Central Venous Catheter (Longline) Insertion
|Reviewed Clinical Practice
- The insertion of a longline should not be considered a routine. However,
infants who are VLBW, likely to be slow to reach full enteral feeds, have IV
access problems or long term IV nutrition needs (NEC, major surgical
problems etc.) may require line placement.
- Infants to have longlines inserted should be discussed on ward round
and/or with a Specialist at the time of presentation.
- In babies <1000g insertion of an umbilical venous catheter on admission
is the preferred option. In those who are very small, sick or have
respiratory distress an umbilical artery catheter should be considered at
the same time. In sick term babies a double lumen UVC should be used as they
may require several infusions.
- Where ever possible discuss the risks of the procedure with the family.
Selecting a long line:
silicone 24G (2F) single lumen 30cm
This is the preferred line for all infants not requiring a second
lumen (i.e. most of our babies).
Vygon – Epicutaneo Cave
Silicone Catheter with blue hub 24G (2F) 30cm
Premicath polyurethane 28G (1F) single lumen
This should be used for infants
weighing < 1000 g only when a 24G line is unable to be inserted.
If used for any other indications, please discuss with specialist on
service or on call first.
Maximum flow rate 10ml/hr
Vygon Nutrioline Twinflo polyurethane 24G
(2F) double lumen 30cm:
This line is only to be used for infants requiring a second lumen
(for example, a baby requiring TPN and Prostaglandin infusion).
- Skin sepsis at insertion site
- Bacteraemia or septicaemia
- Large vein in antecubital
fossa, long saphenous vein or posterior tibial vein
Use a full sterile technique.
DO NOT ATTEMPT THIS PROCEDURE
THROUGH THE PORTHOLES
- Open longline
trolley and add:
- 20 gauge cannula
- Longline set
- Scalpel blade
Use only 10 ml syringe for flushing
- 0.9% NaCl 5ml ampoule
- Heparinised saline 10
- Skin disinfectant
- Duoderm dressing
- Tegaderm or Opsite
- Don mask, gown, and
- Flush the longline with
0.9% NaCl leaving syringe attached
- Cut round the IV cannula
at the hub leaving cannula on the introducer
- Position the infant
maximising access i.e. open the incubator door, slide tray out and use
overhead heater. Secure limbs if necessary
- If an assistant is required
they must wear a gown and sterile gloves
- Clean the skin with the
disinfectant appropriate for the infant’s gestation
Wait about 1 minute until
it dries otherwise it will not be an effective skin prep.
- Create a sterile field with
- Apply tourniquet above site
- Position line, syringe and
forceps on sterile field
- Insert cannula, advance
cannula off the introducer and withdraw introducer
- Insert longline with forceps
and feed to premeasured distance releasing tourniquet when catheter is
through the cannula
- Withdraw cannula over the
longline ensuring the longline is stable by using pressure on the limb above
- If using EPI-Cath, detach longline at blue connection, remove
cannula and reattach connection, ensuring air is not introduced. The
black marker that lies over the metal insert must not be visible.
- Flush longline with 0.5ml of heparinised saline (10U/ml). Do not use
syringe less than 10ml. The smaller the syringe the greater the pressure
– which may rupture the line.
- Coil longline next to site
without crossing longline.
- Steristrips should be
used to anchor the line preventing inward movement and may also help to
keep the longline coiled.
- Place a small piece of
Duoderm on skin under connection and secure everything with Tegaderm.
- Wrap syringe in sterile guard
until position confirmed by x-ray
- The Department of Health (UK) recommended that the line tip is
placed OUTSIDE the heart (Wariyar UK, Hallworth D. Review of four
neonatal deaths due to cardiac tamponade associated with the presence of
a central venous catheter. London, UK: Department of Health; 2001)
- After insertion patency can be maintained by running 0.9% saline at
1ml/hr until catheter position is confirmed on X-Ray. Most PICCs are
radio-opaque and with modern digital technology the imaging can be
enhanced therefore, contrast medium is no longer used in the first
- An X-Ray should be taken with infant positioned in anatomical
position with arms by their side for upper limb lines or legs with hips
slightly flexed for lower limb lines. Theoretically the line tip will be
at its deepest. Note the tip position is influenced by arm placement;
lines placed in the Basilic (medial) vein move towards the heart on
adduction; lines placed in the cephalic (lateral) vein move away from
the heart.1 Remember to remove chest leads.
- If the position of the catheter tip is not clear, a subsequent
X-Ray with contrast is advised (using a sterile technique instill
0.2 - 0.7ml Omnipaque to fill the line and Luer-lock until X-ray taken).
In some circumstances the oro-gastric tube may need to be removed if it
is obscuring adequate visualisation, or a lateral view can be obtained.
Contrast medium may be required to visualise a premicath tip. Consider
the risk of using contrast if there is renal impairment.
- Record in the clinical notes the date, insertion site and length of
catheter. Enter the procedure in the neonatal database.
- It is also important that we note the catheter tip position in the
- If the longline is clearly well into the heart (particularly if it
is curled) and needs to be withdrawn, another radiograph must be
taken after manipulation to ensure that it has been withdrawn far enough
and is in an acceptable position.
Unintentionally Short PICC (ie. Not in a large central vein).
In situations where there is no other venous access:
- They may be used for up to 24hours and the site should be
observed closely for extravasation.
- They should be entered on the problem list as a potential danger
until removed from the patient.
- They should be highlighted on the CLABSI form.
- Use for more than 24hours needs to be discussed with the
consultant on a case by case basis.
- They are a temporary venous access only – not a substitute for a
properly placed longline.
Nadroo A.M., Glass R.B., Lin J., Green R.S.,
and Holzman I.R. Changes in Upper Extremity Position Cause Migration of
Peripherally Inserted Central Catheters in Neonates. Pediatrics
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