Guideline for the use of peripherally inserted central ...



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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:

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 ). 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 ................
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