Central Venous Catheterization
Ha-Young Choi
Angela Rivera
A. Alfred Chahine
Central venous catheters provide stable intravenous (IV) access to sick or low-birth-weight infants who need longterm IV nutrition or medications (1).
A percutaneous central venous catheter, also known as a peripherally inserted central catheter (PICC), is a soft, flexible catheter that is inserted into a peripheral vein and threaded into the central venous system. Central venous catheters may be placed by percutaneous puncture or by surgical cutdown when peripheral percutaneous access is not possible. Totally implantable vascular access devices (ports) are rarely used in neonates and are thus not included in this chapter.
Regardless of the method employed to obtain secure and reliable venous access, the clinician should be familiar with the technique and anatomic considerations unique to the approach. Some form of analgesia and sedation is generally required, with general anesthesia being reserved for more complex access cases. The majority of venous access procedures in the critically ill neonate are performed at the bedside rather than in the operating room. Thus the practitioner should have familiarity with both the risks and benefits of the procedure and analgesia medications (see Chapter 7).
A. Indications
1. Total parenteral nutrition
2. Long-term IV medication administration
3. Administration of hyperosmolar IV fluids or irritating medications that cannot be administered through peripheral IV cannulas
4. Fluid resuscitation
5. Repetitive blood draws (catheters are not usually inserted primarily for this indication in neonates; only larger-lumen catheters may be used for blood draws without risk of clotting)
B. Relative Contraindications
There are no absolute contraindications, as the clinical situation dictates the need for venous access.
1. Skin infection or breakdown/loss of integrity at insertion site
2. Uncorrected bleeding diathesis (not a contraindication for percutaneous catheters inserted in distal peripheral venous sites)
3. Ongoing bacteremia or fungal infection (which may cause catheter colonization and infection)
4. The patient can be treated adequately with peripheral IV access. Central venous catheters have significant risks of complications (2) and must not be used when peripheral venous access is possible and adequate
C. General Considerations, Preparation, and Precautions
1. Plan ahead: Success with PICC placement is higher if the catheter is inserted electively before peripheral veins are “used up” by frequent cannulations.
2. Obtain informed consent prior to performing the procedure.
3. Infant should be on a cardiorespiratory monitor during the procedure.
4. Central venous catheterization must be performed by trained individuals.
5. Central line teams and the use of insertion and maintenance checklists and bundles have been shown to decrease the frequency of catheter-related infections (3, 4, 5).
6. Maintain strict aseptic technique for the insertion and care of central catheter. Hand hygiene (with soap and water or with alcohol-based hand rub) should be performed before and after palpating catheter insertion sites, as well as before and after inserting, replacing,
accessing, repairing, or dressing an intravascular catheter (3).
accessing, repairing, or dressing an intravascular catheter (3).
7. Never leave a catheter in a position where it does not easily and repeatedly withdraw blood during the insertion procedure, to ensure that the tip is not lodged against a blood vessel or cardiac wall as this may lead to infiltration, arrhythmia, and excessive pressure needed for fluid infusion.
8. Always confirm the position of the catheter tip by radiography (both AP and lateral radiographs are recommended) or echocardiography prior to using it.
9. Follow the manufacturer’s instructions for catheter use.
10. Do not submerge the catheter or catheter site in water.
D. Vessels Amenable to Central Venous Access
Table 34.1 lists the sites usually used for central venous catheterization in the newborn.
TABLE 34.1 Vessels Amenable to Central Venous Access | ||||||||||||
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Vessels should be carefully assessed for optimal success in placement as well as decreased complications. Veins may be chosen by visual assessment, transilluminators, or ultrasound. Larger veins are easier to cannulate and are less likely to form a thrombus. Upper-extremity PICC may be associated with fewer complications in neonates than lower-extremity PICC, though reports are variable (6, 7). However lower-extremity PICC is less likely to migrate, whereas the upper-extremity PICC tip location may be affected by arm position and movement (8, 9). When deciding between upper-extremity veins, the basilic vein takes a straighter course to the superior vena cava (SVC) than the cephalic vein (9).
 FIGURE 34.1 Chest radiograph with PICC tip in appropriate position, just above junction of superior vena cava and right atrium. |
E. Position of Catheter Tip (Fig. 34.1)
1. The catheter should be placed in as large a vein as possible, ideally with the tip of the catheter outside the heart, and parallel with the long axis of the vein such that the tip does not abut the vein or heart wall. The recommendations for appropriate position of a central venous catheter tip vary, but there is general agreement that the tip should be located in a central vein but not within the right atrium (10). Noncentral, or “midline” PICCs have a shorter catheter life with higher risks of infiltration (11, 12). Conversely when the catheter tip is in the right atrium, there is a risk of focal myocardial injury, leading to pericardial effusion and cardiac tamponade (13, 14). However, one large retrospective audit of 2,186 catheters showed that catheters with their tips in the right atrium and not coiled were not associated with pericardial effusions (15).
a. When inserted from the upper extremity, the catheter tip should be in the SVC, outside the cardiac reflection, or at the junction of the SVC and right atrium.
b. When inserted from the lower extremity, the catheter tip should be above the L4-L5 vertebrae or the iliac crest, but not in the heart.
2. Confirmation of catheter tip placement.
a. The tip of the radio-opaque catheter is usually seen on a routine chest radiograph (Fig. 34.1).
b. Two radiographic views (anteroposterior and lateral) help to confirm that the catheter is in a central vein. This is particularly important for catheters placed in a lower extremity, where the catheter may inadvertently be in an ascending lumbar vein and may appear to be in good position on an anteroposterior view (16).
c. The use of radio-opaque contrast improves localization of the catheter tip, particularly when the catheter is difficult to see on a standard radiograph.
A 0.5-mL aliquot of 0.9% saline is instilled into the catheter to check patency, followed by 0.5 mL of iohexol. The radiograph is taken, and the line is flushed again with 0.5 mL of 0.9% saline. With this technique, there is no need to inject the contrast material while the radiograph is being taken (17).
A 0.5-mL aliquot of 0.9% saline is instilled into the catheter to check patency, followed by 0.5 mL of iohexol. The radiograph is taken, and the line is flushed again with 0.5 mL of 0.9% saline. With this technique, there is no need to inject the contrast material while the radiograph is being taken (17).
d. Real-time bedside ultrasonography may also be useful in localizing the catheter tip, and decreases radiation exposure to the infant (18).
e. Chest radiographs obtained for any reason should be scrutinized for appropriate catheter position. Routine weekly radiographs taken for this purpose do not appear to reduce the risk of complications (19). The infant’s arm position is important to assess, as there can be significant migration associated with arm movement.
F. Methods of Vascular Access
1. Percutaneous technique
a. Advantages
(1) Simpler to perform and relatively rapid procedure
(2) Vessel is not ligated as in open cutdown methods
(3) Decreased potential for wound infection/dehiscence complications
b. Disadvantages
(1) Beyond the initial insertion into the peripheral vein, further passage of the catheter into its final position is essentially a blind technique, although there is increasing experience with ultrasound imaging during passage
TABLE 34.2 Catheter Materials | |||||||||||||||
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(2) A smaller-caliber catheter may preclude use for blood transfusions and blood draws
2. Cutdown or open surgical technique
a. Advantages
(1) Allows for insertion of larger silicone catheter (2.7 or 4.2 Fr)
(2) If needed for prolonged periods, the catheters can be tunneled under the skin away from the venotomy site, so they can remain in place longer with a lower risk of infection
b. Disadvantages
(1) Requires general anesthesia or IV sedation
(2) Requires surgical incision
(3) Vein is often ligated, so it cannot be reused in the future
(4) Potential for injury to adjacent anatomical structures
(5) Increased potential for wound infection
(6) An operating room is the ideal setting for the procedure, so risks of transport of critically ill neonates need to be taken into consideration
G. Types of Central Venous Catheters
1. Catheter materials: See Table 34.2
2. Types of catheters
a. Percutaneous (PICC) catheters/introducers PICC catheters and kits are available commercially.
PICCs are generally made of silicone or polyurethane. Sizes include 1.2, 1.9, 2, and 3 Fr. Larger sizes are generally not used in the neonatal
population. Most catheters are single lumen. Double-lumen catheters can decrease the need for maintaining concurrent IV access when more than one site is required. PICC introducers/needles are available in 20 to 28 gauge.
population. Most catheters are single lumen. Double-lumen catheters can decrease the need for maintaining concurrent IV access when more than one site is required. PICC introducers/needles are available in 20 to 28 gauge.
b. Surgically placed central venous catheters
Surgically placed central venous catheters for neonates are available in sizes 2.5, 2.7, 3, 4.2, and 5 Fr. Catheters are usually silicone or polyurethane, with tissue ingrowth cuffs that adhere to the subcutaneous tract, anchoring the catheter. Recently, antimicrobial cuffs have become available. Most catheters are single lumen, but a few manufacturers make double-lumen catheters.
PERIPHERALLY INSERTED CENTRAL VENOUS CATHETERIZATION (
VIDEO 34.1)
VIDEO 34.1)A. Insertion Sites (Fig. 16.1, Table 34.1)
The veins used, in order of preference, are
1. Antecubital veins: Basilic and cephalic veins
2. Saphenous veins
 FIGURE 34.2 A: Cannulate the vein using the introducer and needle. B: Retract needle, leaving introducer in place in the vein. Apply pressure to the to vein proximal to the introducer to minimize blood loss. C: Insert the catheter into the introducer sheath to insert into the vein. D: After catheter has been introduced to desired depth, withdraw the introducer from the vein. E: Once introducer is completely outside of the skin, grasping both wings on either side of the introducer, split the introducer and peel it in half lengthwise. (Courtesy and © Becton, Dickinson and Company.) |
3. Scalp veins: Temporal and posterior auricular veins
4. Axillary vein
5. External jugular vein
Right-sided and basilic veins are preferred because of the shorter and more direct route to the central vein. The cephalic vein may be more difficult to thread to the central position because of narrowing of the vessel as it enters the deltopectoral groove and the acute angle at which it joins the subclavian vein. The axillary and external jugular veins are the last choices because they are close to arteries and nerves.
B. Insertion Variations
1. Break-away needle: Needle is inserted into the vein. Next, the catheter is advanced through the needle. The needle is then retracted, split, and removed. There is a potential for shearing or severing the catheter if it is retracted while the needle is in the vein.
2. Peel-away introducer (Figs. 34.2 and 34.3): A needle introducer is used to place a small cannula or sheath into the vein. The needle is then removed and the catheter is threaded through the introducer cannula. The introducer cannula or sheath is then retracted from the vein, split or “peeled” apart, and removed from the catheter.
 FIGURE 34.3 Use of a blunt scalp vein needle to form a hub for a silicone catheter. The plastic needle cover is used to stabilize the needle-catheter junction. A commercially available blunt needle adapter may be inserted and fixed in a similar manner. |
3. Intact cannula (Fig. 34.3): This technique is now rarely used because most commercially available catheters have a hub and introducer needles. A regular IV cannula is used to obtain venous access. The needle is removed. The silicone catheter is threaded through the cannula to its final position. The cannula is then retracted and slipped off the end of the “hubless” catheter. A blunt needle with hub is connected to the end of the catheter. Disadvantage: The blunt needle attachment must be secured well, otherwise leakage can occur.
C. Placement of PICC
1. Equipment (Fig 34.4)
All equipment used, except the mask, head cover, and tape measure, must be sterile. Commercial kits contain many of the necessary items. Assemble all supplies before starting procedure
a. Radio-opaque central venous catheter
b. Break-away or peel-away needle introducer
c. Device for trimming the catheter (based on manufacturer recommendations)
d. Tourniquet (optional)
 FIGURE 34.4 Sample PICC tray and sterile supplies. |
e. Drapes
f. Smooth iris forceps
g. Gauze pads
h. Skin prep: 10% povidone-iodine or 0.5% chlorhexidine solution (per institutional policy)
i. Sterile saline or water (for cleaning skin prior to dressing placement)
j. Transparent dressing
k. Sterile tape strips
l. Sterile heparinized saline solution (0.5 to 1 U/mL heparin or per institutional policy)
m. 5- to 10-mL syringe with blunt needle
n. Connection cannula, or “t-connector”
o. Tape measure
p. Sterile surgical gown, sterile gloves, mask, and head cover
2. Preparation
a. Obtain informed consent and perform “time-out” as per institutional regulations
b. Although anesthesia is not required, nonpharmacologic comfort measures and pain medication should be provided as needed. A small dose of sedative or narcotic analgesic may be useful
c. Gather supplies. Wash hands thoroughly
d. Identify appropriate vein for insertion (see D)
e. Position infant to facilitate insertion (Table 34.3). Restrain infant; provide comfort measures
f. Measure approximate distance from the insertion site to the point where the catheter tip will be placed (Table 34.3)
g. Don mask and head cover
h. Set up/open sterile equipment tray
i. Perform hand hygiene as for a major procedure and don sterile surgical gown and gloves
j. Trim catheter to appropriate size (trimming is based on unit policy and manufacturer recommendations). The catheter is fragile and should be handled with care. Do not clamp, suture, stretch, or apply tension to catheter
TABLE 34.3 Patient Position and Measurement for PICC Insertion | |||||||||||||||||||||
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k. Utilizing sterile technique and a 3-, 5-, or 10-mL syringe, flush catheter with heparinized saline solution, leaving syringe attached. A small-barreled syringe (such as a 1-mL syringe) may generate too much pressure, resulting in catheter rupture (21). Most PICC manufacturers will specify a minimum syringe size.
l. Prepare sterile field: Holding the extremity with sterile gauze prepare a large area at and around the insertion site, working outward in concentric circles. Allow the prep solution to dry. Repeat process with new gauze/prep solution. Place a large sterile drape under and above the extremity, leaving only the insertion site exposed. A large drape or multiple sterile towels should be used to cover an area well beyond the extremity to decrease the risk of accidental contamination (3).
3. Catheter insertion using a break-away needle or a peelaway introducer (Figs. 34.2 and 34.3)
a. Apply tourniquet above insertion site on extremity (optional).
b. Providing slight skin traction, insert needle about 0.5 to 1 cm below the intended vein, at a low angle (approximately 15 to 30 degrees).
c. When a flashback is obtained, advance the needle about 5 to 6 mm at a lower angle to ensure that the whole bevel of the needle is within the vein. If a peel-away introducer with a needle is used, remove the needle at this time and advance the introducer sheath slightly. If the introducer (needle or sheath) is well within the vein, there will be continued blood flow through it.
d. Remove the tourniquet.
e. Using nontoothed iris forceps, gently grasp the catheter about 1 cm from its distal end and thread it slowly into the introducer, a few millimeters at a time.
Caution: When using a break-away needle, never advance the needle or retract the catheter after inserting it into the needle; the catheter may be severed by this action.
f. With small, gentle nudges, a few millimeters at a time, advance the catheter through the introducer to a distance of about 6 to 7 cm into the vein, or to the predetermined distance.
g. Once the catheter is successfully advanced to about 6 or 7 cm, withdraw the introducer carefully (an alternative is to insert the catheter fully to the predetermined distance before withdrawing the introducer).
h. To withdraw the introducer, stabilize the catheter by applying gentle pressure over the vein proximal to the introducer, and then remove it carefully from the insertion site. Break or peel away the introducer by splitting the wings, and then carefully peel it away from the catheter. Make certain the introducer is completely outside the insertion site prior to splitting the introducer, as splitting the introducer while it is still under the skin will tear the skin at the insertion site.
i. Continue to advance the catheter into the vein to the premeasured length, by nudging it farther, a few millimeters at a time, using the fine forceps.
j. Difficulties in advancing catheter: Gently massage the vein in the direction of blood flow, proximal to the insertion site, or gently flush the catheter intermittently with 0.5 to 1 mL of heparinized saline; repositioning the extremity or the head may help.
k. Aspirate to visualize blood return in the catheter, then flush with 0.5 to 1 mL of heparinized saline to clear the catheter.
l. Verify length of catheter inserted and adjust as necessary.
m. Attach sterile extension set as per unit protocol.
n. Apply gentle pressure on insertion site with gauze pad to stop any bleeding.
o. Secure catheter at skin insertion site with a small piece of sterile tape strip (avoid using tape that contains wire) and cover with sterile gauze until radiographic confirmation of position.
 FIGURE 34.5 A: Demonstration of antisepsis of the extremity using Betadine. A) Note cleaning starts at distal end of limb, close to site of insertion, and moves proximally. B) Cleaning should include between fingers and toes. C) Note the use of a new sterile gauze to control the limb. D) After thorough cleaning the area should be draped to maintain a large sterile field. Be sure to allow for ready access to the infant’s airway. Remove outer gloves that were used during the cleaning portion of the procedure. (continued) |
D. PICC Dressings (Figs. 34.5G and 34.6)
1. Iodine containing antimicrobial prep solutions should be removed from the skin with sterile water or saline and allowed to dry before dressing is placed. Do not use topical antibiotic ointments or creams on insertion sites (Fig. 34.5) (2).
2. To prevent migration of the catheter, secure it to the skin a few millimeters from the insertion site with a small piece of sterile tape. Avoid using tape that contains wire and ensure that the insertion site is visible.
3. If the catheter has not been trimmed, loosely coil the excess length of catheter close to the insertion site and secure to the skin with more sterile tape. Ensure that there is no kinking or stretching of the catheter under the dressing.
4. Apply a semipermeable transparent dressing over the area surrounding the insertion site.
 FIGURE 34.5 (Continued) B: A) Apply tourniquet, set up for venipuncture with peel-away cannula introducer. B) Steady the introducer cannula and remove needle, release the tourniquet, then use nontoothed forceps to insert catheter. C) Introduce catheter to desired depth, then withdraw introducer sheath. D) Remove the introducer sheath by splitting and peeling away from the catheter. E) Secure catheter to skin using sterile tape, being sure to keep insertion site visible. Blood should easily aspirate. F) Coil excess catheter and cover with transparent dressing, then apply chevron under and over catheter extension, securing silicone heart proximal to chevron in order to protect the catheter. G) Prior to starting continuous infusion, flush catheter and attach extension tubing (t-connector) with clamp to prevent backflow of blood into PICC after placement. Be sure that all antiseptic has been removed from the skin prior to dressing placement.
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