterile surgical gown, sterile gloves, mask, and head cover
- Although anesthesia is not required, nonpharmacologic comfort measures, pain medication, or sedation should be provided as needed. A small dose of sedative or narcotic analgesic may be useful.
- Gather supplies. Wash hands thoroughly.
- Identify appropriate vein for insertion (see D).
- Position infant to facilitate insertion (Table 31.3). Restrain infant; provide comfort measures.
- Measure approximate distance from the insertion site to the point where the catheter tip will be placed (Table 31.3).
- Don mask and cap, scrub hands, and don sterile surgical gown and gloves.
- Trimming of the catheter to appropriate size is based on unit policy and manufacturer recommendations. Catheter is fragile. Handle it with care: Do not clamp or suture, and do not stretch or apply tension to catheter.
- Utilizing sterile technique, flush catheter with heparinized saline solution, leaving syringe attached. A small-barreled syringe (such as a 1-mL syringe) may generate too much pressure, resulting in catheter rupture (21).
- Prepare sterile field: Place drape under extremity. Utilizing the prep solution, prepare the area at and around the insertion site, working outward in concentric circles. Allow the prep solution to dry. Repeat process with new gauze/prep solution. Drape prepared area, leaving insertion site exposed.
FIG. 31.2. Peripherally inserted central catheter using break-away needle technique. (From Gesco International, San Antonio, TX, USA, with permission.)
- Catheter insertion
- Utilizing a break-away needle (Fig. 31.2)
- Apply tourniquet (optional).
- Providing slight skin traction, insert needle about 1 cm below the intended vein. Insert needle at a low angle (approximately 15 to 30 degrees).
- When a flashback is obtained, advance the needle about 1/4 in at a lower angle to ensure that the whole bevel of the needle is within the vein.
- Using nontoothed iris forceps, gently grasp the catheter about 1 cm from its distal end and insert it into the introducer needle.
FIG. 31.3. Peripherally inserted central catheter using a peel-away cannula introducer. A: Perform venipuncture. When flashback of blood is noted, reduce angle and advance introducer sheath farther to ensure placement in the vein. B:Withdraw the introducer needle from the sheath. Note that the introducer sheath is supported to avoid displacement. C:Insert the catheter into the introducer sheath using fine nontoothed forceps. D: Withdraw the introducer sheath. Note that the catheter is stabilized by applying digital pressure to the vein distal to the introducer sheath. E: Remove the introducer sheath by splitting and peeling it away from the catheter. Complete catheter advancement to premeasured length. F:Aspirate catheter to check for blood return and flush with heparinized saline to ensure patency. (From
Klein C. NeoPicc: The Neonatal and Pediatric Workshop Manual. San Antonio, TX: Klein Baker Medical, 1998
, with permission.)
- Caution: Never advance the needle or retract the catheter after inserting it into the needle; the catheter may be severed by this action.
- If a tourniquet was applied, it should be loosened or removed prior to advancement.
- With small, gentle nudges, a few millimeters at a time, advance the catheter through the needle to a distance of about 5 or 6 cm into the vein.
- Once the catheter is successfully advanced to about 5 or 6 cm, withdraw the needle carefully.
FIG. 31.4. Use of a blunt scalp vein needle to form a hub for a silicone catheter. The plastic needle cover is used to stabilize the needle–catheter junction. A commercially available blunt needle adapter may be inserted and fixed in a similar manner.
- To withdraw the needle, stabilize the catheter by applying gentle pressure over the vein proximal to the needle. Slowly withdraw the introducer needle until it is completely away from the site.
- Break the introducer needle by splitting the wings, and then carefully peel it away from the catheter.
- Continue to advance the catheter into the vein to the premeasured length, by nudging it farther, a few millimeters at a time, using the fine forceps.
- Difficulties in advancing catheter: Gently massage the vein in the direction of blood flow, proximal to the insertion site, or gently flush the catheter intermittently with 0.5 to 1.0 mL of heparinized saline; reposition the arm or head.
- Aspirate to visualize blood return in the catheter, and flush with 0.5 to 1 mL of heparinized saline to clear the catheter.
- Verify length of catheter inserted and adjust as necessary.
- Apply gentle pressure on insertion site with gauze pad to stop any bleeding.
- Secure catheter at skin insertion site with sterile tape strips and cover with sterile gauze until radiographic confirmation of position.
TABLE 31.3 Patient Position and Measurement for PICC Insertion
Site of Insertion
Position of Baby
Supine, abduct arm 90 degrees from trunk; turn head toward insertion site to prevent catheter from traveling cephalad through ipsilateral jugular vein
From planned insertion site, along venous pathway, to suprasternal notch, to third RICS
Saphenous or popliteal veins
Supine for greater saphenous vein, prone for small saphenous or popliteal; extend leg
From planned insertion site, along venous pathway, to xiphoid process
Supine, turn head to side; may have to turn head to midline during procedure to assit advancement of catheter
Follow approximate venous pathway from planned insertion site near ear, to jugular vein, right SC joint, to third RICS
External jugular vein
Supine, turn head to side; place roll under neck to cause mild hyperextension
From planned insertion site, to right SC joint, to third RICS
Supine, externally rotate and abduct arm 120 degrees, flex forearm and place baby's hand behind head; vein is found above artery between medial side of humeral head and small tuberosity of the humerus
From planned insertion site, to right SC joint, to thirt RICS
PICC, peripherally inserted central catheter; RICS, right intercostal space; SC, sternoclavicular.
- Utilizing a peel-away cannula/introducer sheath (Figs. 31.3 and 31.5)
The procedure is similar to using a break-away needle.
- Apply tourniquet (optional).
- Providing slight skin traction, insert needle about 1 cm below the intended vein. Insert needle at a low angle (approximately 15 to 30 degrees).
FIG. 31.5. A: Venipuncture with peel-away cannula introducer. B: Withdraw the introducer needle from the sheath. Note that the introducer sheath is supported to avoid displacement. C: Insert the catheter into the introducer sheath using fine nontoothed forceps. D: Withdraw the introducer sheath. E: Remove the introducer sheath by splitting and peeling it away from the catheter. F: Transparent dressing on PICC catheter. Note that the excess catheter length has been coiled in place under the dressing.
- When flashback is obtained, advance the introducer sheath about 1/4 in at a lower angle to ensure that the tip is within the vein.
- Withdraw the introducer needle while leaving the introducer sheath in place. Successful venipuncture is indicated by the flow of blood from the end of the sheath. Apply gentle pressure over insertion site to minimize blood loss. If a tourniquet was applied, it may be loosened or removed at this stage.
- Caution:Do not reintroduce the needle into the introducer sheath if the venipuncture is unsuccessful. This could result in a sheared or severed sheath.
- Using nontoothed iris forceps, gently grasp the catheter about 1 cm from its distal end and insert it into the introducer sheath.
- With small, gentle strokes, a few millimeters at a time, advance the catheter to the premeasured length.
- Aspirate to visualize blood return, and flush with 0.5 to 1 mL of heparinized saline to clear the catheter.
- Stabilize the catheter by applying gentle pressure to the vein proximal to the insertion site, then withdraw the introducer cannula. Carefully split and peel away the introducer sheath from the catheter.
- Once the introducer sheath has been removed, verify catheter insertion length and adjust with forceps.
- With a gauze pad, apply gentle pressure to insertion site to stop any bleeding.
- Secure catheter at skin insertion site with sterile tape strips, and cover with sterile gauze until radiographic confirmation of position.
- PICC Dressings (Figs. 31.5and 31.6)
- Antimicrobial prep solutions should be removed from the skin with sterile water or saline and allowed to dry before placing dressing.
- To prevent migration of the catheter, secure it to the skin a few millimeters from the insertion site with a small piece of sterile tape.
- If the catheter has not been trimmed, loosely coil the excess length of catheter close to the insertion site and secure to the skin with more sterile tape. Ensure that there is no kinking or stretching of the catheter under the dressing.
- Some manufacturers caution against placing tape that contains a wire directly on the silicone catheter. If the catheter is trimmed to the appropriate length, it may not be necessary to place sterile tape on the catheter.
- Apply a semipermeable transparent dressing over the area surrounding the insertion site.
- Do not allow tapes or transparent dressing to extend around the extremity. The dressing will form a constricting tourniquet as the infant grows or if there is venous congestion.
- Place tape under the catheter hub and criss-cross it over the hub (chevron). Do not obscure visualization of the insertion site (Fig. 31.6).
- To prevent skin breakdown, a skin barrier can be placed under the hub (e.g., Duoderm [Convatec: Bristol-Myers Squibb, Princeton, NJ, USA] or soft gauze). Ensure that the hub is secured.
FIG. 31.6. Peripherally inserted central catheter dressing with trimmed catheter. No excess catheter is present externally. The silicone heart is anchored with a piece of tape, and a sterile transparent dressing is placed over the insertion site. With use of a “chevron” technique, another piece of tape is placed under the catheter extension, next to the silicone heart, and crossed over on top of the transparent dressing. (From
Klein C. NeoPicc: The Neonatal and Pediatric Workshop Manual. San Antonio, TX: Klein Baker Medical, 1998
, with permission.)
- Dressing Changes
- Mild oozing of blood from the insertion site may occur for up to 24 hours. If oozing occurs, the initial dressing
should be changed when it subsides. If oozing of blood is a problem, a small piece of thrombolytic foam can be applied over the insertion site and under the dressing for the first 24 hours after insertion.
- The catheter site dressing should be replaced when it becomes damp, soiled, or loose. Transparent dressings should be changed every 7 days except in those patients in whom the risk of dislodging the catheter outweighs the benefit of changing the dressing (22).
- Inspect catheter site carefully at each dressing change (Table 31.4).
- Catheter may be pulled back if it is too far in, prior to replacing dressing. Do not advance catheter, as the risk of contamination is high.
- Use sterile technique for dressing changes (mask, cap, and sterile gloves; sterile gown is optional).
- Prepare sterile field: Place drape under extremity. Utilizing the prep solution, prepare the skin at and around the insertion site, working outward in concentric circles. Allow the prep solution to dry. Repeat process with new gauze/prep solution. Drape prepared area, leaving insertion site exposed.
- Follow steps D1 through D8 to complete the PICC dressing change.
TABLE 31.4 Examination of the Catheter Site
Note external catheter length
Catheter length should be clearly documented. If external length has changed, get radiograph to assess where the catheter tip is located.
If the catheter is pulled out, cover site with occlusive dressing and measure catheter length to assure that some of the catheter was not retained in the vessel.
Assess for kinks, tension, damage
Kinks and tension can damage catheter. It is recommended that damaged catheters be removed, but some manufacturers provide repair kits.
Insertion site/surrounding skin:
Erythema, drainage, bleeding, edema, phlebitis, skin breakdown
Mild erythema and/or phlebitis is common after the catheter is inserted. If condition is severe and/or is persistent, consider removing catheter.
Mild oozing of blood should not persist longer than 24 h.
Edema may be due to venous stasis from lack of extremity movement, constrictive dressings, thrombus, damage to internal structures, localized infection, or infiltration of infusion into soft tissue.
Avoid skin breakdown by utilizing skin barriers underneath hub, removing dressing adhesives with care, minimizing tape, and removing antiseptics from skin before applying dressing.
Purulent drainage may be due an infectious process. Consider obtaining blood cultures and/or removing the catheter.
Clear drainage may be indicative of infusion leakage. This may be due to catheter occlusion, infiltration, or damage to catheter.
- PICC Care and Maintenance
- Evaluate appearance of the catheter and the tissue around the insertion site frequently.
- Change tubing according to unit policy. Utilize aseptic technique when changing tubing.
- To prevent contamination of the line, enter the PICC only when absolutely necessary. Maintain sterility at connection site when entering the line.
- Do not utilize the PICC for routine blood sampling.
- Prime volumes are usually less than 0.5 mL. Use a 5- to 10-mL syringe when needed to check catheter patency. Do not use force if resistance is encountered. A small-barreled syringe (such as a 1-mL syringe) may generate too much pressure, resulting in catheter rupture (21).
- Add 0.5 to 1 U of heparin/mL of intravenous fluids. The effectiveness of heparin in the prevention of PICC occlusion and catheter thrombosis is unclear at present (23).
- Administer a constant infusion of intravenous fluids at a rate of at least 1 mL/h. Follow the manufacturer's recommendations for maximum flow rates.
- Ensure that medications infused through the line are compatible with IV fluids or that the line is flushed, before and after medication administration.
- Packed red blood cell transfusions should be given through a PICC only in an emergency, as the small catheter size may cause occlusion or hemolysis when older blood is used (24). A peripheral intravenous cannula should be utilized for blood transfusions.
- Monitor quality indicators in order to identify and solve problems. Infection rates, catheter dwell times, patient outcomes, and rates of complications should be monitored (22).
- Remove catheter as soon as it is no longer medically necessary by slowly withdrawing it from insertion site. Clean insertion site with prep prior to withdrawing catheter. Hold pressure over site if bleeding is a problem. Remove prep from skin. Place a clean gauze dressing over site. Document length removed.
Placement of Central Venous Catheters by Surgical Cutdown
- Types of Catheters
Silicone catheters are preferred because they are constructed of relatively inert materials, offer increased pliability, and are associated with lower rates of infection and thrombosis. These catheters are placed in a central vein, and the distal end is tunneled subcutaneously a short distance from the access site to an exit wound. The catheters usually have a single lumen with a Dacron cuff, which adheres to the subcutaneous tract, anchoring the catheter. Polyethylene catheters have a higher rate of infection and thrombolytic complications and are not recommended for long-term intravenous access.
In addition to the relative contraindications delineated earlier, the internal jugular vein should be avoided if the contralateral jugular vein has been catheterized previously, or if there is thrombosis of the jugular venous system on the opposite side.
- Skin prep: Per institutional policy (e.g., 10% povidone–iodine, or 0.5% chlorhexidine solution)
- Gown and gloves
- Cup with antiseptic solution
- Sterile transparent aperture drape; four sterile towels to ensure a sterile operative field
- Four 4- × 4-in gauze squares
- Local anesthetic: 0.5% lidocaine HCl in labeled 3-mL syringe with 25-gauge venipuncture needle
Consider sedation and pain medication in addition to local anesthesia. Patients who are intubated may be given a sedative and muscle relaxant in addition to local anesthesia. When patients are taken to the operating room, general anesthesia is preferred.
- Catheter of choice
- Heparinized 0.25 N saline flush solution (1 U/mL) in 3-mL syringe
- 4-0 Polyglactin suture (Vicryl; Ethicon, Somerville, NJ, USA) and 5-0 nylon suture (black monofilament nylon) on cutting needles (seeAppendix B)
- T connector connected with a sterile 3-mL syringe filled with heparinized saline
- No. 11 scalpel blade and holder
- Two small tissue retractors or self-retaining retractor
- Tissue forceps
- Fine vascular forceps
- Two small, curved mosquito hemostats
- Dissecting scissors
- 4-0 Vicryl suture on small, curved needle; 6-0 polypropylene on a tapered needle. This is used for a purse-string stitch as an alternative to ligation of the vessels.
- Needle holder
- Suture scissors
- Appropriate materials for occlusive dressing of choice
- Cap and mask
- Roll of 4- × 4-in gauze
- Tape measure
- Adhesive tape
In the neonate, the cervical veins are preferable to the lower-extremity veins. The cervical veins are easily accessible and are a proportionately larger size. When the lower extremities are used, the greater saphenous vein is often selected in pediatric patients because of its large size and consistent anatomy. It is not established whether femoral or jugular sites have fewer complications in neonates (25,26).
FIG. 31.7. The jugular veins in relation to major anatomic landmarks.
- Catheter placement via jugular veins
- Immobilize infant in position similar to that for percutaneous insertion of subclavian venous catheter.
- If right side is to be catheterized, turn head to left and extend neck. Care must be taken not to extend the head too much, as this may result in occlusion of the neonatal vein.
- Estimate length of catheter to be inserted by measuring from a point midway between the nipple and the midpoint of the clavicle to a point over the sternocleidomastoid muscle at the junction of the middle and lower third of the neck (Fig. 31.7).
- Put on cap and mask.
- Scrub as for major procedure and put on gown and gloves.
- Prepare neck and scalp area or right chest wall with antiseptic solution such as iodophor and drape out the sterile field.
- Make small, transverse incision (1 to 2 cm) through skin and platysma muscle low in the neck for the external jugular and higher up for the facial vein.
- Free external jugular or facial vein by blunt dissection with curved mosquito hemostat. If internal jugular vein is used, sternocleidomastoid muscle must be split to locate vein.
FIG. 31.8. Catheterization of the external jugular vein; venotomy has been performed prior to inserting the catheter.
- Pass curved mosquito hemostat behind the vein, and place proximal and distal ligatures of 4-0 absorbable suture loosely around vein (Fig. 31.8). Be careful not to twist the vessels as the suture is advanced.
FIG. 31.9. Formation of a subcutaneous tunnel with a Vim-Silverman needle. A: Tunnel on the anterior chest wall. B:Alternative route under the scalp.
- Using a blunt tunneler, create a subcutaneous tract from neck to exit on the chest wall medial to the right nipple. In a baby girl, make sure that the tunnel is far from the breast bud (Figs. 31.9 and 31.10).
- Thread the end of the catheter through the opening in the tunneler, and guide the catheter gently through the subcutaneous tract.
- Fill the catheter system with heparinized flush solution.
- Cut the catheter length to the premeasured distance between the neck incision and a point midway between the center of the nipple line and the suprasternal notch.
- Perform transverse venotomy (Fig. 31.8).
For external jugular or facial vein (27)
- Tie cephalad venous ligature, and exert traction on both ligatures in opposite directions with aid of appropriately prepared assistant.
- Make short, transverse incision in anterior wall of vein, and enlarge gently by inserting and spreading tips of fine vascular forceps.
For internal jugular vein
- To avoid ligation of the vessel, use purse-string suture of 6-0 polypropylene, placed in vessel wall around point of catheter entrance.
- Make incision in vessel as for external jugular vein.
- Bevel intravascular end of catheter (optional).
- Grasp catheter gently with blunt nontoothed tissue forceps, introduce catheter tip, and insert into the vein.
- Leave loop of catheter in neck wound to dampen effect of head movement (Fig. 31.11).
- Close wound with subcuticular 5-0 absorbable suture, taking care not to penetrate the catheter.
- Secure the catheter to the skin with at least one nylon suture to hold it until the cuff has created enough tissue ingrowth.
- Use selected method for fixation and dressing.
FIG. 31.10. Broviac catheter with transparent dressing.
- Proximal saphenous vein cutdown
- Scrub and prepare as for major procedure.
- Prepare as for cutdown on jugular vein.
- Choose right or left groin area for insertion.
- Prepare groin and abdomen on same side.
- Make incision 1 cm long: 1 cm caudad and 1 cm lateral to pubic tubercle (Fig. 31.12).
- Spread incision into subcutaneous tissues, using curved mosquito hemostat.
- Incise superficial fascia.
- Identify saphenous vein lying medial and inferior to its junction with femoral vein at foramen ovale (Fig. 31.12).
- Move 0.5 to 1 cm distally before
- Passing curved mosquito hemostat behind vein. This avoids inadvertent damage to femoral vein.
- Placing two 4-0 absorbable suture ligatures loosely around vein
- Create tunnel, using small hemostat or tunneling instrument, in subcutaneous plane laterally onto abdomen, just above or lateral to umbilicus or on lateral thigh.
- Flush catheter with heparinized saline and replace cap.
FIG. 31.11. Insertion of a catheter into the common facial vein. Incision is below the angle of the mandible at the level of the hyoid bone. The facial vein is ligated at the junction of the anterior and posterior tributaries. Inset: The catheter is looped in the neck wound to “dampen” the effect of head movement. Alternatively, a subcutaneous tunnel may be made with a catheter exit site on the anterior chest wall. (Reproduced from
Zumbro GL Jr, Mullin MJ, Nelson TG. Catheter placement in infants needing total parenteral nutrition utilizing common facial vein. Arch Surg. 1971;102:71
, with permission of American Medical Association.)
FIG. 31.12. Anatomic view of the site of incision for proximal saphenous vein cutdown with underlying femoral triangle.
- Pull catheter through tunnel into groin wound so that Dacron cuff is just within the skin incision.
Estimate length of catheter to be inserted so that tip will be in inferior vena cava at junction with right atrium.
- Cut catheter to appropriate length, and bevel intravascular end (optional).
- Dissect saphenous vein to junction with common femoral vein.
- Visualizing the junction prevents inadvertent direction of catheter into lower extremity.
- Apply traction to vein, using caudad suture. Lateral tension may also be applied by a scrubbed assistant, using fine nontoothed vascular forceps.
- Make transverse venotomy.
- Dilate vein, if necessary, with blunt dilatator.
- Moisten catheter with saline to ease passage into vein.
- Maintain back-traction on caudad suture to control bleeding.
- Visualize catheter entering common femoral vein to ensure cephalad direction of catheter.
- Obtain radiograph to confirm position in inferior vena cava, once estimated length is inserted (radiographic contrast material may be required).
- Ligate vessel with caudad suture, and tie down cephalad suture without occluding catheter.
- Check for easy backflow of blood in catheter.
- Flush catheter with 2.5 to 3 mL of heparinized saline. If catheter is capped, while infant is transferred from operating room to intensive care unit, clamp catheter while plunger of heparin syringe is moving forward to ensure positive pressure in line to prevent backflow and clotting of blood.
- Close groin wound with subcuticular 5-0 absorbable suture, taking care not to penetrate catheter with needle.
w.Secure the catheter to the skin with at least one nylon suture to hold it until the cuff has created enough tissue ingrowth.
- Cover with dressing of choice.
- Sterile Dressing for Surgically Placed Central Venous Lines
Routine changing of central venous catheter dressings depends on the type of dressing. Transparent dressings should be changed at least every 7 days, and gauze dressings every 2 days. All dressings should be changed when damp, loose, or soiled (22).
Strict sterile technique is used for all central line dressings.
- Antiseptic skin prep solution: Per institutional policy (e.g., 10% povidone–iodine or 0.5% chlorhexidine solution)
- Sterile gloves, mask, cap, and sterile gown (optional)
- Scissors (optional)
- Cotton-tipped applicator
- 4- × 4-in sterile gauze square
- Dressing of choice
- Semipermeable transparent dressing
- Sterile 2- × 2-in gauze squares or presplit 2- × 2-cm gauze dressing
- Normal saline or sterile water
- Adhesive tape (if sterile tape not available, use fresh unused roll)
- Procedure should be undertaken by trained personnel.
- Ensure that all personnel wear masks if within 6-ft radius of sterile area.
- Use strict aseptic technique.
- Remove dressing with care, to avoid cutting or dislodging catheter.
- If it is necessary to clamp the catheter, close the clamp on the catheter according to the manufacturer's directions. If the catheter does not have a clamp, use a rubber-shod clamp. Never place a clamp directly on the catheter.
- Never advance a dislodged catheter into the patient.
- Do not place adhesive tape on silicone tubing because this may occlude or damage the catheter.
- Do not routinely apply prophylactic topical antimicrobial or antiseptic ointment at the insertion site because of the potential for promoting fungal infections and antimicrobial resistance (22).
When a subcutaneous tunnel is used, occlusive dressing should be applied to both the cutdown site and the catheter exit site.
- Restrain patient appropriately, utilizing nonpharmacologic comfort measures.
- Put on head cover and mask.
- Scrub as for major procedure.
- Put on gown and gloves.
- Prepare sterile work area, using “no-touch” technique.
- Remove old dressing and discard.
- Inspect catheter site carefully (Table 31.4).
- Culture site if there is drainage or it appears inflamed.
- If area around catheter is contaminated with dried blood or drainage, clean with diluted hydrogen peroxide/sterile water solution (1:1).
- Remove gloves. Don sterile gloves.
- Cleanse area with antiseptic solution, starting at catheter site and working outward in circular motion for 2 to 4 cm. Repeat twice. Allow area to dry.
- Remove antiseptic with sterile water or saline gauze and allow to dry.
FIG. 31.13. Occlusive dressing for a central venous line using presplit gauze. A: Placing split gauze over the skin entry site. B:Covering split gauze and the catheter with sterile gauze. Entire dressing is then covered with adhesive tape or clear dressing.
- Apply dressing of choice.
- Clear, adhesive, hypoallergenic, transparent dressing allows for continuous inspection of catheter insertion site (Fig 31.10).
- If necessary, cut dressing to desired size.
- Anchor dressing to skin above catheter skin entry site, so that the point of skin entry is at the center of the dressing.
- Remove remainder of adhesive backing while applying dressing smoothly over site.
- Standard occlusive gauze dressing
- Cut gauze halfway across, or use presplit gauze. Place around catheter as shown in Fig. 31.13.
- Cover remainder of external catheter length (not hub) with sterile gauze.
- If sterile tape is not available, discard outer layer of tape on roll.
- Cover gauze with tape.
- Label dressing with initials and date.
- Secure intravenous tubing with tape to prevent tension on the center (a stress loop can decrease tension on the catheter).
- Care of the Catheter When Not in Use for Continuous Infusion
To maintain patency and prevent clotting of the catheter when the line is used intermittently. Only large-bore catheters (2.5 Fr or larger) may be kept patent by this technique. PICC lines that are 2 Fr or smaller tend to clot easily if continuous infusions are interrupted.
- 3 mL of heparin–saline solution (10 U/mL) in a 10-mL syringe (follow manufacturer's guidelines for syringe sizes)
- Alcohol wipes
- Catheter clamps (must have no teeth or be padded), or use clamp provided on catheter (Fig. 31.10)
- Clean gloves
- Intravenous injection cap (needleless is recommended)
- Converting to a heparin lock
- Wash hands thoroughly.
- Don clean gloves.
- Prepare sterile work area.
- Using aseptic technique, open sterile injection cap package and prefill injection cap with heparinized saline.
- Clean the outside of the hub–intravenous tubing connection with an antiseptic such as alcohol wipes. Work outward in both directions. Allow to dry.
- Clamp catheter with padded hemostat, or close catheter clamp.
- Holding hub with alcohol swab, disconnect catheter hub from intravenous tubing.
- Connect preflushed injection cap into hub of catheter (gently flushing during connecting can prevent air from entering catheter).
- Release clamp and flush line with 1 to 3 mL of heparinized saline (depending on size of catheter).
- Reclamp catheter while plunger of heparin syringe is depressed to prevent blood from backing into catheter (positive pressure).
- Secure catheter and tape to chest or abdomen.
- Flush catheter with heparinized solution every 6 to 12 hours (per institution policy).
- Flushing catheters
Equipment is same as for heparin lock.
- Wash hands thoroughly.
- Put on gloves and prepare sterile work area.
- Prepare intravenous injection cap with antiseptic solution. Allow to dry.
- If injection cap is part of a needleless system (recommended), connect flush syringe to cap. If the cap is not a needleless device, insert needle into intravenous catheter plug. Always use a 1-in needle. A longer needle can puncture the catheter.
- Unclamp catheter and slowly inject 1 to 2 mL of heparin solution (depending on catheter size). Reclamp catheter while injecting solution to prevent blood from flowing back into catheter. Positive-pressure injection caps are available to prevent backflow.
- Changing intravenous catheter injection cap: Most manufacturers recommend changing injection caps every 3 to 7 days, after blood product administration, or when they appear damaged (see specific manufacturer's instructions).
- Patient's condition no longer necessitates use.
- Occluded catheter
- Local infection/phlebitis
- Sepsis and/or positive blood cultures obtained through the catheter (catheter colonization). There are rare clinical circumstances when a catheter is left in place despite sepsis and antibiotic or antifungal therapy is administered through it in an attempt to clear the infection, but this may be associated with an increased risk of morbidity and mortality (28, 29).
Surgically implanted central venous catheters should be removed by a physician or other person specifically trained to remove cuffed and/or tunneled catheters.
- Remove dressing.
- Pull catheter from vessel slowly over 2 to 3 minutes.
Avoid excessive traction if catheter is tethered, because the catheter may snap (see Complications).
- Apply continuous pressure to the catheter insertion site for 5 to 10 minutes, until no bleeding is noted.
- Inspect catheter (without contaminating tip) to ensure that entire length has been removed.
- The cuff on the tunneled catheter should be dissected out under local anesthesia with IV sedation. If cuffs are retained, they may rarely cause more than a persistent small subcutaneous lump, although they can occasionally extrude through the skin.
- If desired, antibiotic ointment may be placed over site.
- Dress with small, self-adhesive bandage or gauze pad and inspect daily until healing occurs.
Complications of Central Venous Lines
- Damage to other vessels and organs during insertion
- Possible during both percutaneous and surgical placement of central venous catheters
- Complications include bleeding, pneumothorax, pneumomediastinum, hemothorax, arterial puncture, and brachial plexus injury (20,30, 31).
- Mechanical phlebitis may occur in the first 24 hours after line placement as a normal response of the body to the irritation of the catheter in the vein.
- Management of mild phlebitis (mild erythema and/or edema): Apply moist, warm compress, and elevate extremity.
- Remove the catheter if symptoms do not improve, if phlebitis is severe (streak formation, palpable venous cord, and/or purulent drainage), or if there are signs of a catheter-related infection.
- Catheter migration/malposition (2, 8, 9, 10, 11, 12, 13, 16) (Fig 31.14)
- Can occur during insertion or from spontaneous migration at any point during the catheter dwell time. During insertion, the catheter can enter a side vein or reverse direction, causing it to loop or curl backward.
- Sites of misplacement include the cardiac chambers, internal jugular vein, contralateral subclavian vein, ascending lumbar vein, and others, with consequences such as pericardial effusion or pleural effusion, cardiac arrhythmias, tissue extravasation/infiltration, and thrombosis.
- The decision to remove the catheter or attempt to correct the position is based on the location of the tip. Although PICCs are intended to be placed in central veins, occasionally, the tip is in a noncentral location (e.g., in the subclavian vein). These noncentral PICCs may be used temporarily, provided the fluids administered through them are isotonic, but the care of the catheters must be as stringent as for centrally placed catheters (32).
- The catheter should be pulled back a few centimeters if the tip is in the heart, as serious consequences such as cardiac arrhythmia, perforation, or pericardial effusion can occur.
- Spontaneous correction of malpositioned lines has been demonstrated in some cases (33). If the tip of the catheter is looped into the internal jugular or in the contralateral brachiocephalic vein, the catheter may be used temporarily (using isotonic fluids that are suitable for peripheral venous cannulae) and re-evaluated radiologically in 24 hours. If the catheter has not moved spontaneously into the desired location, it should be removed.
- Infection (most common complication)
- Catheter-related sepsis (CRS) rates range from 0% to 29% of lines placed and from 2 to 49 per 1,000 catheter days, with the smallest and most immature infants being at greatest risk (2, 34, 32, 36).
- Strict protocols for central line care and a methodology of surveillance with a data feedback mechanism are recommended to decrease the rate of infection, which can vary significantly among neonatal intensive care units (4, 22, 34, 36).
- Management of catheter-related sepsis: Remove central venous line if possible. Prompt removal of the line is recommended forStaphylococcus aureus, gram-negative, or Candidasepsis. Treatment with appropriate antibiotics without removal of the line may be attempted in infants with coagulase-negative Staphylococcus sepsis, but repeated positive cultures mandate removal of the line (28, 29).
- Catheter dysfunction
- Obstruction of the catheter is characterized by increased pump pressures, or inability to infuse fluids or withdraw blood.
- Dysfunction may be due to malposition, fibrin thrombosis, precipitates caused by minerals or drugs, or lipid deposits (36, 37).
- Check catheter position on chest radiograph.
- If malposition is ruled out, review history of fluids and drugs administered through the catheter to determine probable cause of occlusion.
- Remove the catheter if it is no longer medically critical.
- Attempt clot dissolution only if maintenance of catheter is essential.
- Equipment required: Face mask, sterile gloves and drape, prep solution, sterile three-way stopcock, a 10-mL syringe, and a 3-mL syringe filled with 0.2 to 0.5 mL of agent for clot dissolution.
- Agents for clot dissolution (37)
- Hydrochloric acid, 0.1 N, for calcium salt precipitates or drugs with pH < 7
FIG. 31.14. Various venous malpositions of subclavian venous catheters. A: Jugular. B: Looped in the right atrium with the tip in the superior vena cava. C: Looped in the superior vena cava. D: Looped in the innominate vein with the tip overlying the left scapula. E: Knotted in the left atrium.
- Sodium bicarbonate, 8.4%, 1 mEq/mL, for medications with pH > 7
- Ethanol, 70% concentration, for lipid deposits
- Recombinant tissue plasminogen activator, 0.5 to 1 mg/mL, for fibrin or blood clot (37, 38, 39)
- Recombinant urokinase, 2,000 to 5,000 IU/mL, for fibrin or blood clot (40)
- Use strict aseptic technique.
- Remove IV tubing and cap to maintain sterility. After cleaning with prep, attach a three-way stopcock to catheter hub.
- Attach an empty 10-mL syringe to the side port of the three-way stopcock and a prefilled 3-mL syringe to the other port. Avoid use of 1-mL tuberculin syringe.
- Turn the stopcock off toward the prefilled syringe and open toward the empty syringe.
- Aspirate on the empty syringe, creating negative pressure in the occluded catheter.
- While maintaining the negative pressure, turn the stopcock off to the empty syringe and open to the prefilled syringe. The negative pressure in the catheter will automatically cause the medication in the prefilled syringe to flow into the catheter.
- Allow the medication to dwell in the catheter for 20 minutes to 1 hour.
- Aspirate after the dwell time to check for blood return, discard the aspirate, and flush the catheter with sterile normal saline. Resume catheter use.
- If the procedure is unsuccessful, it may be repeated once, or a different declotting agent may be tried.
- Do not use hydrochloric acid immediately before or after using sodium bicarbonate.
- Continuous infusions of low-dose recombinant tissue plasminogen activator or urokinase may be attempted if bolus doses do not clear the occlusion. Risk of hemorrhagic complications should be evaluated (41, 42).
- Thrombosis, thromboembolism
- About 90% of venous thromboembolic events in neonates are associated with central venous catheters (43). They include:
- Deep venous thrombosis
- Superior vena cava syndrome
- Intracardiac thrombus
- Pulmonary embolism
- Renal vein thrombosis
- The complications of venous thrombosis include loss of venous access, potential danger of injury to affected organ or limb, thrombus propagation, embolization to other areas, and infection.
- Management of thromboembolism in neonates is controversial. The severity of thrombosis and the potential risk to organs or limbs dictate the degree of intervention required, including the use of thrombolytic/anticoagulant therapy or surgical intervention (44).
- Extravascular collection of fluid
- Pericardial effusion with or without cardiac tamponade (Fig. 37.3) (2, 8, 9, 10, 11, 12, 13). This serious complication presents as sudden cardiac collapse or unexplained cardiorespiratory instability. The cardiothoracic ratio is increased, and pulsus paradoxus may be noted (Fig. 37.1). Immediate pericardiocentesis may be life-saving (Chapter 37).
- Pleural effusion
- Mediastinal extravasation
- Catheter breakage
- Catheters may be severed by the introducer needle during insertion of a PICC, snap because of excessive tension on the external portion of the catheter, or rupture because of excessive pressure. Other common causes include external clamps, kinking of the catheter, constricting sutures, and poorly secured catheters. The intravascular portion of the broken catheter is at risk for embolization (45).
- In the event of catheter breakage, immediately grasp and secure the extravascular portion of the broken catheter to prevent migration.
- If the catheter is not visible outside the baby, apply pressure over the venous tract above the insertion site to prevent the catheter from advancing. Immobilize the infant, and obtain a radiograph immediately to localize the catheter.
- Surgical and/or cardiothoracic intervention may be required if the catheter is not visible externally.
- Damaged or broken catheters must be removed and replaced. Repaired catheters and catheter replacement over a guidewire place the patient at risk for infection or embolization. If no other options exist owing to limited venous access, the catheter can
sometimes be repaired, utilizing meticulous aseptic technique. Repaired PICCs should be considered temporary, and a new catheter should be placed as soon as possible. Some manufacturers offer repair kits and instructions. A butterfly or blunt needle may be used in an emergency (46) (Fig. 31.15).
- Tethered catheter
- Difficulty in removing catheter may be due to the formation of a fibrin sheath or secondary to sepsis.
- Place warm compresses on skin along the vein.
- Use gradual, gentle traction on the catheter.
- Thrombolytic therapy (47)
- Surgical removal through a peripheral incision
FIG. 31.15. Emergency catheter repair using butterfly needle (46). (From Neonatal Network, Santa Rosa, CA, USA, with permission.)
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