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I have been placing percutaneous intravenous central catheters (PICCs) in neonatal patients for almost 25 years, and I admit taking apart the process seems a bit daunting. One of the most important factors for successful insertion is good planning.

The first thing I do is identify the patient. Any neonate who is less than 1,250 grams, requiring antibiotics or total parental nutrition for more than 5 days is an obvious candidate. An infant over 1,000 grams requiring frequent blood draws could be considered for a larger PICC as the unit I work in uses the line for blood drawing as well as fluids and antibiotics. The patient should not have active bacteremia or fungemia.

Once I identify the patient, I review the current fluid status and recent complete blood count. A platelet count over 50,000 and normal hematocrit are preferable, and if out of acceptable range, it’s best to take time to correct these before attempting the procedure.

After I have identified the patient and assessed the individual factors, I will put in several prep orders. These orders include an intravenous (IV) 20 ml/kg 0.9 Normal Saline bolus, 1 mcg/kg fentanyl, and 0.1mg/kg versed given via IV. The bolus is to be completed immediately prior to procedure, the sedation and analgesia just before the start. I almost always follow this pre-procedure protocol, especially if this is not the first PICC attempt on the patient. Blood vessels in neonates tend to be especially friable and, in my experience, a normal hematocrit, fluid bolus, and appropriate pre-medication minimize that obstacle.

Next, I examine the patient’s vessels and look for the biggest vessel that is suitable for a PICC. I start with extremities as a PICC dressing is maintained easiest on an extremity. Recently, I have preferentially used the right saphenous if it’s suitable. The main reason I have been doing this is that there is more leeway on the placement of the tip of the line than in an upper extremity. Upper extremity lines have a smaller acceptable target area, a higher incidence of line migration; the observation of the tip placement on X-ray is very sensitive to the patient’s arm position when the X-ray is taken. Also, a lower extremity line will often remain in a central position through patient growth.

The procedure of PICC placement is well documented. The few variations I use when I place a PICC include: my own positioning and I cut the catheter to the exact length.

One important pearl I would give to the novice PICC inserter is to practice your IV insertion skills. Proficiency in IV insertion will not guarantee that a PICC insertion will be easier, but without the IV skills, insertion of PICCs in neonates will be less successful.

Like any other procedure, PICC line placement requires patience and practice. The methodology I use has been refined over the 25 years I have been doing this in the NICU. If you are interested and would like to discuss it, please do feel free to email me at

Christine O'Malley

Christine O'Malley is a neonatal nurse practitioner at the University of Chicago Comer Children's Hospital.

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