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Standard operating procedure for the insertion and maintenance of peripherally inserted central (PIC) lines in neonates
Author: Dr Sharon English

Submission date: 4th March 2014

Review date: 3 years
Aims

To standardise and optimise the insertion and management of peripherally inserted central (PIC) lines in neonates, and to reduce the rate of PIC line related bacteraemia.


Introduction

PIC lines are used extensively in neonates for the administration of fluids, parenteral nutrition and drugs. They are often used for extended periods of time, and there is a high risk of bacterial colonisation and consequent bacteraemia. The importance of asepsis, correct insertion technique and good post insertion care cannot be overemphasised.


Indications for PIC lines

  • Administration of TPN or glucose infusions with >12.5% glucose concentration

  • Administration of drugs that should be infused centrally e.g. inotropes

  • Predicted long standing need for IV access where repeated cannulation may be difficult and traumatic e.g. long courses of antibiotics >5 days, dinoprostone / alprostadil infusions


Preparation

Each operator must have an assistant/observer at the bedside. You must use the Matching Michigan checklist (Appendix 1) and refer to the Neonatal Procedures hand book for insertion technique. Please ensure that the infant has received the appropriate pain relief prior to the procedure. Where time allows the baby should have topical anaesthesia applied (Ametop®(tetracaine 4%)) 30 minutes prior to the procedure. Oral sucrose 24% should also be given in non-sedated babies unless contraindicated. Please refer to procedural pain guideline: http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=797

Remember to accurately measure required line length before embarking on procedure. For insertion in an upper limb or scalp vein, measure from the site of insertion to the sternal notch. For insertion in a lower limb vein, measure from the site of insertion to the xiphisternum.
Competence

All doctors, regardless of level of training, who are required to insert a PIC line, must be signed off as competent by the PIC line team (Appendix 2) before inserting lines without supervision. You will need to be signed off for two successful insertions. If you have not been signed off you must be supervised by a member of the team. Where supervision is taking place, both operator and supervisor should be sterile, and a third person (usually the nurse looking after the baby) should be available to observe.



Attempts

An insertion attempt is defined as one needle puncture of the skin. PIC line attempts must be limited to two attempts (two needle punctures) at ST1-3 level, followed by a maximum of two attempts at ST4-8 level. After this only a member of the PIC line team should attempt line insertion. If a baby is deemed to have difficult venous access, the first attempt should be made at ST4-8 or ANNP level. For each separate attempt, the skin must be cleaned again with fresh ChloraPrep® and a new needle used.


Sterile zone

A sterile zone should be created around the bed space using screens. Both operator and assistant (where required and available) should scrub to the elbow and wear gown, gloves, surgical hat and mask. Once the operator and assistant are sterile, they should not come out of the sterile zone. If the operator or assistant leave the zone e.g. to review an X-ray, they should de-scrub and re-scrub to maintain sterility. The operator must not leave the sterile zone to go to a bin; a bucket on wheels should be available within the sterile zone. The zone should not be entered by personnel not assisting, supervising or observing the procedure


Equipment

Metal trolleys should be used, and must be decontaminated with Sani-cloth before use (see Trust IPC asepsis video http://lthweb/content/aseptic/v4/index.php ). The operator and/or assistant should prepare all necessary equipment on the clean trolley. Once the operator is sterile, if further equipment is required, the observer must fetch and open packs. The largest bore line possible should be inserted. Most infants should have the larger bore 2F/23G (Nutriline) line. 1F/27G lines (Premicaths) must be reserved for those babies <25 weeks or with particularly difficult venous access (decision to use Premicath must be made by ST4-8, ANNP or consultant)


Skin preparation
Line insertion

Refer also to the neonatal procedures online handbook for insertion technique: http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=3249




  1. Pick suitable vein (medial/lateral antecubital vein, long saphenous vein, superficial temporal)




  1. Clean site with 2% chlorhexidine/70% alcohol (ChloraPrep® Frepp 1.5ml), and allow to air dry for 30 seconds. In babies under 30 weeks gestation, use a dabbing rather than rubbing motion to maintain skin integrity. In babies < 28 weeks gestation and < 1 week old, clean skin again with sterile water, to minimise risk of skin burns. The operator must check that no cleaning solution has pooled around or underneath the baby



  1. Prepare sterile field - make hole in paper towel and put limb through hole - wrap end held by assistant in sterile gauze

  2. Assemble the long line and flush through with saline making sure there are no loose connections

  3. Place tourniquet (piece of sterile gauze) in appropriate place

  4. Identify vein

  5. Insert peelable cannula in vein. Blood will flush back identifying correct positioning




  1. Handling of the line should be kept to the minimum. The line should be fed through the butterfly or cannula using non-toothed forceps. The line should be flushed at intervals with 0.9% sodium chloride to prevent thrombus formation and to check patency of the vessel. When the line is in its final position, check that it will bleed back (essential for nutrilines only, premicaths may not bleed back) and flush with 0.9% sodium chloride.




  1. Split the peelable cannula and remove.


Dressing

Steri strips should be used to secure the line at the site of entry and a small piece of gauze to protect the skin from the hub. Prior to obtaining an X-ray the line should be coiled without kinking and should be covered in a clear dressing (e.g. tegaderm), in an aseptic manner. The sterile zone should then be covered with a sterile towel. A smart site should be attached to the end of the line, and an X-ray requested.


The operator must either remain within the sterile zone, or will need to rescrub and gown after the X-ray. If the line position needs to be adjusted, this must be done under sterile precautions. The tegaderm should be carefully removed, the skin cleaned again with ChloraPrep®, and a new dressing applied. The dressing must:

  • Fully cover the line and hub

  • Not encircle the limb

  • Be clean and intact (ie no visible blood on dressing)



Position
The tip of all PICC lines must lie outside the heart and be straight. Aim for the SVC for upper limb or scalp lines, and the IVC for lower limb lines. If the tip lies within the right atrium, it must be withdrawn so that it lies outside the heart, and the new position confirmed on X-ray. All adjustments to line position must be recorded in the notes. Please ensure that X-rays for newly inserted PICC lines are reviewed by a consultant on the next ward round. If a PICC line tip lies outside the SVC or IVC the line should be removed unless a consultant decision has been made to use it as a short long line (limit glucose content of IV fluids to 12.5%). PICC lines which take an abnormal path or where contrast does not flow towards the heart should always be removed.

If the line follows an irregular route it may have passed into superficial veins. Be aware of the risk of a saphenous vein catheter entering the ascending lumbar veins- this usually gives a “wiggly” route parallel to the vertebral column, or even a “loop the loop” in the pelvis . The line must be removed.
Nutrilines (any vein) - Nutrilines are radio-opaque and therefore contrast is not normally required unless there is doubt about the line position. After completing the procedure de-gown. If the line tip position is not clear then try image contrast inversion on PACS. If still not clear consider injection of contrast medium as below. If the PIC line is in the lower limb and has not reached the IVC, the position of the tip and direction of flow should be confirmed using contrast. If adjustment is needed then re-scrub and gown and perform as new sterile procedure.
Premicath lines (any vein) - Premicaths are more easily identified if sterile contrast medium (Omnipaque 300®) is injected prior to the X-ray. Dilute 1ml Omnipaque 300® with 1ml of 0.9% sodium chloride. Prime line with 0.2mls of diluted contrast (this is to prime the line, not to flush beyond the line). Do not flush with saline. Leave the patient area and de-scrub. Request X-ray and review on PACS as above. If position incorrect then re-scrub and adjust as a sterile procedure. Remove the tegaderm carefully, clean the skin with ChloraPrep®, adjust the line and re-cover with a clean dressing.
Please note the volume of contrast to fill the line is very small (0.2 mls)
Once the position has been confirmed place a green long line sticker in the baby’s notes. Ensure long line insertion is recorded on Badger.

Maintenance

PIC dressings should not routinely be changed. If a dressing is noted to be soiled or has separated from the skin, it should be replaced with full aseptic precautions. The skin should be cleaned with ChloraPrep®, and a new sterile dressing applied.



Accessing the line

Repeated accessing of lines increases the chances of infection, and therefore must be minimised. The line should be accessed in a strict aseptic manner. The “hub” should be cleaned with a 2% chlorhexidine wipe (Sani-Cloth GHG 2%) for 15 seconds and allowed to air dry. Any flush should be drawn up using a needle or stylet.



When to remove PIC lines

Refer also to the long line sepsis guideline: http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=654


PIC lines should be removed:

  • immediately a baby reaches full enteral feeds (NOT 24 hours later), unless being used for drugs

  • if a baby is bacteraemic and deteriorating or not improving after 48 hours of IV antibiotics

  • in cases of fungal or staphylococcus aureus bacteraemia

  • when no longer required for drug infusion

  • if the skin around the insertion site becomes inflamed or discharges

  • If there is any sign of extravasation (in this case stop any infusion immediately, X-ray the line and inform the registrar or consultant)

In a baby who deteriorates with a PIC line in situ consideration should be given to a central line complication. If there is suspicion of pleural effusions an urgent pleural tap should be performed. An ultrasound may help to guide this, but a pleural tap will be diagnostic. Abdominal ultrasound should be requested where peritoneal extravasation is suspected.


Any deviation from this should be discussed with a consultant and documented in the baby’s notes. Date and reason for PIC line removal must be recorded in baby’s notes and on Badger.
Review

This guideline will be reviewed after a further 3 years by the author. Central line infection rates are currently audited regularly, and will inform review of the guideline.


Provenance

Author: Dr Sharon English

Consultant Neonatologist

Leeds Teaching Hospitals NHS Trust

Tel: 0113 3928537

Email: Sharon.english@leedsth.nhs.uk


Procedure: PIC line insertion
Target patient group: Patients on the neonatal unit
Target professional group: Neonatal consultants, Neonatal ST1-8 trainees,

ANNPs, neonatal nursing staff




Evidence base
The majority of this guideline is based on level B evidence published in peer reviewed journals (see references). This includes the evidence for skin preparation, line position and aseptic technique. The remainder of the guideline including indications for insertion and removal of PIC lines is based on consensus opinion and current practice (level C). The guideline has been peer reviewed by all LTHT neonatal consultants, as well as a sample of ST1-8 trainees and ANNPs. It has also been reviewed by the MDT at a neonatal infection prevention and control meeting, and at the neonatal team meeting. Comments were collated by the author and changes made to the draft as appropriate. Some changes were also made to reflect recommendations following a cluster of IR1s and an IR2 regarding PIC line insertion or care, which occurred during the writing of this document.

References


  1. Stoll BJ, Gordon T, Korones SB, et al. Late-onset sepsis in very low birth weight neonates: a report from the National Institute of Child Health and Human Development Neonatal Research Network. J Pediatr 1996; 129(1):63–71.

  2. Stoll BJ, Hansen N, Fanaroff AA, et al. Late-onset sepsis in very low birth weight neonates: the experience of the NICHD Neonatal Research Network. Pediatrics 2002;110(2):285–291.

  3. Pratt RJ, Pellow Cm, Wilson JA et al. epic2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. J Hospital Infection 2007;65S:S1-S64

  4. http://www.patientsafetyfirst.nhs.uk/Content.aspx?path=/interventions/relatedprogrammes/matchingmichigan/

  5. Visscher M, deCastro MV, Combs L et al. Effect of chlorhexidine gluconate on the skin integrity at PICC line sites. J Perinatology 2009;29:802-807

  6. Bizzarro MJ, Sabo B, Noonan M et al. A quality improvement initiative to reduce central line-associated bloddstream infections in a neonatal intensive care unit. Infect Control Hosp Epidemiol 2010;31:241-248

  7. DoH. Review of four neonatal deaths due to cardiac tamponade associated with the presence of a central venous catheter: recommendations and Department of Health response. DOH 2001

This guideline incorporates and replaces the previously published guideline ‘Neonatal Long Line Placement and Position’: http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=917




Insert patient sticker here



Neonatal CVC Insertion Checklist


This checklist should be completed by an observer. The procedure must be stopped if any of these elements of this CVC care bundle checklist are not followed


Baby’s Name:

Baby’s Unit No:

Procedure:

Date:

Time:

Operator/s:

Nurse observer:

Before the procedure Yes No


1

Required equipment gathered





2

Designated trolley cleaned





3

Hat & mask worn by operator (& supervisor where applicable)





4

Hands decontaminated with soap and water





5

Sterile gown and gloves worn by operator (& supervisor where applicable





During the procedure


6

2% Chlorhexidine/70% isopropyl alcohol (Chloraprep) used for skin prep and allowed to dry for 30 seconds





7

Large sterile drape used to cover infant





8

Sterile field maintained





9

Sterile field covered with sterile towel while awaiting X Ray





After the procedure


10

Sterile dressing used (Tegaderm)





11

Attach ‘closed’ needle-free system (Smart site)





12

Decontaminate hands after removal of gloves (Wash/Gel)






Procedure stopped* - Comments:


Completed checklist to be placed in baby’s notes. *If procedure has been stopped please inform PIC line team.



Neonatal PIC Line Team

The PIC line team will consist of practitioners who have proven expertise in the insertion of PIC lines in neonates. The team will be responsible for the supervision and training of new doctors in the insertion of PIC lines. New doctors may not insert PIC lines unsupervised until signed off by a member of the PIC team.


Central members of the team will be:
Sally Kemp

Sue Welch

Sharon English

Kathryn Johnson

Liz McKechnie

Cath Harrison

Haytham Ali

Hannah Shore



Helen Yates
Other members may be added once proficiency has been proven, but these should not be rotating doctors (Senior neonatal GRID trainees may be considered). Only members of the PIC team may train and supervise others.


Trainee Name
Grade
GMC number


Neonatal PIC line Insertion Competencies

Pre Procedure Competencies




Achieved

Achieved

Task







1

Identifies appropriate analgesia for infant







2

Identifies appropriate site and measures for correct length of line







3

Identifies an assistant and sources Matching Michigan checklist







4

Cleans metal trolley to aseptic standard







5

Appropriate equipment gathered







6

Hat and mask in place







7

Demonstration of hand washing to aseptic standard







8

Puts gown and gloves on to aseptic standard









Procedure Competencies

Task

Achieved

Achieved

1

Appropriate skin preparation demonstrated (Chloraprep with sterile water if infant <28weeks and <1 week)







2

Sterile towels applied to maintain sterile field







3

Long line assembled and flushed with 0.9% NaCl to ensure no leak







4

Insertion technique followed according to Neonatal Procedures handbook







5

Line fed into catheter using non - tooth forceps








6

Demonstration of line flushing and bleeding back during and at end of procedure








7

Line fixed appropriately using steristrips and tegaderm







8

Smart site flushed with 0.9% NaCl and connected







9

Maintenance of sterile integrity at all times during procedure









Post Procedure Competencies

Task

Achieved

Achieved

1

Appropriate drawing up of contrast and priming of the line for X ray as required (premicaths only). See guideline







2

Identifies correctly position on X ray and whether line is acceptable for use. See guideline







3

Documents procedure in notes using sticker







4

Successful completion of Matching Michigan CVC Checklist










Supervisor signature







Supervisor print name







Date












SOP for the insertion and maintenance of PIC lines in Neonates

Dr Sharon English November 2011




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