Iowa Neonatology Fellows and Neonatal Nurse Practitioners

Peer Review Status: Internally Peer Reviewed - 4/21/11

Background and General Information 

Percutaneously placed, central intravenous catheters (PICC) are an important part of neonatal patient management at the University of Iowa Children’s Hospital and elsewhere. They have proven valuable in helping to provide adequate long-term nutritional support as well as providing long-term vascular access for the administration of medications.
The risk/benefit ratio of placement and duration of central line use must always be considered on an individual basis.

Who needs a PICC line?

  • Infants who need prolonged parenteral nutrition
  • Infants needing long term intravenous drug therapy 
  • Infants needing hyperosmolar intravenous fluids or irritating medications
  • Infants with difficult or limited intravenous access

Risks of PICC line placement and use

Generally the risks of percutaneously placed intravascular central catheters are lower than those of catheters placed surgically. Risks include but are not limited to:

  • Catheter sepsis – Infection is the most common complication from the use of PICC lines.  It is more common in the smallest and most premature infants at the time of insertion.  Catheter insertion should be delayed, if possible, in infants with positive blood cultures until a negative culture is obtained.  Catheters already in place in an infant who develops a blood stream infection should have their PICC line removed if the infection cannot be cleared. Removal of the line is considered for blood cultures growing S. aureus, gram negative organisms, or candida species.
  • Phlebitis.  Mechanical phlebitis may occur in the first few days after insertion and is often a normal response of the body to the irritation of the catheter.  Mild phlebitis, (mild erythema and/or edema) can be managed with warm dry compress in infants with intact skin, and extremity elevation.  If phlebitis is severe, (streak formation, palpable venous cord, and/or purulent drainage) or if there are signs of catheter related infection the line will likely need to be removed.  Please discuss removal with supervising physician.
  • Catheter migration or malposition and vessel erosion.  This can occur during insertion or at anytime during the catheter dwell time. Consequences of malposition or erosion in the infant are dependant on the site of the tip location and can include: pericardial, pleural or peritoneal effusion, cardiac arrhythmias, tissue extravasation/infiltration or migration into small vessels.

Initial confirmation of PICC line tip location

  • Upper extremity vessel:  Obtain an A/P chest X-ray with the arms in adduction and the head turned away from the side of placement.  Successful central placement in the superior vena cava, (SVC) is above the pericardial reflection line.  If the tip cannot be clearly visualized a right posterior oblique film, 20 degrees off midline) should be taken.
  • Lower extremity vessel:  Obtain two X-ray views of the abdomen, one A/P and one cross table lateral. Successful central tip placement is in the inferior vena cava, (IVC)
  • A neonatologist and nurse practitioner, or at least 2 medical team members should evaluate the X-rays to confirmed line placement.  Location of the catheter tip must be documented in the procedure note. 

Monitoring PICC line tip location during line maintenance:

  • Weekly and as needed monitoring of PICC lines with appropriate X-ray studies with discussion of current tip location in rounds and documentation when appropriate in the progress note.
  • Documentation of tip location when seen on routine X-rays in progress notes.

Catheter dysfunction:

  • Characterized by inability to infuse fluids, withdraw blood or the leaking of fluid.
  • May be caused by malposition, thrombosis, presence of precipitates, lipid deposits, or mechanical issues, (e.g., patient positioning, dressing too tight).
  • If cause cannot be resolved the line should be removed after discussion with NNP, Neonatal Fellow or Staff.

Catheter Breakage:

  • Can be severed by the introducer needle during insertion, snap because of excessive tension or rupture because of excessive pressure.  The intravascular portion of the catheter is at risk of embolization.
  • In the event of breakage; grasp and secure the exposed portion of the catheter to prevent migration.  If there is no exposed portion apply pressure over the venous tract above the insertion site, immobilize the infant and obtain an X-ray.  Staff Neonatologist and Pediatric Surgery should be notified for intervention.
  • Damaged or broken catheters must be removed and replaced.  Repaired catheters and replaced catheters over a guidewire place the patient at increased risk for infection and embolization.  If no other options are available a repaired catheter should be considered temporary.
  • Prophylactic antibiotic coverage should be considered.

Tethered Catheter:

  • Difficulty removing a catheter may be due to formation of a fibrin sheath or secondary to sepsis.
  • Limit the number of attempts to remove the catheter by experienced personnel to two.
  • Reposition the limb to minimize bends in the catheter and slowly remove the catheter.
  • Inject saline into the catheter while slowly removing the catheter.
  • Application of warm, dry heat over the catheter tract and insertion site for 20 minutes may decrease encountered resistance due to venospasm.  Avoid direct pressure on the insertion site and catheter tract during removal to help avoid venospasm.
  • Notify surgery and the attending Neonatologist for all incidents that involve catheters that have a history of dysfunction and can’t be removed by the usual traction force.
  • Inform the family that the PICC line may be required to be surgically removed

Catheter Placement Procedure

  • PICC line catheters in the NICU are placed by trained professionals who meet ongoing competency requirements.  In our NICU these professionals include Neonatologists, Neonatology Fellows and Nurse Practitioners.
  • Parents are informed about the needs, risks and alternatives for the procedure.
  • PICC line appropriate fluids are ordered and are on the unit
  • A time out procedure form is completed.
  • Consideration is given to pain control options appropriate for the infant.
  • An introducer and catheter kit are obtained from the Omnicell under the patient’s name.  Unused kits and introducers are replaced in the Omnicell and credited under the patient’s name.
  • A PICC line cart with additional line placement and dressing supplies is brought to the patient room for easy access.
  • Hand washing and sanitizing is completed.
  • Vein selection typically involves the basilic, cephalic, saphenous, popliteal, external jugular, temporal and post auricular veins. Catheterization success is highest in veins that have not previously been used for peripheral IV’s. The length of catheter needed is measured on the infant with a paper tape measure in centimeters prior to scrubbing the site and donning sterile attire.
  • Maintain sterile technique. Everyone wears a hat and mask.  The LIP/Physician and assistant wear sterile gowns and gloves in addition to hats and masks with eye shield recommended for the inserter.
  • Catheters are cut prior to insertion to the proper length to minimize problems associated with migration. The guillotine razor found in the catheter kit is used to cut the catheter. 
  • Follow manufacturer’s instructions for insertion and use Betadine scrub if infant is less than 2 months of age and 2% chlorhexidine gluconate for infants greater than 2 months.  A large body drape is used to maintain sterile technique.  Dress site according to unit recommendations.  Run normal saline through line at 2 ml per hour until central tip placement is confirmed.
  • Confirm central placement with appropriate X-rays and have second member of the medical team confirm.  Inform nursing staff the line can be used as planned and complete the “blue card” Keep me Safe! I Have a Central Line.”
  • Complete procedure note.  A note should be completed even if the attempt was unsuccessful.
  • Complete charge form regardless if the procedure was successful or not.

Care and Use of Percutaneous Central Catheters

  • Dressings should remain intact at all times after line placement.  Dressings should be changed by a trained team member from the nursing/ARNP/physician staff if non-secure or sterility is questioned.
  • IV fluids infusing in a PICC line should contain heparin usually at a concentration of 0.25 units per ml of fluid if the rate is greater than or equal to 2ml per hour and 0.5 units per ml if the rate is less than 2ml per hour.  Total heparin received by an infant in 24 hours should not exceed 100units/kg/day.
  • Maximum fluid rates for each type of catheter are recommended by the manufacturer and should be considered before line placement.
  • When a PICC line is used for nutritional purposes, glucose concentrations up to 25% may be used to provide adequate calories if the catheter has been successfully placed in the vena cava. However, in doing so one should try to use less concentrated dextrose solutions since the risk of thrombosis goes up with the use of increasingly hyperosmolar solutions. Attempts should be made to fully utilize other less hyperosmolar means of providing calories. This might include using lipid solution to provide additional calories and/or to use a faster rate of infusion with a less concentrated dextrose solution. These considerations should be evaluated on a continuing basis. When central placement is not achieved in the vena cava dextrose concentration should be kept at 12.5% or less.
  • When PICC lines are used for medications careful attention must be paid to fluid compatibilities. To prevent contamination of the line enter the line only when absolutely necessary and maintain sterility.
  • PICC lines should not be used for routine lab draws or to give a red blood cell transfusion due to increased risk of infection, clotting of the line and hemolysis of red blood cells.
  • A notation of PICC line tip location should be documented in the daily note if visible on X-ray.
  • A PICC line should be removed as soon as it is safe to do so.  If total fluid intake is 100ml/kg/day by any other route and tolerated, and if the line is no longer needed for medication administration the line can be removed.
  • A nurse practitioner or a physician may remove a PICC line.  A Central Line Removal procedure note must be completed.  At the time of its removal, the length of the catheter from its tip to entry point into the plastic hub should be measured and compared to the placement procedure note and recorded in the removal procedure note. Discrepancies should be discussed with the supervising physician if breakage is a concern.
  • Always consider the PICC line as a source of infection or complication with any clinical deterioration in the infant.
  • If repair of a PICC line is considered and possible it should be discussed with the supervising physician and performed under sterile technique according to the manufacturer’s recommendations

References

  1. Coit AK, Kamitsuka MD; Pediatrix Medical Group. Peripherally inserted central catheter using the saphenous vein: importance of two-view radiographs to determine the tip location. J Perinatol. 2005 Oct;25(10):674-6
  2. Harako ME, Nguyen TH, AJ Cohen.  Optimizing the patient positioning for PICC line tip determination.  Emerg Radiol 2004;10:186-189.
  3. Hogan MJ.  Neonatal vascular catheters and their complications.  Radiol Clin North Am 1999;37:1109-1125.
  4. MacDonald, MG, Ramasethu, J. editors. 2002.  Atlas of Procedures in Neonatology
  5. Nadroo AM, Lin J, Green RS, Magid MS, IR Holzman.  Death as a complication of peripherally inserted central catheters in neonates.  J Pediatr 2001;138:599-601.
  6. Pettit J, M Mason-Wyckoff.  2001 Peripherally Inserted Central Catheters:  Guideline for Practice.  National Association of Neonatal Nurses.
  7. Standards of Practice-Department of Nursing, University of Iowa Hospital and Clinics, Children’s and Women’s Services, Policies and Procedures. N-CWS-PEDS-08.055.  Central Catheters-Pediatric Bundle.  Also 08.060, 08.130, 08-140.  N-07.050 and IC-02.000.

Reviewed 4/2011. A. Gronstal ARNP, M. Lofgren ARNP, J. Klein MD, J. Dagle MD