Percutaneous central venous catheter insertion for neonates

Peripheral CVC is contraindicated in these situations:

• infection - systemic or cutaneous near the proposed point of insertion
• anatomical irregularities in the baby's extremities or chest that could interfere with proper placement of the catheter.

Follow this procedure:

1. Select an appropriate vein (the basilic and long saphenous veins are preferred).
2. Determine the length of catheter to be inserted by measuring the distance between the proposed insertion site and the mid-sternum.
3. Consider methods of pain relief including:
   1. EMLA application (0.5-1 g) to the proposed site 60-90 minutes  prior to insertion
   2. oral sucrose
   3. swaddling of the infant
   4. intravenous infusion of opioids.
4. Secure mask.
5. Open the sterile tray and catheter.
6. Wash hands with chlorhexidene and don gown and sterile gloves.
7. Apply a tourniquet if required.
8. Flush the catheter with sterile saline.
9. Prepare the insertion site with cleanser and allow to dry. Skin cleansing at the insertion site is one of the most important measures to prevent catheter-related sepsis.
10. Using a 10 mL syringe, draw up and flush the catheter with sterile saline.
11. Use slight tension on the skin to stabilise the vein and then insert the introducer needle into the vein. Release the tourniquet. Stabilise the introducer needle to maintain its position in the vein and holding the catheter through the protective sleeve, use fingers or smooth forceps to carefully advance the catheter in short increments approximately 5 cm into the vein.
12. Withdraw the introducer needle completely out of the insertion site, keeping the needle parallel with the skin to avoid cutting the catheter.
    To separate the introducer needle from the catheter, remove the clip that holds the two halves of the introducer needle together. Grasp opposite halves of the introducer needle by the front wing portions and pull the two halves of the needle apart until the needle splits completely. The Epicutaneo-cave Neocath doesn't have a splitting introducer needle and is removed from the catheter by unscrewing the blue Easy-lock connector. When reconnecting ensure that the catheter is fully inserted into the hub (the black mark on the catheter shouldn't be visible).
13. Discard the needle into ‘sharps’ container.
14. Advance the catheter in short increments to the desired position. To help with proper placement of the tip, turn the infant's head toward the access side with the chin on the shoulder.
15. Remove the stylet slowly and steadily from the catheter. (Note that the Epicutaneo-cave Neocath does not have an introducer stylet.)
16. Flush the catheter with 0.9 per cent normal saline.
17. Verifying the position of the catheter:
    The location of the catheter tip must be assessed prior to use. This is usually and most easily accomplished by x-ray, ensuring that the entire length of the catheter is visualised. Preferred tip locations include the superior vena cava (above T4) or the inferior vena cava outside the heart shadow and below T9. If the catheter tip is beyond the desired position it MUST be withdrawn. This must be done as an aseptic procedure, following which the position of the tip of the catheter must be confirmed radiographically, using contrast again if necessary. The tip of the catheter must never be left inside any part of the heart. Catheters that display angulation, curvature, or looping within the right atrium, carry a particularly high risk of pericardial tamponade and demand urgent correction. When imaging, the relevant bodypart should be positioned so the catheter follows the shortest path to the heart (to be confident that the line would not be too far into the heart in a different position). Therefore:
    1. For scalp insertions, include the upper neck, and chest. This will allow for assessment of catheter malposition or coiling of the catheter along the route of the vein. 
    2. For leg insertions: X-ray should include the upper leg, abdomen, and chest. For saphenous lines the leg should be flexed at the hip and knee. 
    3. For arm insertions: X-ray should include the upper portion of the extremity of insertion, chest and neck. For lines in the basilic vein the arm should be flexed at the elbow and fully adducted, and for axillary venous lines the arm should be fully adducted. For lines in the cephalic vein the arm should be flexed at the elbow and abducted to 90.
18. Contrast (not required with brands of catheters that are radio-opaque): Using a 10 mL syringe inject the contrast medium (Omnipaque 180 mg iodine/mL) and ask the radiographer to take the chest x-ray five seconds after injection. The catheter dead space is very small (0.1-0.2 mL) so only inject 0.2-0.5 mL of contrast medium. A 10 mL syringe must be used because rapid injection since a 1 or 2 mL syringe is capable of generating pressures above the catheter bursting pressure. The contrast medium does not require dilution. Preferable tip locations include superior or inferior vena cava just outside the right atrium. If the catheter tip is beyond the desired position it can be withdrawn. Catheters that are not far enough in can only be advanced if the insertion site is still sterile.
19. The decision to use a catheter that is not centrally located must be made after a careful assessment of the necessity of needing vascular access versus the higher risk of catheter complications.
20. Secure the catheter by taping it flat against the skin using ‘steri-strips’. Place the catheter hub on a small roll of sterile gauze. Cover the insertion site and hub with Tegaderm. Take care not to completely wrap the Tegaderm around the limb. Using sterile technique connect the catheter to a bag of infusion fluid.
21. Record the catheter type and gauge, insertion site, length inserted, location of catheter tip and the date of insertion in the patient's history.

Issues to note regarding management of CVC:

• Routine dressing changes are not necessary,as this increases the risk of bacterial contamination and accidental dislodgment of the catheter. The dressing should only be changed if:
  • it becomes insecure
  • the catheter becomes twisted or kinked
  • there is bleeding or inflammation.
• Blood or blood products should not be routinely infused through the peripheral CVC. The catheters may rupture if subjected to high pressure. This is most likely to occur if the catheter is flushed using a 1 or 3 mL syringe. Therefore the catheters should only be flushed using a 10 mL syringe.

Possible complications include the following:

• Infection is the most common complication although one randomised trial suggests that infection is no more common in central than peripheral lines.
• Thrombosis is more likely to occur if the line has not been advanced into a large central vein.
• Extravasation into the skin and pleural, pericardial and epidural spaces could occur.
• The introducer needle can inadvertently cut the catheter allowing the severed end of the catheter to embolise into the infant.

The catheter should be removed when:

• its use can be no longer justified
• bacteraemia and/or clinical symptoms persisting beyond 48-72 hours despite appropriate antibiotic therapy
• septicaemia due to fungal infection
• evidence of septic emboli or endocarditis
• limb becomes increasingly oedematous.

Use sterile technique when removing the catheter. To remove the catheter, grasp the catheter tubing, not the Luer hub, and pull in a slow, continuous movement, keeping the catheter parallel to the vein.

If the catheter has been removed because of suspected sepsis, the tip should be sent for microbiological examination. Catheter tips are not routinely sent for microbiological examination.

References

• Percutaneous Central Venous Catheterisation protocol, Southern Health Care Network - Monash Medical Centre, Newborn Services
• Janes M, Kalyn A, Pinelli J, Paes, B. A randomized trial comparing peripherally inserted central venous catheters and peripheral intravenous catheters in infants with very low birth weight. Journal of Pediatric Surgery, Vol 35, No 7 (July), 2000: pp 1040-1044.
• AM. Nadroo, RB. Glass,J Lin, R S. Green, I R. Holzman, Changes in Upper Extremity Position Cause Migration of Peripherally Inserted Central Catheters in Neonates Pediatrics 2002; 110 :131-136
• Zenker M, Rupprecht T, Hofbeck M, Schmiedl N, Vetter V, Ries M. Paravertebral and intraspinal malposition of transfemoral central venous catheters in newborns. J Pediatr 2000;136:837-40.
• Benjamin, D, Miller W, Garges H et al. Bacteremia, central catheters, and neonates: When to pull the line. Pediatrics 2001;107:1272-1276.
• Racadio J, Johnson N, Doellman D. Peripherally inserted central peripherally inserted central venous catheters: Success of scalp-vein access in infants and newborns. Radiology 1999; 210:858-860.
• Bagwell C, Salzberg A, Sonnino R, Haynes J. Potentially lethal complications of central venous catheter placement. J Pediatr Surg 35:709-713. Product information (L-Cath and First PICC)