Chapter 42

I. INDICATIONS

Percutaneous central venous catheterization (also called peripherally inserted central catheter [PICC]) involves inserting a long small-gauge catheter into a peripheral vein and threading it into a central venous location. The catheter is placed peripherally but is longer than the usual intravenous (IV) device, and hence its tip lies in a more central location. The catheter can be placed in large vessels such as the cephalic and basilic veins in the arm or the saphenous vein in the leg.

1. When IV access is anticipated for an extended period of time.

2. In low birthweight infants when it is anticipated that full enteral feedings will not be achieved within a short period.

3. For the delivery of fluids, nutritional solutions, and medications when other venous access is not acceptable (eg, hypertonic IV solutions).

II. EQUIPMENT

1. Basic supplies. Cap, mask, sterile gloves, a sterile gown, transparent dressing, and sterile tape strips (for stabilization of the catheter), a sterile tray (multipurpose tray or umbilical artery catheter tray), povidone-iodine solution or locally approved bactericidal skin prep, a sterile tourniquet (or a rubber band), saline flush solution, and a T-connector.

2. Percutaneous catheter device. Two types of insertion devices are available: silastic (silicone) catheters (usually without introducer wire) and polyurethane catheters (usually with an introducer wire). Several sizes and double-lumen catheters are also available. National Association of Neonatal Nurses (NANN) guidelines recommend the following catheter sizes: infants <2500 g, 1.1–2F (28- to 23-gauge catheter); infants ≥2500 g, 1.9–3F (26- to 20-gauge catheter).

III. PROCEDURE

There are 2 commonly used types of catheters, and some of the smaller ones come with guide wires. The procedure varies if a guide wire is or is not present because the guide wire needs to be removed before blood is withdrawn or the catheter is flushed. It is suggested that the person placing the catheter should be familiar with the specific manufacturer's guidelines for placement of the catheters used. Special training is suggested before the placement of these devices. A review of the NANN Guideline for Peripherally Inserted Central Catheters (see Selected Reference) is also suggested and is helpful.

1. Obtain informed consent and perform a time out. Gather the equipment and assemble the tray with the catheter using sterile technique.

2. Select a suitable vein in the arm, such as the cephalic or basilic vein, or use the saphenous vein in the leg. (See Figure 43–1.) Position the infant so that the selected vessel is accessible. Restrain the infant to prevent contamination of the sterile field with the other extremities. It is helpful to have a second person available to help stabilize the infant's position, to help maintain sterility, and to offer a pacifier and comfort measures.

3. Determine the length of the catheter. Measure the distance between the insertion site and the desired catheter tip location. (For catheters placed in the upper extremities, measure to the level of the superior vena cava or the right atrium; for catheters placed in the lower extremities, measure to ...

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