Precautions for Central Venous Catheters in Neonates

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

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.

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.

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

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

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.

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.

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.

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

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.

Guidelines for the Prevention of Intravascular Catheter- Related Infections

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

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

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

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.

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.

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

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

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

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

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

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

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.

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.

Malpositions of Subclavian Venous Catheters  Catheter is in Jugular Vein

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

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

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

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.

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).

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

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

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

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

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

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.

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.

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.

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.

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

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

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.

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Precautions for Central Venous Catheters in Neonates

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