Chapter 36

1. Indications. Percutaneous central venous catheterization (peripherally inserted central catheter, or 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 it is anticipated that an infant will need IV access for several weeks.

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

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

2. Equipment. Cap and mask, sterile gloves, a sterile gown, and a neonatal percutaneous catheter device are needed. Two types of devices are available: Silastic catheters, which generally do not have an introducer wire, and polyurethane catheters, which contain an introducer wire. Several sizes are available, ranging from 24 gauge to as small as 28 gauge in diameter, which is useful in infants <1000 g. Double-lumen catheters are also available. Transparent dressing (for stabilization of the catheter), a sterile tray (multipurpose tray or one used for umbilical artery catheter placement may be used), povidone-iodine solution, a sterile tourniquet (or a rubber band), saline flush solution, a T-connector, and sterile tape strips (Steri-Strips) for catheter stabilization.

3. Procedure. There are two commonly used types of catheters, and some of the smaller ones come with guidewires. The procedure varies if a guidewire is or is not present because the guidewire needs to be removed before blood is withdrawn or the catheter is flushed.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. A review of the National Association of Neonatal Nurses (NANN) Guideline for Peripherally Inserted Central Catheters is also suggested (Pettit J, Wyckoff MM: Peripherally Inserted Central Catheters: Guideline for Practice. Glenview, IL: National Association of Neonatal Nurses, 2007).

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

1. Select a suitable vein in the arm, such as the cephalic or basilic vein, or use the saphenous vein in the leg (see Figure 37–1). 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.

1. Determine the length of the catheter by measuring 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 the inferior vena cava.) Catheters are typically marked at 5-cm increments to assist with placement.

1. Put on the cap and mask, wash your hands, and then put on the sterile gown and ...

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