Introduction
There are many terms and acronyms commonly used in neonatology that most people are not familiar with. Even medical clinicians who do not have any NICU experience are unlikely to know what a UAC or UVC is. And most parents probably didn’t realize that you can access a newborn’s venous and/or arterial system through their umbilicus until the providers explained the procedure or what type of intravenous or arterial access your baby had while in the NICU.
For our 40th podcast episode, we reviewed some of those common NICU acronyms, but specifically the different intravenous and arterial line options commonly used in the NICU. These terms may be casually discussed during conversations between NICU clinicians, but it is important that as a parent, you understand the different peripheral and central lines infants in the NICU commonly need. Not only should you understand what they are, but you should also know when they are used or why one option is chosen over another. Additionally, it is imperative that you know the potential complications with each line, so you know what questions to ask when the NICU providers speak with you about each option.
So continue to read or start listening now and get ready to become empowered as we review peripheral and arterial lines common to the NICU!
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Episode 40
Peripheral and Central Lines Used in the NICU
What are the different options?
Most infants in the NICU require IV or intravenous access at some point. There are several options for lines and catheters that deliver intravenous fluids, medications, parenteral nutrition, and blood products for neonates. The decision of which line is appropriate is typically dependent upon the infant’s gestational age, their clinical condition, and how long the providers anticipate the need for IV access. Additionally, some of the variations between units are based on their individual unit protocols or there may be demographic variations as well.
Today we are going to review the different modes of IV access commonly used in the NICU including Peripheral Intravenous Line (PIV), Umbilical Artery Catheter (UAC), Umbilical Venous Catheter (UVC), Peripherally Inserted Central Catheter (PICC line), and Central Venous Line (CVL).
I touched on all of the lines and catheters that we will be discussing in this episode way back on episode 5 of the podcast: NICU Equipment from Head to Toe: What You Need to Know
We also, we had our artist draw a beautiful image to help NICU parents identify and understand many of the machines, lines, and equipment commonly used in the NICU. Go and grab your free PDF so you can follow along now!
Peripheral IV (PIV)
We will start with the most basic, a peripheral IV, commonly referred to as a PIV. A peripheral IV is commonly used in the NICU for many babies. It is started just as an IV on an adult would be. There is a small needle used to access the vein, then the needle is removed and a small, short catheter is thread into the vein. IV fluids, medications, parenteral nutrition, and blood products may be given through a PIV.
Peripheral IVs on infants, children and adults are not meant to last very long. They may become infiltrated meaning fluid begins to leak outside of the vein into the surrounding soft tissue or become dislodged after just one day or a few days. The length of time they last is dependent upon each individual, their veins, and how caustic the IV solutions are that are infusing.
What are the benefits of a central line?
Infants, but especially premature infants have very fragile veins. Additionally, infants admitted to the NICU typically need IV access for days if not weeks or months, which is why central IV access is frequently needed. With central lines, the tip or end of the catheter ends near the heart in one of the larger veins which allows it to last longer, makes it less likely to become dislodged, and is less likely to cause damage.
Additionally, since central catheters are closer to the heart where blood flow is stronger, the flow of the medications, parenteral nutrition, and IV fluids will be stronger and more constant. Especially with crucial, life-saving medications, a central line ensures that medications are delivered safely and will diffuse throughout the body more quickly.
Central lines also allow the providers to deliver medications and IV fluids with higher concentrations without concern of them being irritating to the veins. For example, most infants are given Dextrose solutions through their IV. But once dextrose levels beyond 12.5% are needed, they are considered more hypertonic and have to be infused through a central catheter to avoid vein irritation or damage.
Fetal Circulation
Before we move on to umbilical lines, it is important to understand the anatomy of the umbilical cord and fetal circulation. In utero, the placenta accepts the blood without oxygen from the fetus through blood vessels that leave the fetus through the umbilical arteries – there are two of them. Next, blood goes through the placenta, picks up oxygen and the oxygen rich blood and nutrients return to the fetus via the single umbilical vein. The oxygenated blood that enters the fetus bypasses the fetal liver via the ductus venosus and enters into the right side of the heart.
As I mentioned, there are supposed to be 2 umbilical arteries and one umbilical vein, but in approximately 1% of pregnancies, there is just one umbilical artery, which is referred to as a single umbilical artery.
Umbilical Artery Catheter (UAC)
The umbilical artery is accessible in newborns through a procedure known as umbilical artery catheterization. An umbilical artery catheter (UAC) provides direct access to the arterial system which is useful for NICU patients who require frequent blood sampling and measurements of the systemic arterial blood pressure. Now, not every infant requires a UAC line. Umbilical artery catheters are usually reserved for infants that need frequent measurements of arterial blood gasses, frequent blood sampling, or continuous blood pressure monitoring in either extremely premature or critically ill neonates.
Although it is not the preferred method, UACs may occasionally be used as a temporary solution to infuse parenteral nutrition or certain medications if no other IV access is available, but this decision is unit dependent. The maximum dextrose concentration administered through the UAC is 15%. Indomethacin, vasopressor medications, calcium boluses, and/or anticonvulsant medications should not be administered through the UAC.
How is a UAC placed?
Only NICU providers or transport nurses, who have undergone adequate training should perform the procedure. The UAC procedure is completed and maintenance of the line should all be done under sterile technique since it is a central line. Since there are two umbilical veins, the provider can start with either one. The arteries in the umbilical cord are quite small, thick walled, and constricted. The inserter must take some time to carefully dilate the artery they are attempting to place the catheter in.
There are calculations based on the infant’s weight or size the inserter performs prior to the procedure to estimate how far they should advance the catheter. Once the catheter is placed in the pre-calculated and hopefully correct location, the provider will verify the tip location by ordering an X-Ray.
How to secure a UAC
Once the catheter placement is verified, the UAC line will be secured. There are a variety of methods to secure umbilical lines with and without sutures including commercially available securement devices like the NeoBridge by NeoTech. Effective securement is especially important with umbilical lines, but specifically umbilical artery catheters so the catheter does not become dislodged since it is a direct line into the infant’s arterial system. Additionally, infants should be placed either on their sides or back to monitor for any dislodgement or bleeding.
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As I mentioned, UAC lines are ideal for drawing labs, including arterial blood gasses. When drawing blood from the line, it should be done under sterile fashion and care should be taken to not withdraw the blood or to reinfuse the blood back the infant too quickly.
How long can a UAC remain in place?
As per the Centers for Disease Control and Prevention or the CDC, it is recommended that umbilical artery catheters are only left in place for a maximum of 5 days. Some sources state 5 to 7 days. Regardless, there should be a daily conversation with the NICU care team to evaluate if the UAC line is still necessary or if it can be removed.
Potential UAC complications
Insertion of a UAC is not without complications. Infants with a UAC in place are at risk for an infection, specifically a central-line associated bloodstream infection. Additional potential complications may also include but are not limited to vascular complications including vasospasm, thrombosis, embolism and/or an infarction can occur.
Percutaneous arterial line (PAL)
If an infant is critical and still requires frequent blood draws, arterial blood gasses or continuous blood pressure monitoring, a percutaneous or peripheral arterial line or PAL may need to be placed. A percutaneous arterial line is placed by inserting a needle most commonly into the radial artery in the infant’s wrist. The needle is removed once the artery is accessed and a small catheter is advanced. Once in place, the line is carefully secured.
Potential PAL complications
There are some complications to consider when there is a peripheral arterial line including but not limited to vasospasm, embolism, thrombosis, air embolism, hemorrhage, infection, infiltration, and/or nerve damage. Additionally, PALs in my personal experience are difficult to maintain for extended periods of time, but they do help NICU clinicians to manage critical infants.
Umbilical Venous Catheter (UVC)
An umbilical venous catheter (UVC) is placed in the single vein of the remnant umbilical cord. It is used for preterm or critically ill neonates that require intravenous administration of fluids, medications, parenteral nutrition, and/or blood products.
How is a UVC placed?
The provider will calculate the anticipated length the catheter needs to be inserted prior to the initiation of the procedure. The insertion and maintenance of a UVC should also be done with sterile technique. The vein in the umbilical cord is larger than the arteries, thin-walled and is easily accessible so it does not typically require dilation.
Once the catheter enters into the umbilical vein, it travels through the medial part of the left portal vein then through the ductus venosus (DV) with the goal of the tip to end near the junction of the inferior vena cava (IVC) and right atrium (RA). Umbilical venous catheters often unintentionally take the collateral route into the portal system near the hepatic branch of the portal vein. The catheter cannot remain near the liver, so the inserter must try to maneuver the catheter to the central location or at the very least, pull it back some and consider leaving it at a lower level which is called a low-lying UVC.
To confirm accurate placement of the UVC, an X-ray is typically done. Although recently, the introduction of ultrasound-based methods for tip navigation and tip location is growing in the neonatology world. Despite the accuracy of ultrasound guided UVC placement, many NICUs continue to use X-Rays to confirm placement, possibly due to the need for targeted training with providers on the use of the point-of-care ultrasound or POCUS.
How to secure a UVC?
UVCs need to be secured properly as well with one of the common modalities or commercially available products like the NeoBridge by NeoTech.
How long can a UVC remain in place?
According to the CDC, UVCs can remain in place up to 14 days, although other sources recommend just 7 days. It is recommended that if a central line is anticipated to be needed for more than 5-7 days, a PICC line should be attempted which we will cover shortly rather than leaving in a UVC for an extended period of time.
Potential UVC complications
Just as with UACs, UVCs do not come without risks or potential complications. The most commonly reported adverse effect for UVCs is infection, or central-line associated bloodstream infection (CLABSI). Additionally complications may include but are not limited to migration, arrhythmias, pericardial effusion, thrombosis, extravasation, hepatic complications, blood loss and/or hemorrhage.
Peripherally Inserted Central Catheter (PICC)
Peripherally inserted central catheters (PICC lines) are used for long-term IV access to administer medications, fluids, and/or parenteral nutrition. Just as it says, a PICC line is started peripherally in a peripheral vein either in an infant’s hand, arm, axilla, foot, leg, or scalp.
How is a PICC line placed?
The inserter measures the anticipated length based on the insertion site, trims the catheter accordingly, then once the vein is accessed with an introducer or needle, the needle is removed and the catheter is thread through the vascular system until the tip is in either of the two major veins near the heart, the superior vena cava (SVC) or inferior vena cava (IVC).
PICC lines inserted in the upper extremities, axillae, or scalp vessels, should lie in the SVC above the right atrium of the heart and if they are inserted in the lower extremities, they will lie in the IVC. PICC lines are typically inserted by a member of the PICC line team or one of the nurse practitioners. Just as with the previous central lines we have discussed, placement and maintenance of a PICC line is all done under sterile technique.
Confirmation of the tip is done typically by an X-Ray, but PICC lines can also be placed in interventional radiology or through the guided ultrasound technique. Once central placement is verified, the insertion site and external portion of the catheter is secured with a transparent dressing.
How long can a PICC line remain in place?
PICC lines may stay in place for several weeks or months if needed. They can be used in place of a UVC or replace the UVC once it is removed around 5-7 days of age. The CDC recommends inserting a PICC line if IV access and therapy are needed for more than 6 days.
Common PICC line complications
Complications associated with PICC lines include but are not limited to infiltration, catheter occlusion, infection, air embolism, migration, and/or pericardial effusions.
Central Venous Line (CVL)
And finally, a central venous line (CVL) is typically placed if the NICU clinicians were unable to place a PICC line and the infant still needs long-term IV access or in surgical patients. IV fluids, medications, parenteral nutrition, and typically blood products can be delivered via a CVL. Central venous lines are placed surgically in the chest or groin area and the catheter is thread so the tip sits just outside the heart.
Central-line associated bloodstream infection (CLABSI) prevention
As I mentioned previously, all central lines place infants at risk for central-line associated bloodstream infections CLABSIs). They are the most common type of nosocomial, or hospital-acquired infections in neonates. Bloodstream infections also place infants at an increased risk of mortality and may lead to poor growth and negative neurodevelopmental outcomes. Due to the devastation that often follows a CLABSI, there continues to be a large amount of studies with the focus on ways to reduce the incidence of central-line catheter-related infections.
Regular Education
In attempts to minimize the incidence of CLABSIs, it is important that all of the medical staff is educated regularly and repeatedly about central lines, the appropriate practices during catheter insertion and maintenance, and other policies for catheter-related infection prevention.
Dedicated PICC line team
One prominent method to prevent CLABSIs is by only allowing skilled medical personnel to manage insertion and maintenance of central lines in the NICU by a designated line care and/or PICC teams.
Appropriate patient-to-nurse ratios
Appropriate patient-to-nurse ratios should also be maintained to allow adequate time to care for the central line and to change fluids and/or tubing under sterile technique. This is incredibly important as research has shown that elevated patient-to-nurse ratios are associated with an increase in CLABSIs.
Bundles
Intervention bundles for central lines in the NICU are recommended for both insertion and maintenance. Studies have shown that bundles with a checklist encourage compliance and ultimately a reduction in CLABSIs. Other practices to prevent CLABSIs include scrubbing the hub prior to accessing the line as well as appropriate hand hygiene.
Skin antiseptics
Appropriate use of skin-antiseptics is recommended to cleanse the skin prior to insertion with either 70% alcohol, tincture of iodine, or a >0.5% Chlorhexidine with alcohol. As we discussed in our 35th podcast: Skin Care: Clinical Guidelines for the NICU, the use of Chlorhexidine is not approved in infants less than 2 months of age due to concerns of contact dermatitis, potential systemic absorption, and possible toxic effects, But, we do know that Chlorhexidine is superior for skin disinfecting in children and adults, but it is not approved due to the limited safety data in infants. Although many units use chlorhexidine in their NICUS, the CDC guidelines have said that there is insufficient evidence to make proper recommendations on the safety and efficacy of chlorhexidine in infants younger than 2 months of age. As a result, the use of chlorhexidine in the ELBW infant is controversial and should be used per each institution’s guidelines.
Low dose Heparin for patency
Also, with central lines, it is recommended to add low dose Heparin 0.25 – 1.0 Units/mL to maintain the patency of the catheter. The exact dose will vary between institutions and their policies.
Remove any central line when it is no longer needed
And finally, as I previously mentioned, it is crucial to remove any central line as soon as possible and when they are no longer needed to minimize complications and the risk of a central-line associated bloodstream infection.
Variations in policies
It is also important to mention that each NICU and their protocols for when they place central lines and how long they keep in UACs, UVC, and/or PICC lines will vary. Some NICUs will place UVCs if an infant is below a certain gestational age like 28 or 30 weeks’ gestation, where other units may start PIVs then place a PICC line if needed rather than inserting a UVC.
As a parent, I think it’s important for you to not only know what kind of IV access your infant has, but to also understand the differences between peripheral IVs and the different central lines options. As always, if you have questions or do not understand something, please ask your infant’s care team or provider for clarification.
Closing
I hope you enjoyed this basic review on IV access and central lines commonly used in the NICU. I think it is important that parents understand what the different peripheral and central lines are that are commonly used in the NICU. It is also important to know what complications may be associated with each line. I hope this review has been valuable for you whether you are a novice NICU clinician or a NICU parent.
As always, if your baby is in the NICU, ask their provider for clarification on what type of IV access they have or will likely have in the future so you thoroughly understand the plan of care for you baby.
References
Andrea, V., Prontera, G., Rubortone, S., Pezza, L., Pinna, G., Barone, G., Pitturati, M., & Vento, G. (2022). Umbilical Venous Catheter Update: A Narrative Review Including Ultrasound and Training. Frontiers in Pediatrics, 9, 1-9.
Cho, H. & Cho, H. (2019). Central Line-Associated Bloodstream Infections in Neonates. Korean Journal of Pediatrics, 62(3), 79-84.
Dumpa, V. & Avulakunta, I. (2022, April). Umbilical Artery Catheterization. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK559111/
Eichenwald, E. Hansen, A., Martin, C., & Stark, A. (2017). Cloherty and Stark’s Manual of Neonatal Care, Eight Edition. Wolters Kluwer.
Gomella, T., Eyal, F., & Bany-Mohammed, F. (2020). Gomella’s Neonatology: Management, Procedures, On-Call Problems, Diseases, and Drugs, Eight Edition. McGraw-Hill.
Gardner, S., Carter, B., Enzman-Hines, M., & Niermeyer, S. (2021). Merenstein & Garner’s Handbook of Neonatal Intensive Care Nursing: An Interprofessional Approach, Ninth Edition. Elsevier.
Remian, K. & Majmundar, S. (2022, June). Physiology, Fetal Circulation. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539710/
