6. Maintain strict aseptic technique for the insertion

and care of central catheter. Hand hygiene (with soap

and water or with alcohol based hand rub) should be

performed before and after palpating catheter insertion sites, as well as before and after inserting, replacing, accessing, repairing or dressing an intravascular

catheter (2).

7. Never leave a catheter in a position where it does not

easily and repeatedly withdraw blood during the insertion procedure, to ensure that the tip is not lodged

against a blood vessel or cardiac wall.

8. Always confirm (both AP and lateral radiographs are

recommended) the position of the catheter tip by radiography or echocardiography prior to using it.

9. If possible, the line should be inserted and cared for by

specifically trained personnel. Central line teams and

the use of insertion and maintenance checklists and

bundles have been shown to decrease the frequency of

catheter-related infections (3).

10. Do not submerge the catheter or catheter site in water.

Chapter 32 ■ Central Venous Catheterization 195

Table 32.1 Vessels Amenable to Central Venous Access

Blood Vessel Recommended Technique

Upper extremity: Cephalic, basilic, median cubital,

or axillary vein

Percutaneous or surgical

Lower extremity: Saphenous vein or femoral vein Percutaneous or surgical

Scalp vein Percutaneous technique, amenable only to PICC lines

External jugular vein Percutaneous or surgical

Internal jugular vein or common facial vein Surgical technique

D. Vessels Amenable to

Central Venous Access

Table 32.1 lists the sites usually used for central venous

catheterization in the newborn.

E. Position of Catheter Tip (Fig. 32.1)

1. The catheter should be placed in as large a vein as possible, ideally outside the heart, and parallel with the

long axis of the vein such that the tip does not abut the

vein or heart wall. The recommendations for appropriate position of a central venous catheter tip vary, but

there is general agreement that the tip should not be

within the right atrium (4–6). However, one large retrospective audit of 2,186 catheters showed that catheters

with their tips in the right atrium and not coiled were

not associated with pericardial effusions (7).

a. When inserted from the upper extremity, the catheter tip should be in the superior vena cava (SVC),

outside the cardiac reflection, or at the junction of

the SVC and right atrium.

b. 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.

2. Confirmation of catheter tip placement

a. The tip of the radio-opaque catheter is usually seen

on a routine chest radiograph (Fig. 32.1), but there

can be significant interobserver variability in assessing the position, even with digital enhancement (8).

b. Two radiographic views (anteroposterior and lateral)

help to confirm that the catheter is in a central vein.

This is particularly important for catheters placed in a

lower extremity, where the catheter may inadvertently

be in an ascending lumbar vein and may appear to be

in good position on an anteroposterior view (9).

c. The use of radio-opaque contrast improves localization of the catheter tip, particularly when the

catheter is difficult to see on a standard radiograph.

A 0.5-mL aliquot of 0.9% saline is instilled into the

catheter to check patency, followed by 0.5 mL of

iohexol. The radiograph is taken, and the line is

flushed again with 0.5 mL of 0.9% saline. With this

technique, there is no need to inject the contrast

material while the radiograph is being taken (10).

d. Ultrasonography may also be useful in localizing

the catheter tip (11).

e. Chest radiographs obtained for any reason should be

scrutinized for appropriate catheter position. Routine

weekly radiographs taken for this purpose do not

appear to reduce the risk of complications (6).

F. Methods of Vascular Access

1. Percutaneous technique

a. Advantages

(1) Simpler to perform and relatively rapid procedure

(2) Vessel is not ligated as in open cutdown methods

(3) Decreased potential for wound infection/

dehiscence complications

b. Disadvantages

(1) Beyond the initial insertion into the peripheral

vein, further passage of the catheter into its final

position is essentially a blind technique, although

there is increasing experience with ultrasound

imaging (11).

(2) A smaller-caliber catheter may preclude use for

blood transfusions

Fig. 32.1. Chest radiograph with PICC tip in appropriate position, just above junction of superior vena cava and right atrium.