Caution: When using a break-away needle, never

advance the needle or retract the catheter after

inserting it into the needle; the catheter may be severed by this action.

f. With small, gentle nudges, a few millimeters at a

time, advance the catheter through the introducer

to a distance of about 6 to 7 cm into the vein.

g. Once the catheter is successfully advanced to about

6 or 7 cm, withdraw the introducer carefully (an

alternative is to insert the catheter to the predetermined distance before withdrawing the introducer).

h. To withdraw the introducer, stabilize the catheter by

applying gentle pressure over the vein proximal to

the introducer, and then remove it carefully from

the insertion site. Break or peel away the introducer

by splitting the wings, and then carefully peel it

away from the catheter.

i. Continue to advance the catheter into the vein to

the premeasured length, by nudging it farther, a few

millimeters at a time, using the fine forceps.

j. Difficulties in advancing catheter: Gently massage

the vein in the direction of blood flow, proximal to

the insertion site, or gently flush the catheter intermittently with 0.5 to 1 mL of heparinized saline;

repositioning the extremity or the head may help.

k. Aspirate to visualize blood return in the catheter,

and flush with 0.5 to 1 mL of heparinized saline to

clear the catheter.

l. Verify length of catheter inserted and adjust as necessary.

m.Attach sterile extension set as per unit protocol.

n. Apply gentle pressure on insertion site with gauze

pad to stop any bleeding.

Table 32.3 Patient Position and Measurement for PICC Insertion

Site of Insertion Position of Baby Measurement

Antecubital veins Supine, abduct arm 90 degrees from trunk; turn head toward

insertion site to prevent catheter from traveling cephalad

through ipsilateral jugular vein

From planned insertion site, along venous pathway,

to suprasternal notch, to third RICS

Saphenous or popliteal veins Supine for greater saphenous vein, prone for small saphenous or

popliteal; extend leg

From planned insertion site, along venous pathway,

to xiphoid process

Scalp veins Supine, turn head to side; may have to turn head to midline during procedure to assist advancement of catheter

Follow approximate venous pathway from planned

insertion site near ear, to jugular vein, right SC

joint, to third RICS

External jugular vein Supine, turn head to side; place roll under neck to cause mild

hyperextension

From planned insertion site, to right SC joint, to

third RICS

Axillary vein Supine, externally rotate and abduct arm 120 degrees, flex forearm and place baby’s hand behind head; vein is found above

artery between medial side of humeral head and small tuberosity of the humerus

From planned insertion site, to right SC joint, to

third RICS

PICC, peripherally inserted central catheter; RICS, right intercostal space; SC, sternoclavicular.

200 Section V ■ Vascular Access

A B

C D

E F

Fig. 32.5. A: Venipuncture with peel-away cannula introducer. B: Withdraw the introducer needle

from the sheath. Note that the introducer sheath is supported to avoid displacement. C: Insert the catheter

into the introducer sheath using fine nontoothed forceps. D: Withdraw the introducer sheath. E: Remove

the introducer sheath by splitting and peeling it away from the catheter. F: Transparent dressing on PICC

catheter. Note that the excess catheter length has been coiled in place under the dressing.