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 The procedure varies if a guide wire is or is not present because the guide wire needs to be removed before blood is withdrawn or the catheter is flushed.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.
Obtain informed consent and perform a time out. Gather the equipment and assemble the tray with the catheter using sterile technique.
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.
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 the inferior vena cava.) Catheters are typically marked at 5-cm increments.
Put on the cap and mask, wash your hands, and then put on the sterile gown and gloves. If others are helping or observing at the bedside, anyone within about 3 ft of the bedside should don a cap and mask and observe maximal sterile barrier precautions. Anyone assisting and scrubbed in should have full cap, mask, gown, and gloves.
Prepare the area of insertion. This should be done with a triple prep of povidone-iodine solution or unit-approved bactericidal agent, and allow the solution to dry. Some catheters warn against using alcohol due to degradation of the catheters. (Consult your manufacturer's guidelines.) Note: Catheters that do not contain a guide wire require flushing with saline before being inserted into the vessel (see specific product package insert).
Pain. The American Academy of Pediatrics recommends topical anesthetics for IV catheter insertion (topical anesthetics proved not to be effective in one study for PICC placement). Other nonpharmacologic pain prevention and relief techniques can be used. Other recommendations include systemic opiate-based analgesia.
Have an assistant apply the tourniquet if using a nonsterile tourniquet.
Place sterile drapes over most of the patient. Allow for maximal sterile barrier precaution, a large sterile field around the area of insertion, and cover most of the infant.
Remove the plastic protector from the introducer needle.
Insert the introducer needle into the vein. Confirm entry into the vein by observing for a flashback of blood in the needle. Do not advance the introducer needle once the flashback (or the blood) has been noted, or you may puncture through the other side of the vessel (Figure 42–1).
Release the tourniquet.
Hold the introducer needle to maintain the position in the vein. Slowly advance the catheter through the introducer needle with a pair of smooth forceps or fingers into the vein. Do not use a hemostat or ridged forceps because it may damage the catheter (Figure 42–2).
Once the catheter has been advanced to the premeasured location, stabilize the catheter by placing a finger over the vessel where the catheter has been introduced (∽1–2 cm above the tip of the introducer needle). Then carefully withdraw the introducer needle completely out of the skin. The area may bleed around the catheter. Hold sterile gauze to the area until the bleeding resolves (Figure 42–3).
Separate the introducer needle from the catheter by using the technique specified by the manufacturer of the needle. Grasp the opposite halves of the introducer needle, and carefully peel each half apart until the needle splits completely (Figure 42–4).
While removing the needle, occasionally the catheter also partially pulls out of the vein and has to be readvanced to the desired location.
If a guide wire is present, remove the wire slowly and steadily from the catheter. Do not attempt to reintroduce the wire once it has been removed from the catheter.
As the introducer wire is withdrawn, a blood return may or may not be observed in the catheter, depending on the size of catheter. Smaller catheters are less likely to have blood return. Using a 3-mL syringe, aspirate the blood through the catheter until the blood reaches the hub. (Slightly more pressure is necessary to withdraw blood through the very small diameter of the catheter; however, if blood is returning, the catheter is patent and in the intravascular system.) Once the blood has been aspirated back to the catheter hub, place a T-connector and flush the catheter with normal saline. (Because of the small diameter of the catheter, it will take slightly more pressure on the syringe to aspirate the blood and to flush solution through the catheter; however, do not use excessive pressure when flushing the catheter because it can cause catheter rupture or fragmentation with possible embolization.) Note: Practice the flushing technique on another catheter before attempting insertion and flushing of a catheter in a patient if you are unfamiliar with this type of catheter.
Secure the catheter to the extremity by placing a sterile tape strip over the catheter at the insertion site to anchor the catheter. Curl the remaining external catheter, making sure there are no kinks, and cover with a sterile transparent dressing. Do not suture the catheter in place.
Connect the IV fluid. New fresh sterile IV fluids should be connected to the new catheter. Heparin should be used. Cochrane review recommends prophylactic use of heparin in peripherally placed central venous lines because it allows a higher number of infants to complete their therapy, and reduces the risk of catheter occlusion. The American College of Chest Physicians Evidence-Based Clinical Guidelines (2012) recommends UFH continuous infusion 0.5 U/kg/h to maintain patency in neonates with central venous access devices.
Obtain a radiograph to verify the central catheter tip location. Most catheters are radiopaque and therefore can be seen on radiograph; however, because of its small size, it may be difficult to assess the location of the tip. Some manufacturers suggest injecting contrast medium (∽0.3–1 mL) through the catheter just before the radiograph to assess catheter tip placement. Note: Ideally, the position of the catheter tip should be in a central location in the superior vena cava for upper body insertions and the thoracic inferior vena cava for lower extremity insertions. However, if the catheter has a blood return and is patent but could not be advanced to a central location, it may be pulled back in the proximal portion of the extremity and used as a midline catheter. Hypertonic solutions should not be infused through a midline catheter.
When placing the PICC in the lower extremity. A cross-table lateral x-ray should be done to assess the proper placement of the catheter in the inferior vena cava.
Chart the size and the length of catheter that has been inserted and the position of the catheter on radiograph.
Precautions
Do not measure the infant's blood pressure on the extremity containing the percutaneous catheter. Occlusion or damage to the catheter may occur.
Do not trim the catheter before placement unless specified by the manufacturer. A rough cut end may increase thrombus formation.
Do not use a hemostat or ribbed forceps to advance the catheter because it could damage the catheter.
When inserting the catheter through the introducer needle, do not pull the catheter back through the introducer needle. Doing so could sever the catheter.
Do not suture the catheter itself. The catheter is very small, and a suture would occlude it.
Do not attempt to infuse blood products or viscous solutions through the catheter. This could cause the catheter to become occluded.
Take care when flushing the catheter. Excessive pressure could rupture it. Do not use a syringe <3 mL to the flush line.
Maintenance of the catheter
Prevention of central line–associated bloodstream infection (CLABSI) (see later) begins before insertion with strict guidelines for placement and maintenance of the catheters. Strict hand washing technique is also necessary.
The transparent dressing should remain in place over the catheter. Routine dressing changes are not recommended because of the risk of tearing or dislodging the catheter. The dressing should be changed, using sterile technique, only if the current dressing has drainage under it or is no longer occlusive. Assess dressing each shift to assess condition, making sure it is dry and occlusive. If the dressing is peeling up, it may need to be changed using sterile technique.
Examine the site and extremity or area where the catheter is located frequently for inflammation (erythema) or tenderness (as per unit's specific IV protocol).
Fluids and medications running through the catheter should be prepared using sterile conditions and heparinized according to hospital or unit protocol for central catheters.
Limit the number of times the catheter is accessed to decrease infection. Clean hubs and injection sites with antiseptic before entering the line for any reason. Research suggests that the hub is a common site of contamination and subsequent infection. The number of times the hub is opened and the duration of catheter use are both related to the presence of catheter associated infections.
Removal of the catheter. The catheter can remain in place for several weeks. Several studies have shown an increase in the infection rate after ∽2–3 weeks.
Gently remove the occlusive dressing from the extremity and the catheter, being careful not to tear the dressing from the catheter.
Grasp the catheter tubing near the insertion site, and gently pull the catheter in a continuous movement. If resistance is met, do not apply force and do not stretch the catheter. Doing so could cause the catheter to rupture.
Apply a moist, warm compress to the area above the catheter tract for several minutes, and then reattempt removal of the catheter. If catheter is still resistant, consult NANN Practice Guidelines (see Selected Reference). It may take several hours to days to remove some catheters.
Once the catheter is removed, inspect and measure it to make sure the entire catheter was removed from the vein. Compare this length with the initial measurement at the time of placement. Cover the area with a sterile dressing.