• Total/partial parenteral nutrition
• Concentrated (>12.5%) glucose infusions
• Infusions of glucose >5% + calcium gluconate 
• Inotrope infusions
• Prolonged drug or fluid administration where peripheral access is difficult

• Infection at proposed insertion site
• Systemic sepsis: defer until sepsis treatment commenced and blood cultures negative
• Tissue perfusion concerns 

• Sterile gown and gloves 
• Cleaning solution as per unit policy 
• Sodium chloride 0.9% for injection
• Tape measure
• Overhead light
• Neonatal long line – appropriate for size of baby and expected rate of infusion
• Decide whether double or single lumen line required
• Long line insertion pack or, if not available, individual items to include:
  
  • dressing pack with swabs and plastic dish 
  • sterile towels/sheets
  • non-toothed forceps
  • 5–10 mL syringe
  • Steri-Strip™
  • sterile scissors
  • clear dressing (e.g. Tegaderm™/Opsite)

Consent and preaparation

• Inform parents and obtain verbal consent as recommended by BAPM
• Use 2-person technique with assistant observing the procedure
• Discuss timing of procedure with nurses
• Keep baby warm, work through portholes
• Identify site of insertion
  
  • typically long saphenous at ankle or medial/lateral antecubital vein at elbow
  • where access difficult, other large peripheral veins or scalp veins anterior to ear may be used
  • right long saphenous vein is preferable to the left – latter more commonly associated with malposition in the left ascending lumbar vein leading to risk of extravasation of PN into CSF
• Measure distance, aiming to insert tip of catheter into superior or inferior vena cava (to upper sternum for upper limb insertion or to xiphisternum for lower limb insertion)

Developmental care

• Unless contraindicated, give sucrose or breast milk and non-nutritive sucking [see Non-nutritive sucking (NNS) guideline]
• Shield baby’s eyes from bright light
• Second person to provide containment holding (see Pain assessment and management guideline)

Aseptic insertion

• Maintain strict asepsis throughout
• Prime catheter and cut small piece of gauze for under hub
• Clean site and allow to dry. Ensure that cleaning fluid does not pool beneath baby
• Puncture site with needle from pack and follow instructions for the catheter
• Avoid use of cannulae for long line insertion
• When blood flows back through the needle, insert line using non-toothed forceps
• If appropriately placed, the line will pass easily beyond the tip of the needle
• Release tourniquet if used
• There may be some resistance when the line passes joints, such as knee, and gentle repositioning of baby’s limb may help
• Should catheter advancement become difficult, infuse a little fluid whilst simultaneously advancing catheter
• Never withdraw catheter back through needle
• When in place, withdraw needle as stated in catheter instructions
• Catheter should allow free aspiration of blood in the final position
  
  • with small size catheter (1 Fr), there may not be aspiration of blood into the syringe, however blood should appear in the catheter

Securing catheter

• Aim to minimize the risk of injury to the skin and potential catheter migration 
• When haemostasis achieved, fix with Steri-Strips™. Place small piece of gauze under hub, and cover with Tegaderm™/Opsite, making sure that all dressing and site is covered, but not encircling the limb tightly. Ensure line insertion site is visible through clear dressing
• Connect a sterile 5 mL syringe containing sodium chloride 0.9% and infuse at 0.5 mL/hr while awaiting X-ray, to ensure that the line does not clot off

Determining catheter position

• X-ray to determine position
  
  • aim is to view full length of line
  • request chest/abdominal X-ray (including upper/lower limb requests as per local policy) 
• If inserted in upper limb, ensure arm is at 90° angle to thorax during X-ray
• Small gauge neonatal long lines can be difficult to see on plain X-ray
• Use X-ray magnification, contrast adjustment and inversion to aid process
• Use of radiopaque contrast medium may help in detection of some malpositioned catheters, but cannot guarantee catheter correctly sited. Refer to local policy
• After any adjustment of catheter, repeat X-ray to confirm catheter tip position
  
  • post-processing radiograph should be available with the X-ray to help identify tip of catheter
• Upper limb catheter
  
  • tip should preferably be in superior vena cava when the corresponding arm positioned perpendicular to the chest wall, but other large veins e.g. innominate, subclavian are acceptable
  • ensure tip of catheter crosses shoulder joint 
  • if any concern regarding possibility of malposition of catheter continue to infuse with sodium chloride 0.9% 0.5 mL/hr and seek consultant review
• Lower limb catheter 
  
  • tip should ideally be in inferior vena cava above L4–L5
  • left saphenous PICC should cross the midline at L4/L5 and run to the right side of the vertebral column in the IVC with the tip outside the heart
  • if catheter does not cross the midline or has a tortuous course the line may be in a small vessel. Lateral X-ray will demonstrate posterior deviation of the line towards the vertebral column 
  • if malposition suspected continue to infuse with sodium chloride 0.9% 0.5 mL/hr and seek consultant review of X-ray
• Catheter tips in axillary, cephalic and femoral veins are acceptable if the benefit outweighs increased risks of reinsertion. Discuss with consultant before connecting PN to line
• Monitor site closely
• If catheter tip beyond desired location, using aseptic technique, remove dressing and withdraw catheter the measured distance. Redress with new sterile dressing and confirm new position by X-ray

Failure of insertion

• If second operator is required following an unsuccessful attempt at placement, use fresh equipment 

• Record in case notes:
  
  • date and time of insertion
  • success of insertion and number of attempts 
  • type and gauge of catheter
  • site and length of insertion
  • X-ray position and alterations
• Consultant neonatologist/paediatrician to verify position within 24 hr of insertion
• Insert tracking stickers from all packs

Dressings and site care

• Routine dressing changes are unnecessary
• Replace aseptically only if dressings lift or catheter visibly kinked or becomes insecure
• Observe site every shift for bleeding, leaking of infusate and signs of infection (redness, swelling) and document in daily care summary

Line management and medication

• Minimise number of line breaks
• Intermittent medications only given via this route in extreme circumstances. (This is a senior medical decision). Plan timing to match infusion changes
• When breaking into line, observe hand hygiene, wear sterile gloves and clean connection as per local infection control policy
• Change tubing used to give blood products immediately after transfusion (use to give blood product only if it is difficult to insert alternative IV line)

Position mangement

• Repeat X-ray weekly to detect line migration
• Never routinely resite a line
• Review continued need on daily ward rounds and remove as soon as possible
• Comment on line position: 
  
  • when bedside ECHO undertaken or
  • if X-ray taken for any other reason  

Clinical deterioration of a baby in whom a central venous catheter is present should raise the question of catheter related complications, particularly infection, extravasation and tamponade

Prevention

• Do not give blood products and medications routinely through long line
• Avoid the use of small syringes (<2 mL) for bolus injections – generate high pressures which may result in catheter damage
• Avoid the use of alcohol or acetone to clean the catheter –  may result in catheter damage
• Limit line breaks as above
• Do not exceed pressure limits given by manufacturer –  risk of damage to the line

Catheter-related sepsis

• Commonest complication

• See Infection (late onset) guideline 

Extravasation of fluids

• Into pleural, peritoneal, pericardial (above) and subcutaneous compartments 
• Seek immediate advice from senior colleagues and follow Extravasation injuries guideline

Extravasation to CSF

• Most commonly associated with catheters placed in long saphenous vein
• Can cause varying neurological signs including irritability, abnormal movements, seizures and hypotonia
• Production of lipaemic fluid (either white “milky” coloured fluid or fluid with a high triglyceride content) is pathological and suggests this complication

Suspected/proven pericardial tamponade

• Suspect if any of the following symptoms: 
  
  • acute or refractory hypotension
  • acute respiratory deterioration
  • arrhythmias
  • tachycardia/persistent bradycardia
  • unexplained metabolic acidosis
• Have high suspicion in baby with acute deterioration; act quickly – associated with high morbidity and mortality
• Confirm by X-ray (widened mediastinum, enlarged cardiac shadow) or by presence of pericardial fluid on echocardiogram
• Drain pericardial fluid (see Pericardiocentesis guideline) and remove catheter

Embolisation of catheter fragments

• Lines can snap if anchored within a thrombus
• If undue resistance encountered during removal, do not force
• Inform consultant; if accessible it may need surgical removal

Indications

• Clinical use is no longer justified
• Currently no evidence for early elective removal of the line and replacing it to prevent infection
• Remove 24 hr after stopping parenteral nutrition to ensure tolerance to full enteral feeds, running glucose 10% through line at 0.5 mL/hr to maintain patency
• Complications – see Complications

Technique

• Using aseptic technique:
  
  • remove adhesive dressing very carefully
  • pull line out slowly, using gentle traction in the direction of the vein, grasping line not hub
  • ensure catheter complete
  • if clinical suspicion of line infection, send tip for culture and sensitivity
  • apply pressure to achieve haemostasis
  • document removal in notes