Includes: different methods of venous access, CDC guidelines for prevention of catheter-related infections as well as precautions for umbilical catheters use .. Prepared by Dr. Maged Zakaria, NICU Resident, Ain-Shams University Maternity Hospital

1. Central Venous Catheters
Consultant Neonatologist,
Head of the NICU Ain-Shams University Maternity Hospital

2. What is meant by a central line?
 It’s an intravascular catheter that terminates at or close to the heart
or in one of the great vessels which is used for infusion, withdrawal
of blood, or hemodynamic monitoring.
 The following are considered great vessels:
1. Aorta
2. Pulmonary artery
3. SVC and IVC
4. Brachiocephalic veins
5. Internal jugular veins
6. Subclavian veins
7. External iliac veins
8. Common femoral veins
9. In neonates, Umbilical arteries and vein.

3. Methods of Vascular Access
 Cutdown or Open Surgical Technique
 Advantages
 Allows insertion of larger silicone catheter (3 or 4.2 Fr)
 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.
 Disadvantages
 Requires general anesthesia/IV sedation
 Requires surgical incision
 Vein is often ligated, so it cannot be reused in the future.
 Potential for injury to adjacent anatomical structures
 Increased potential for wound infection
 An operating room is the ideal setting for the procedure, so risks of
transport of critically ill neonates need to be taken into consideration.

4. Methods of Vascular Access
 Percutaneous Technique (PICC)
 Advantages
 Simple and relatively rapid
 May not require sedation
 Vessel is not ligated as in open cutdown methods
 Decreased potential for wound infection
 Disadvantages
 A blind technique beyond the initial insertion.
 Smaller-caliber catheter may preclude use for blood transfusions
 Injury to adjacent anatomic structures

5. Common Indications
Long-term IV medication or TPN administration
(usually more than 2 weeks)
Administration of hypertonic IVF (i.e. 15-25%
dextrose and 5-6% aminoacids) that cannot be
administered through peripheral IV cannulas

6. Contraindications of CVC
Absolute
 Skin infection at insertion site
Relative
 Uncorrected bleeding abnormalities (but this is not a
contraindication for PICC)
 The patient can be treated adequately with
peripheral IV access.

7. Position of Catheter Tip
 The catheter tip should be
1. Within the SVC or IVC
2. 1 cm outside the cardiac shadow in preterm neonates
3. 2 cm outside the cardiac shadow in term neonates
 When inserted from the upper extremity, the tip
should be in the SVC, outside the cardiac shadow
and above the T2 vertebra.
 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.

8. Position of Catheter Tip
 The catheter tip should be
1. Within the SVC or IVC
2.
3.
The tip of the catheter
1 cm outside the cardiac shadow in preterm neonates
2 cm outside the cardiac shadow in term neonates
shouldthe SVC, outside the cardiac shadow
be at the junction
 When inserted from the upper extremity, the tip
should be in
and above the vena cava and the
of insertedT2 vertebra. extremity, the catheter
the from the lower
 When
tip should be right atrium
above the L4/ L5 vertebrae or the iliac
crest, but not in the heart.

9. Position of Catheter Tip
 Chest radiograph with
PICC tip in appropriate
position, just above
junction of superior vena
cava and right atrium.

10. Complications of Central Venous Lines
 Infection (most common complication)
 Catheter-related sepsis range from 0-29% of lines placed and from 2-
49 per 1,000 catheter days, with the smallest and most immature
infants being at greatest risk.
 Strict aseptic protocols for central line care are recommended to
decrease the rate of infection.
 Management of catheter-related sepsis:
1. Remove CVC for Staph. aureus, gram-negative, or Candida sepsis.
2. Treatment with appropriate antibiotics without removal of the
line may be attempted but repeated positive cultures mandate
removal of the line.

11. Guidelines for the Prevention
of Intravascular Catheter-
Related Infections

12. Hand Hygiene
 Wash hands with conventional antiseptic-containing
soap and water or with waterless alcohol-based gels.
 When?
1. Before and after palpating catheter insertion sites
2. Before and after inserting, replacing, accessing,
repairing, or dressing an intravascular catheter.
 Palpation of the insertion site should not be performed
after the application of antiseptic, unless aseptic
technique is maintained
 Use of gloves does not obviate the need for hand hygiene

13. Aseptic Technique During Catheter Insertion And Care
 Wear clean or sterile gloves when inserting an
intravascular catheter in general.
 Wearing clean gloves rather than sterile gloves is
acceptable for the insertion of peripheral intravascular
catheters if the access site is not touched after the
application of skin antiseptics.
 Sterile gloves should be worn for the insertion of arterial
and central catheters
 Wear clean or sterile gloves when changing the dressing
on intravascular catheters

14. Sterile Dressing
For Surgically Placed Central Venous Lines
Routine changing
of CVC dressings
depends on the
type of dressing:
1. Transparent
dressings should be
changed at least
every 7 days

15. Sterile Dressing
For Surgically Placed Central Venous Lines
Routine changing
of CVC dressings
depends on the
type of dressing:
1. Transparent
dressings should be
changed at least
every 7 days
2. Gauze dressings
should be changed
every 2 days.

16. Sterile Dressing
For Surgically Placed Central Venous Lines
Routine changing
of CVC dressings
depends on the
type of dressing:
1. Transparent
dressings should be
changed at least
every 7 days
2. Gauze dressings
should be changed
every 2 days.
3. All dressings should
be changed when
loose, or soiled.

17. Replacement of the Administration sets
 Replace administration sets no more frequently than at
72-hour intervals, unless catheter-related infection is
suspected or documented
 Replace tubing used to administer blood, blood products,
or lipid emulsions (those combined with amino acids and
glucose i.e. TPN) within 24 hours of initiating the
infusion.
 If the solution contains only dextrose and amino acids,
the administration set does not need to be replaced more
frequently than every 72 hours

18. Parenteral Fluids
 Complete the infusion of lipid-containing solutions
within 24 hours of hanging the solution
 Complete infusions of blood or other blood products
within 4 hours of hanging the blood
 No recommendation can be made for the hang time
of other parenteral fluids. Unresolved issue

19. Injection Ports
 Clean injection ports with 70% alcohol before
accessing the system.
 Cap all stopcocks when not in use.

21. Ensure that all
components of the
system are
compatible to
minimize leaks and
breaks in the system
Minimize
contamination risk by
wiping the access port
with an appropriate
antiseptic and
accessing the port Needle-Free IV Access Device
only with sterile
devices

22. Preparation and Quality Control of IV Admixtures
 Admix all routine parenteral fluids in the pharmacy in a laminar-flow hood
using aseptic technique
 Do not use any container of parenteral fluid that has visible turbidity, leaks,
cracks, or particulate matter or if the expiration date has passed
 Use single-dose vials for parenteral additives or medications when possible
 Do not combine the leftover content of single-use ampoules for later use
 If multi-dose vials are used
1. Refrigerate after they are opened if recommended by the manufacturer.
2. Cleanse the access diaphragm with 70% alcohol before inserting a device
into the vial
3. Use a sterile device to access a multidose vial
4. Avoid touch contamination of the device before penetration
5. Discard multidose vial if sterility is compromised

23. Complications of Central Venous Lines
 Damage to vessels and organs during insertion
 Bleeding, pneumothorax, pneumomediastinum, hemothorax, arterial
puncture, and brachial plexus injury
 Phlebitis
 Mechanical phlebitis may occur in the first 24 hours after line
placement as a normal response of the body to the irritation of the
catheter in the vein
 Management of mild phlebitis (mild erythema and/or edema): Apply
moist, warm compress, and elevate extremity
 Remove the catheter if symptoms do not improve, if phlebitis is
severe (streak formation, palpable venous cord, and/or purulent
drainage), or if there are signs of a catheter-related infection

24. Complications of Central Venous Lines
 Catheter migration/malposition
 Occur during insertion when the catheter enter a side vein or
reverse direction or from spontaneous migration at any time.
 The decision to remove the catheter or attempt to correct the
position is based on the location of the tip. Although PICCs are
intended to be placed in central veins, occasionally, the tip is in
a non-central location (e.g. in the SCV). These non-central
PICCs may be used temporarily, provided the fluids
administered through them are isotonic.

25. Complications of Central Venous Lines
 Catheter migration/malposition
 Pull catheter backwards if the tip is in the heart to avoid
serious consequences such as cardiac arrhythmia, perforation,
or pericardial effusion.
 If the tip of the catheter is looped into the IJV or in the
contralateral brachiocephalic vein, the catheter may be used
temporarily (using isotonic fluids that are suitable for
peripheral venous cannulae) and re-evaluated radiologically in
24 hours. If the catheter has not moved spontaneously into the
desired location, it should be removed.

26. Malpositions of Subclavian Venous Catheters
 Catheter is in Jugular
Vein

27. Malpositions of Subclavian Venous Catheters
 Catheter is looped in
right atrium and tip is in
the SVC !!

28. Malpositions of Subclavian Venous Catheters
 Catheter is looped in the
SVC

29. Malpositions of Subclavian Venous Catheters
 Catheter is knotted in the
left atrium.

30. Complications of Central Venous Lines
 Thrombosis and Thromboembolism
 About 90% of venous thromboembolic events in neonates are
associated with CVC, include:
 DVT
 SVC syndrome
 Intra-cardiac thrombus
 Pulmonary embolism
 Renal vein thrombosis
 Management of thromboembolism in neonates is controversial.
 The severity of thrombosis and the potential risk to organs or limbs
dictate the degree of intervention required, including the use of
thrombolytic/anticoagulant therapy or surgical intervention.

31. Complications of Central Venous Lines
 Prevention and treatment of Thrombosis
Heparin (5000 u/mL)
To maintain patency of peripheral and central vascular catheters: 0.5-1 u/mL of IVF.
Treatment of Thrombosis: 75 u/kg bolus, followed by 28 u/kg/h IVI. Measure aPTT 4h
after initiating therapy, then adjust dose to achieve aPTT of 60-85 seconds. Limit
treatment to 10-14 days

Side Effects and Contraindications
Heparin-induced thrombocytopenia 1% (check platelets /2-3 days)
Osteoporosis (with long-term use)
Contraindicated in infants with evidence of intracranial or GI bleeding or
thrombocytopenia (<50.000/mm3).

32. PRBCs transfusions should be given through a CVC only in
Do not utilize CVC for routine blood sampling
an emergency, as this procedure may cause occlusion or
hemolysis when older blood is used.
A peripheral IV cannula should be utilized for blood transfusions

33. Complications of Central Venous Lines
 Extravascular Collection of Fluid
 Pleural effusion
 Mediastinal extravasation
 Hemothorax
 Chylothorax
 Ascites

34. Complications of Central Venous Lines
Pericardial effusion with or without cardiac tamponade
 Presented as :
1. Sudden collapse or unexplained
cardio-respiratory instability
2.Increased cardiothoracic ratio
3.Pulsus paradoxus
 Immediate
pericardiocentesis may be
life-saving. Echocardiogram image of a PT infant
with pericardial effusion and CVC in LA

35. Pulsus paradoxus is
caused by the normal
slight decrease in
systolic arterial
pressure during
inspiration.
With cardiac
tamponade, this is
exaggerated, because
of decreased filling of
the left side of the
heart with the
inspiratory phase of
respiration. Pulsus Paradoxus

37. The ideal location of
the tip of the umbilical
catheter is T9–10, just
above the right
hemidiaphragm and
below the heart.

38. The ideal location of
the tip of the umbilical
catheter is T9–10, just
above the right
hemidiaphragm and
below the heart.
On a radiograph, the
catheter will lie to the
right of the vertebral
column in the inferior
vena cava.

39. o Note how the UVC swings
immediately superior from the
umbilicus, slightly to the right as
it traverses the ductus venosus
into the (IVC).
oThe distal tip of this line is just
superior to the right atrial-IVC
junction, and it might optimally
be pulled back slightly into the
IVC.
oNote how the thinner UAC
(arrows) heads inferiorly as it
proceeds to the iliac artery and
then ascends posteriorly and to
the left until it reaches the level of
D7.
The normal course of an UVC, with an UAC (arrows) in position for comparison.

40. Recommendations for Umbilical Catheters
Replacement of Catheters
 Remove and do not replace UACs with any signs of
CRBSI, vascular insufficiency or thrombosis.
 Remove and do not replace UVCs if any signs of
CRBSI or thrombosis are present
 Replace UVCs only if the catheter malfunctions.

41. Recommendations for Umbilical Catheters
Catheter-site Care
 Cleanse the umbilical insertion site with an antiseptic before catheter
insertion, povidone-iodine can be used.
 Don’t use topical antibiotic ointment or creams on umbilical catheter
insertion sites because of the potential to promote fungal infections and
antimicrobial resistance.
 Add low doses of heparin (0.5--1.0 u/ml) to the fluid infused through
UACs.
 Remove umbilical catheters as soon as possible when no longer needed or
when any sign of vascular insufficiency to the lower extremities is observed.
 Optimally, UACs should not be left in place >5 days
 UVCs should be removed as soon as possible when no longer needed but
can be used up to 14 days if managed aseptically.

42. Securing Lines
Umbilical Lines Secured Umbilical Lines secured
by a bridge with transparent dressing

43. Catheter Removal
Indications
 Patient's condition no longer necessitates use.
 Occluded catheter
 Local infection/phlebitis
 Sepsis and/or positive blood cultures obtained
through the catheter (catheter colonization).
Rarely, a catheter is left in place despite sepsis with antibiotic or antifungal
therapy is administered through it to clear the infection, however this may
be associated with an increased risk of morbidity and mortality

44. Catheter Removal
Technique
 Remove dressing
 Pull catheter from vessel slowly over 2 to 3 minutes.
 Apply continuous pressure to the catheter insertion site for 5
to 10 minutes, until no bleeding is noted.
 Inspect catheter (without contaminating tip) to ensure that
entire length has been removed.
 Send catheter to lab for culture and sensitivity.
 If desired, antibiotic ointment may be placed over site.
 Dress with small, self-adhesive bandage or gauze pad and
inspect daily until healing occurs.