Iowa Neonatology Handbook: Procedures

Percutaneous Placement of Central Venous Catheters

Iowa Neonatology Fellows
Peer Review Status: Internally Peer Reviewed

I. Background and General Information: 

A. Percutaneously placed, central intravenous catheters have become an important part of neonatal patient management over the past several years at the University of Iowa and elsewhere. They have proved of value in helping to provide adequate long-term nutritional support as well as providing long-term vascular access for the administration of medications such as antibiotics and prostaglandin E1. The risks of percutaneous, and intravascular central catheters are lower than those of catheters placed surgically. These include local or systemic infection, and thrombosis with or without infiltration. Manifestations of the latter include redness or swelling of an extremity, the chest wall, and/or the neck. 

B. When used for nutritional purposes, glucose concentration up to 25% may be used to provide adequate calories if the catheter has been successfully placed in the vena cava or right atrium. 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. 

II. Catheterization Procedure:

Commonly used sites for catheterization include the basilic, cephalic, saphenous popliteal, external jugular, and temporal veins. (The vessels with the highest success rate of catheterization are those which have not been previously used for peripheral IV's.) Cap, mask, sterile gloves and sterile gown are worn by the operator (mask only by nurse assistant), and the procedure is performed aseptically. Ideally the catheter tip should lie a few centimeters from the right atrium. This can be estimated by knowing the catheter length and how far from its insertion site it needs to be threaded. To confirm this, a post-insertion AP x-ray will be taken and the tip identified. The x-ray to be ordered for most catheters is a single AP view of the lower chest and upper abdomen. 

III. Care of Percutaneous Central Catheters: 

A. IV fluids need not contain heparin if the flow rate is 5 ml/hr or greater; if flow rate is < 5 ml/hr fluid should contain heparin, usually at a concentration of 0.25 - 0.5 unit/ml, but at a rate not to exceed 100 U/kg day; (50 U/kg/day in infants <1000 g). 

B. Initial IV fluids should contain dextrose at a concentration not greater than 10%; if the catheter tip is positioned in a central vein ,the dextrose concentration may be advanced slowly to as high as 25% (see A above). 

C. IV rates should be kept at 3 ml/hr or greater, and less than that recommended by the catheter manufacturer (generally <20 ml/hr for a 27 or 28-gauge catheter) 

D. 24-gauge silastic catheters may be repaired by cutting the hub and cannulating the catheter with a 28-gauge blunt needle. This should be done with sterile technique. 27 and 28-gauge catheters cannot be repaired. The dressing is not routinely changed. 

E. Blood samples should not be drawn through the catheter. If suspicions occur regarding the need to remove the catheter or if other questions about the catheter arise, consult a nurse or physician member of the Neonatal Percutaneous Central Catheter Team. 

F. More detailed nursing instructions for the placement, care and handling of the catheter are available on the NICU in the Policy and Procedure Manual. 

G. Removal of a percutaneous central catheter should be performed by a nurse or physician member of the Percutaneous Central Catheter Team, if possible. 

H. 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 recorded on the special form in the patient's chart. 

IV. Requesting Placement of Central catheters by Patient's Physician:

A. Requests for central line placement can be made by consulting a member of the Neonatal Percutaneous Central Catheter Team. (This needs to be followed by a written order.) A Catheter Team member will inspect the patient's veins for suitability of catheter placement and report his/her impression to the resident, fellow or staff physician making the request. If the patient appears suitable the following need to be done by the patient's physician in coordination with the physician placing the catheter: 

1. schedule the date and time of the procedure with a Catheter Team member;

2. order IV solution and have present on unit.

3. discuss procedure with patient's parent(s).

B. Responsibilities of the Percutaneous Catheter Team include:

1. answering additional questions parents may have after their discussion with their baby's primary physician;

2. order and examine chest x-ray following catheterization procedure

3. put procedure note in Progress Notes and fill out Percutaneous Line Consult Sheet.

4. discuss results of procedure with baby's primary physician.

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