Line insertion techniques

Key points

Choice of line

Midlines:

Can be used for around 2 weeks

Can be removed easily if infected

Central lines (Neck):

Can be used for 2 weeks, offers central access for PN, chemotherapy, can withdraw bloods etc

Can be removed easily if infected

PICC lines:

Can be used for around 6 weeks, offers central access for PN, chemotherapy, can withdraw bloods etc.

Can be removed easily if infected

Hickman/Broviac lines:

Single, double, triple lumen - should aim to manage with as few lumens as possible due to infection risk

Last around 2 years, offers central access for PN, chemotherapy, can withdraw bloods etc.

Often requires general anaesthetic if needing removal

Percutaneous internal jugular (IJV) access is the most common technique

In limited access scenarios the sublclavian and femoral vessels can be used

The line is placed with an USS guided Seldinger technique

Trendelenburg (Head down) position should be used when accessing the neck vessels due to risk of air embolus

Ideal tip position is SVC/Right atrial junction

Open external jugular cutdown is also possible, and has the advnatage of preserving the IJV

Open IJV cutdown ideally should not be used for line insertion, as it causes scarring and risks the vessel, however in neonates <3kg it is often necessary

Portacaths:

Single, double lumen - should aim to manage with as few lumens as possible due to infection risk

Last around 3 years, offers central access for PN, chemotherapy, can withdraw bloods etc.

Requires general anaesthetic if needing removal

Vascular access same as Hickman lines

Port itself can be placed on the chest wall, or abdominal wall if accessing the femoral veins

Umbilical arterial (UAC) and venous (UVC) catheters:

UAC 5 day limit

UVC 14 day limit

Can also insert surgically by incising above or below umbilicus

UVC ideal tip position: IVC/RA junction (xiphisternum)

UAC ideal tip position: between T6-T10 (mid heart level)

Umbilical catheter choice:

UVC – use a double lumen 4Fr catheter

UAC – use a single lumen catheter 3.5Fr for <1.5kg and 5Fr for >1.5kg

UVC - If the line is being placed for emergency access, advance the catheter 1-2 cm past the point of initial blood return in the catheter, which is usually 4-5 cm in a full-term.

If the line is being placed for more long-term access, the line should be advanced into the inferior vena cava just below the right atrium, which is usually 10-12 cm in a full-term neonate

References

Dumpa V, Avulakunta ID. Umbilical Artery Catheterization. [Updated 2023 Apr 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559111/