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Central Line Care - PICC insertion in the neonate

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Indications

The insertion of a longline should not be considered a routine. However, infants who are VLBW, likely to be slow to reach full enteral feeds, have IV access problems or long term IV nutrition needs (NEC, major surgical problems etc.) may require line placement.

  • Infants to have longlines inserted should be discussed on ward round and/or with a Specialist at the time of presentation. 
  • In babies <1000g insertion of an umbilical venous catheter on admission is the preferred option. In those who are very small, sick or have respiratory distress an umbilical artery catheter should be considered at the same time. In sick term babies a double lumen UVC should be used as they may require several infusions. 
  • Where ever possible discuss the risks of the procedure with the family. 

Selecting a long line

  • Vygon silicone 24G (2F) single lumen 30cm
    This is the preferred line for all infants not requiring a second lumen (i.e. most of our babies).
  • Vygon - Epicutaneo Cave Silicone Catheter with blue hub 24G (2F) 30cm
  • Vygon Premicath polyurethane 28G (1F) single lumen 20cm
    This should be used for infants weighing < 1000 g only when a 24G line is unable to be inserted. 
    If used for any other indications, please discuss with specialist on service or on call first. 
    Maximum flow rate 10ml/hr
  • Vygon Nutrioline Twinflo polyurethane 24G (2F) double lumen 30cm
    This line is only to be used for infants requiring a second lumen (for example, a baby requiring TPN and Prostaglandin infusion). 

Contraindications

  • Skin sepsis at insertion site
  • Bacteraemia or septicaemia

Sites

Large vein in antecubital fossa, long saphenous vein or posterior tibial vein

Procedure

Important: Use a full sterile technique.DO NOT ATTEMPT THIS PROCEDURE THROUGH THE PORTHOLES

Insertion Distance

  • For longlines inserted via the leg, measure from insertion site to xiphisternum.
  • For longlines inserted via the arm, measure from insertion site to the sternal notch.

Equipment Required

  • Open longline pack onto trolley and add:
    • 20 gauge cannula
    • Longline set
    • Scalpel blade
    • Use only 10 ml syringe for flushing
    • 0.9% NaCl 5ml ampoule
    • Heparinised saline 10 unit/ml
    • Skin disinfectant
    • Steristrips
    • Duoderm dressing
    • Tegaderm or Opsite dressing

Procedure

  • Don mask, gown, and gloves.
  • Flush the longline with 0.9% NaCl leaving syringe attached
  • Cut round the IV cannula at the hub leaving cannula on the introducer
  • Position the infant maximising access i.e. open the incubator door, slide tray out and use overhead heater. Secure limbs if necessary
  • If an assistant is required they must wear a gown and sterile gloves
  • Clean the skin with the disinfectant appropriate for the infant's gestation and age.
    Wait about 1 minute until it dries otherwise it will not be an effective skin prep.
  • Create a sterile field with sterile guards
  • Apply tourniquet above site
  • Position line, syringe and forceps on sterile field
  • Insert cannula, advance cannula off the introducer and withdraw introducer
  • Insert longline with forceps and feed to premeasured distance releasing tourniquet when catheter is through the cannula
  • Withdraw cannula over the longline ensuring the longline is stable by using pressure on the limb above the cannula
  • If using EPI-Cath, detach longline at blue connection, remove cannula and reattach connection, ensuring air is not introduced. The black marker that lies over the metal insert must not be visible.
  • Flush longline with 0.5ml of heparinised saline (10U/ml). Do not use syringe less than 10ml. The smaller the syringe the greater the pressure - which may rupture the line.

Securing the Line

  • Coil longline next to site without crossing longline.
  • Steristrips should be used to anchor the line preventing inward movement and may also help to keep the longline coiled.
  • Place a small piece of Duoderm on skin under connection and secure everything with Tegaderm.

Confirm the position

  • Wrap syringe in sterile guard until position confirmed by x-ray
  • The Department of Health (UK) recommended that the line tip is placed OUTSIDE the heart (Wariyar UK, Hallworth D. Review of four neonatal deaths due to cardiac tamponade associated with the presence of a central venous catheter. London, UK: Department of Health; 2001)
  • After insertion patency can be maintained by running 0.9% saline at 1ml/hr until catheter position is confirmed on X-Ray. Most PICCs are radio-opaque and with modern digital technology the imaging can be enhanced therefore, contrast medium is no longer used in the first X-Ray.
  • An X-Ray should be taken with infant positioned in anatomical position with arms by their side for upper limb lines or legs with hips slightly flexed for lower limb lines. Theoretically the line tip will be at its deepest. Note the tip position is influenced by arm placement; lines placed in the Basilic (medial) vein move towards the heart on adduction; lines placed in the cephalic (lateral) vein move away from the heart.1 Remember to remove chest leads.
  • If the position of the catheter tip is not clear, a subsequent X-Ray with contrast is advised (using a sterile technique instill 0.2 - 0.7ml Omnipaque to fill the line and Luer-lock until X-ray taken). In some circumstances the oro-gastric tube may need to be removed if it is obscuring adequate visualisation, or a lateral view can be obtained. Contrast medium may be required to visualise a premicath tip. Consider the risk of using contrast if there is renal impairment.
  • Record in the clinical notes the date, insertion site and length of catheter. Enter the procedure in the neonatal database.
  • It is also important that we note the catheter tip position in the clinical record.
  • If the longline is clearly well into the heart (particularly if it is curled) and needs to be withdrawn, another radiograph must be taken after manipulation to ensure that it has been withdrawn far enough and is in an acceptable position.

Unintentionally Short PICC (ie. Not in a large central vein).

In situations where there is no other venous access:

  • They may be used for up to 24hours and the site should be observed closely for extravasation.
  • They should be entered on the problem list as a potential danger until removed from the patient.
  • They should be highlighted on the CLABSI form.
  • Use for more than 24hours needs to be discussed with the consultant on a case by case basis.
  • They are a temporary venous access only - not a substitute for a properly placed longline.

Resources

References

  1. Nadroo A.M., Glass R.B., Lin J., Green R.S., and Holzman I.R. Changes in Upper Extremity Position Cause Migration of Peripherally Inserted Central Catheters in Neonates. Pediatrics 2002;110(1):131-136.

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Document Control

  • Date last published: 31 March 2017
  • Document type: Clinical Guideline
  • Services responsible: Neonatology
  • Owner: Newborn Services Clinical Practice Committee
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years